A
Bibliography ,
Research:
Employee
Benefit Research Institute
• Education
and Research Fund
Library of Congress Cataloging in Publication Data Main entry under title: A Bibliography
of research,
health
care programs.
Includes index. 1. Medical economics--United States--Bibliography. 2. Medical care--United States--Bibliography. 3. Insurance, Health--United States--Bibliography. I. Employee Benefit Research Institute. II. Employee Benefit Research Institute. Education and Research Fund. [DNLM: 1. Health services research--United States-Bibliography. 2. Financing, Organized--United States--Bibliography. ZWA 20.5 B582 ] Z6675.E2B5 [RA410.53] 016.3621'0973 81-12521 ISBN 0-86643-021-0 AACR2
_) 1981 Employee Benefit Income Education and Research Fund 1920 N Street. N.W.,
Research
Institute
Suite 520
(202) 659-0670 Printed
in the United States of America
Permission to quote from or reproduce materials in this publication is granted when appropriate acknowledgement is made. The views in this publication are thGse of the authors and do not necessarily reflect the views of the Employee Benefit Research
Institute,
its trustees,
members,
or other staff.
Contents Foreword ................................................................ Preface .................................................................. Introduction ......................................................... Methodology ......................................................... Limitations .......................................................... Overview of Findings ................................................. Directions for Use ......................................................... Listings of Citations and Abstracts ..................................... Information Sources .................................................. Indexes .............................................................
'
Completed Research ...................................................... Research in Progress ...................................................... Information Sources ....................................................... Sources of Information on Health Care Programs ........................... Educational Institutions, Research Organizations and Foundations ................................................... Trade and Professional Associations .................................... Federal Government .................................................. State Governments ................................................... Indexes and Clearinghouses Publishers ........................................................... Source List of Health Care Program Periodicals ............................ Author Index ............................................................. Title Index ............................................................... Sponsoring Organization Index ............................................. Subject Index ...........................................................
v vii vii vii viii viii ix ix ix x I-I II-I IIi-I IIl-! lII-I lII-3 III-3 Ill-5 . .III-6 ill-6 III-7 IV-I V-I VI-I VII-I
o.. lU
Foreword The Employee Benefit Research Institute (EBRI) was founded in 1978 to contribute to the development of effective public policy through research and educational programs. The institute is committed to the belief that the availability of good information will contribute to its objectives and that the most effective first step is a review of what has already been undertaken. EBRI starts its research program in each area of employee benefits by compiling comprehensive bibliographies of recent research. The bibliographies should help EBRI and other organizations define the areas in which additional work is most needed and avoid duplication of effort. A Bibliography of Research: Health Care Programs was developed by the Education and Research Fund of the Employee Benefit Research Institute and is part of an ongoing commitment to provide timely and relevant information in the field of employee benefits. This bibliography summarizes relevant research on the characteristics, costs, and utilization of health care services under current and proposed health care programs. Special attention was given to the different financing methods, delivery systems, and program costs of various types of health care programs. The bibliography is intended to assist policymakers, employee benefit specialists, researchers, and others interested in the health care field to identify research activities in the delivery of health care benefits and programs. Because of the vast and rapid degree of change in the health benefit field, an effort was made to include research from both the public and private sectors in order to facilitate an awareness of the interrelationships among health care programs. This bibliography was prepared by Aspen Systems Corporation under contract Bibliography development was coordinated by Catherine Thomson of EBRI.
to the EBRI Education
and Research
Fund.
Appreciation is expressed to all the individuals and organizations who participated in the development of the bibliography by contributing their time, energies, and resources. A special note of gratitude is extended to the research department and library of the Health Insurance Association of America and to the EBRI member firms who generously donated or lent materials. Special recognition is made of the EBRI-ERF Project Advisory Group, which assisted in identifying and reviewing the contents and presentation of this bibliography. Dallas L. Salisbury Executive DJirector September,
1981
Preface Introduction This bibliography lists completed and ongoing research on health care programs with specific attention to the costs and utilization of health care services under current and proposed health care programs. Topics included are: • Characteristics of the U.S. health care system such as the demand for and supply of health care services, the utilization of these services, projections of health care costs and expenditures, and a discussion of other market influences on health care, such as medical technology and socioeconomic factors that affect the availability, delivery, and utilization of health care. • Descriptions and comparisons of public and private health care programs providing or paying for treatment. These include benefit and coverage levels, program characteristics, reimbursement methods, and funding]financing arrangements. • Discussions of legislative actions, government regulations, voluntary cost containment efforts, and policy initiatives that influence the financing, delivery, and management of health care programs. Given the breadth of this approach, the diversity of the sources used and the complexity of the topics included, the bibliography encompasses a broad range of health care program research. However, it is not an exhaustive compilation of research. Rather, it is meant to be a selective representation of research on health care programs. The inclusion of particular publications was based on their overall relation to the general theme of impacts on health care delivery, health care costs, and third party payors. The diversity of subject matter is also reflected in the variety of documents included in this collection: journals, scientific magazines, textbooks, government reports, special analyses, dissertations, unpublished reports, and reference materials, including subject bibliographies. An effort was made to include less widely published information to draw the user's attention to the range of research activities in this field. EBRI intends to update this bibliography on a periodic basis to identify timely, pertinent research as quickly as possible.
Methodology For this bibliography, EB RI sought to identify research and relevant information that contributes to an understanding of health care program characteristics and costs and the impact these factors have on individuals, firms, the government, and the economy. Health care programs are defined as any organized system of providing health care or financing medical expenses. Such programs may be provided as a result of the employment relationship or via publicly sponsored plans. Examples of the variety of plans studied are commercial insurance plans, service benefit plans, prepaid plans, medicare, and medicaid. For the purposes of this bibliography, research is defined as empirical analyses and theoretical works that either present new information or review previously developed research. This definition allows inclusion of a wide range of materials and sources, but attempts to exclude documents involving individual commentary, unsupported opinion, and general reporting. The base period for this bibliography is 1975 to the present, although older citations are included if they present major findings not superseded by more recent investigations. The effort to identify health care program research covered a wide range of groups, including employee benefit consulting firms, insurance companies, Federal and State governments, research organizations, university research centers, and publishers of health care information. Letters of inquiry, survey questionnaires, and telephone followup were used to elicit information from over 200 organizations and individuals. A list of sources of information on health care programs is contained in Section III. Although some of these organizations do not conduct or sponsor research, they are knowledgeable sources in the field, possessing particular insights and resources of potential interest. Section III also contains a list of periodicals that served as major sources of citations in the bibliography.
vii
Research centers and libraries were also contacted, i:_cluding the National Library of Medicine, the Department of H,.:ahh and Human Services Parklawn Health Library, and the Health Insurance Association of America Library. The research departments _f EBRI member firms also provided valuable assistance.
Limitations The research investigation led to the identification of a large body of information. Despite this variety,; many areas of research lack specifidty, continuity of investigation, and documentation, evaluation, or interpretation. In some instances, indepth documentation of results of innovative studies was difficult to obtain or was simply out of print. In other cases, only a secondary sour,.:e of information, such as a description of a study contained in a trade magazine, was available. Some sponsoring or perforating organizations considered their research information to be proprietary and, for a number of reasons, could not release it. This is not to indicate that such organizations would not cooperate with individual users in providing needed data, only that some information is not available for widespread distribution• This bibliography does not list the individual reports of serial publications, surveys, or data bases maintained by research organizations. Rather, it identifies the name of the series published by such organizations in Section Ill. For instance, the National Center for Health Statistics publishes a series called "Vital and Health Statistics," which now contains over 200 individual publications. Listings of individual publications in a series are usually available from the data source•
Overview
of Findings
With respect to the citations contained in the bibliography, several observations research can be made:
regarding activities in the field of health care program
• General analyses_descriptions of the U.S. health care system includingpopulation, programs, facilities, manpower, andfinancial characteristics. Considerable work is being conducted by the Federal Government, the health care industry, and private foundations. Major data reporting systems such as those sponsored by the National Center for Health Statistics and the Health • Care Financing Administration, as well as the reporting systems of national associations and research groups such as the American Hospital Association, the American Medical Association, and the Health Insurance Association of America, provide a wealth of information on national health care activities. This information is presented in many forms: serial publications, reoorts, and resource services. Much of the analysis of program characteristics is based on information about health care programs obtained from such organizations. However, no system in itself provides a comprehensive view of U.S. health care. A composite must be drawn from multiple sources within the public and private sectors. '
• R_'search on health care programs. Available research on actual program experiences, program costs, and characteristics both w_thin programs and among programs is far more difficult to obtain. More information is available on the utilization rates and costs of publicly sponsored plans. The information on private sector plans tends to be less centralized. In this area, the reports and projects by private organizations such as fhe Health Insurance Association of America are important for developing national comparisons. It should be emphasized that the research in the private sector does tend to be more limited. For example, to obtain information on the Blue Cross/Blue Shield Plans, one must not only contact their national associatiom but also the individual State organizations to identify related ongoing activities. • Policy analysis literature. Perhaps the most widely documented topics in the health field are those pertaining to current and proposed methods for reducing costs and improving the quality of care. Many proposals abound, but the number of comprehensive reviews is more limited. For instance, among the proposals on National Health Insurance, there are several for the inclusion of mental health, drug abuse, pharmacy, and home health care services under a national plan. Others propose revising eligibility and cost sharing requirements under existing plans. In attempting to select and balance the presentati_ms of these theoretical and proscriptive documents, we focused on those related to the cost implications of change• In addition, we identified other proposals for change, such as cost containment efforts within the private sector. Emphasis was also placed on State government activities and comparisons w_,*hforeign health care systems.
viii
Directions for Use The format of this bibliography related publications.
is intended to assist users in identifying publications of interest as well as to guide users to other
Listings of Citations and Abstracts The listings of citations and abstracts are divided into two sections: Section I contains published research. Section II contains research in progress. So that users can distinguish between published and in-progress works in the indexes, abstract numbers for research in progress are 8000 or higher. In future updates of this bibliography, newly identified research in progress will be added to Section II and current research in progress will be added to Section I as it is completed. Each entry in the bibliographic Abstract number "title
collection
lists the following information:
Personal and/or organizational author Performing organization and address Sponsoring organization and address Document date (or estimated completion Number of pages Availability/ordering information Abstract
date for the research in progress section)
Subject descriptors The abstracts presented in the bibliography are brief, informative, nonevaluative representations of documents, providing a summary of the information contained in the originals_ Each abstract is of sufficient length, usually between 200 and 250 wol_ls, to allow the reader to grasp the salient points of the document and to judge its relevancy to particular research endeavors. Depending on the original document, abstracts include the following information: •
The purpose of the work reported in the document;
• The methodology • The results,
and data employed;
conclusions,
or recommendations
• The number of appendices, entire document.
charts,
reached; and
tables, notes,
references,
or other physical
quality indicators
included
in the
Information Sources Section III lists major sources of information on health care program research. In most cases, these represent organizations provided information for this bibliography.
that
The "Sources of Information on Health Care Programs" list includes organizations that either conduct or sponsor health care program research. It also includes other organizations that served as information sources for the bibliography. Addresses are included for each organization as are the titles of periodicals published by each. This list is divided into six parts:
ix
• • • •
Educational Institutions, Research Organizations Trade and Professional Associations Federal Government State Governments
and Foundations
• Indexes and Clearinghouses • Publishers The "Source List of Health Care Program Periodicals" list includes the periodicals that served as major sources of citations for the bibliography. It also includes other periodicals and newsletters that served as secondary sources of information on research in the health care program area.
Indexes Four indexes are provided to assist in using this bibliography. Each index lists the title and abstract number of each relevant citation, which should enable the user to identify items of interest quickly. Abstract numbers 8000 and higher denote research in progress and are contained in Section II. The indexes included are: Section IV - Author Index Section V - qStle Index Section V1 - Sponsoring Organization Sectiotl VII - Subject Index
Index
The subject index is intended to help the user locate citations on particular topical areas. Research on health care programs was divided into 14 major subject categories for the purposes of this bibliography. These categories are indicated in bold face in the following listing. For each major subject category; subcategories were developed to permit more specificity in indexing each citation. If a particular topic did not fit into one of the subcategories, it was indexed according to its corresponding major subject category. For instance, there is no separate indexing term for Veterans Health Benefit Programs. Research on this subject is indexed under the major category "Publicly sponsored/mandated health plans." In other instances, research covered a broad range of topics. In this case, the citation was indexed by major subject category only rather than using a larger number of more specific terms. Therefore, in general, the major subject categories will either contain citations that present broader information or citations that report on topics of lesser importance to this bibliography. Cross-indexing is possible if the user compares the citations listed under individual headings. For instance, the "Prepaid plans" term lists all citations that discuss any aspect of this type of health plan. The "' Preventive services" term lists all citations that discuss this topic. To find out about publications that discuss preventive services in prepaid plans, the user would look for the citations that are listed under both indexing terms. This type of cross-indexing is possible with any combination of indexing terms. Following is a listing of indexing terms developed for this bibliography. They are listed in major category/subcategory order. The body of the subject index, however, lists these terms in alphabetical order to assist the user. Explanatory notes are also provided to clarify the definitions of particular indexing terms. Characteristics
of U.S. Health Care System
Demographic features of population - specific information on age, sex, race, income, etc. Demand_utilization o{ health care programs Trends in health status -. information on disease trends, incidence, rates Health information_data systems - information networks, data bases, statistical surveys, etc. Health Care Costs Health care cost trends/prolections Cost_benefit analyses Cost containment efforts - also cost control, cost reduction Economic/Commercial Influences - economic, market or external influences on health care demand, utilization and cost, including malpractice, health planning, etc. Supply/availabili O' of services - manpower paraprofessionals, etc.
development,
problems of maldistribution,
physician competition,
Medh'al teehnology impacts - technology assessment, cost of new products, etc. National economk' conditions - influences of external economic conditions such as unemployment,
new
inflation, etc.
Third Party Payors - overviews of public and private health care providers of payment Health insurance industry Economics of third party payors - analyses of the structure/economics of the field Competition/interaction among third party payors Impact of third party coverage - upon health care services/providers/users Private Health Care Plans - specific types of health care plans Commercial health insurance plans - private insurers Service benefit plans - nonprofit insurers, Blue Cross/Blue Shield Prepaid plans - health maintenance organizations, individual practice associations Government employee plans - private insurance for employees of Federal/State/local governments Nonemployment-related plans - association plans, medigap policies, dread disease plans, malpractice recovery, etc. Publicly Sponsored/Mandated Health Plans. Veterans benefit system, CHAMPUS - Civilian Health and Medical Program of the Uniformed Services, U.S. Public Health Service, State-mandated health insurance and disability programs, etc. Medicare Medicaid Workers' compensation Participation in Health Care Programs Participants in health care programs Eligibility requirements - for coverage, benefits Nonparticipants in health care programs - the non- covered population Health Care/Services - with respect to coverage/noncoverage Medical_surgical services Diagnostic services - X-ray, laboratory tests, etc. Dental services
by health care programs
Mental health services - also includes alcoholism and drug abuse services Preventive services - routine physicals, vaccinations, weight control, smoking cessation, health promotion programs Therapeutic services - physical therapy, treatment for chronic conditions, medical appliances and devices Pharmaceutical services - drugs and medical supplies Hsion/hearing services Hospital services Home health services Facilities Providing Health Care Inpatient facilities - short-term, acute care hospitals Outpatient facilities - doctors' offices, clinics, surgical centers, etc. Intermediate care facilities - skilled nursing home, hospice Long-term care facilities Plan Design/Program Provisions - under health plans Deductible/co-insurance Reimbursement - fee schedules, per diem rates, etc. Limitations on coverage - maximum benefits, dollar/day limitations, etc. Exclusions from coverage - who or what is excluded from coverage Mandated benefits - benefit plan provisions required by State law Funding/Financing of Health Care Programs - financial support of health care programs, includes rate setting, provider reimbursement, etc. Premium determination_underwriting Claims administration - as it relates to cash flow, financing Source of premium payment - entity responsible for paying premium, the employer or employee role, public funding sources Methods of payment determination - how payments to providers are determined; i.e., prospective reimbursement, rate review, capitation reimbursement, etc.
xi
Providers of Health Care Services Physicians Nurses Allied health professionals
- characteristics,
- nurse practitioners,
behavior of providers
physician assistants,
etc.
Policy/Changes re Health Care - present/proposed methods to change or control the health care system Present legislation_regulations - effects of existing legislation, tax treatment, regulations Voluntary initiatives - private sector efforts at cost containment, health promotion, etc. Policy initiatives - recommendations for changes to present legislation/regulation or for new programs National health insurance ( NHI) Comparisons regarding foreign health policies - as the foreign experience applies to the U.S. Evaluations/Outcome of Health Care Programs Comparisons of health care programs Outcome_evaluation of quality assurance - studies to evaluate the quality of health care or programs Outcome_evaluation of health administration - studies to evaluate the efficiency of health administration, organization
xii
management,
I. Completed Research 1. Access to Ambulatory Care and the U.S. Economy.
Descriptor(s): National economic conditions, Outpatient facilities, Supply/availability of services, Medical/surgical services.
Frank A. Sloan and Judith D. Bentkover. Policy Analysis, Inc., Brookline, MA 02147 National Center for Health Services Research, Hyattsville, MD.
2. Aeeeu to Medical Care for the Elderly. Do Non-Price Barriers Matter.
1979, 174 pp. Availability:
D.C. Heath and Co., Lexington,
MA 02173.
Robert Lee. Urban Inst., Washington, DC 20037 Administration on Aging, Washington, DC.
This study was designed to gauge the impact of adverse economic conditions of the late 1970's on patient access to ambulatory care. It sought to ascertain if the gains of the past decade in mainstreaming public access to health care services through programs such as medicare and medicaid have been reversed during the recent economic adversity and if low-income groups have been predominantly affected by such a reversal. The emphasis was on ambulatory care because of the physician's "gatekeeper" role in the health care system and because of the current trend to overutilize hospitals. The study also sought to advance the state-of-the-art of research on access to ambulatory care. The study consists of a review of pertinent literature on patient access to ambulatory care, analysis of time series and cross-sectional evidence Ofa descriptive nature, and multivariate analysis. Data utilized derive from 1969-1975 Health Interview Surveys and a 1975 medical access study by the University of Chicago. The following indicators were subjected to analysis: physician visits, physician visits relative to health status measures, the patient's tendency to have a usual source of physician's services, the patient's frequency of having encountered one or more problems in obtaining medical care, unmet needs reported by patients, the patient's choice of physician provider, length of patient waits in physician's office, length of time the physician spent with the patient during a recent visit, and the delay between the time the patient made an appointment and the actual visit. Viewed in its entirety, the evidence showed a definite link between the performance of the economy on the one hand and patient access to physician's services on the other. However, the effects of the former on the latter axe not dramatic. It is not to be expected that future periods of inflation and recession will result in a total reversal of the gains in access realized during the preceding decade. One figure, tables, chapter notes, an index, and an appendix delineating wage and income variables are provided,
Apr 1978, 34 pp. AvMlabih'ty: Urban Inst., Washington,
DC 20037.
This paper reviews barriers other than cost that the elderly face in seeking medical care. These barriers include travel time, office waiting time, transportation costs, appointment waiting time, and time required for diagnosis and treatment. Analysis to date does not allow firm conclusions about the access problem, primarily because available evidence and data are limited. The literature provides an inadequate basis for assessing access problems faced by the elderly, since aggregate comparisons may disguise problems confronting specific elderly population subgroups. For purposes of this analysis, health status is a primary determinant of the use of medical services. Variables affecting use of services focus on income, living arrangements, feasible modes of transportation, and age. An assessment of access to care for the elderly or subgroups of the elderly poses three problems. The problems include establishment of a concept of optimal or needed care, determination of how older people differ from younger people when seeking outpatient care, and measurement of the importance of access barriers. For study purposes, it is assumed that a particular group uses services appropriately, and other groups are compared with it. In addition, a panel of physicians assessed needed care, given certain symptoms. Study data do not confirm the theory that, on the average, older persons face more substantial nonprice access barriers than younger persons. Nevertheless, it is fair to conclude that access to adequate medical care is a major problem for many potpie. It is therefore recommended that the distribution of medical personnel be improved and that both educational and financial changes be made to encourage the provision of ambulatory and home medical care. Diagrams, 14 tables and 27 footnote references are included.
I-1
Working Paper 5904-6.
Descriptor(s): Economic/commercial bility of services.
4. Achievements and Problems of Medicaid.
influences, Supply/availaKaren Davis. Robert Wood Johnson Foundation, Princeton, NJ. 1976, 8 pp. A vMlability. Public Health Reports v91 n4 p309-316 Jul/Aug 76.
3. Access to Medical Care. The Impact of Outreach Services on Enrollees of a Prepaid Health Insurance Program.
Paala K. Diehr, Kathleen O. Jackson and M. Fickle Boscha. National Center for Health Services Research, Hyattsville, MD. 1975, 15 pp. Availabih'ty: Jnl. of Health and Social Behavior v16 n3 p326340 Sep 75. The impact of outreach services on access to medical care for a group of families and individuals enrolled in two prepaid health insurance programs is examined in this study. Outreach semces have been introduced in many programs designed to increase access of the poor to medical care, but few controlled studies have examined their impact. Here, low-income families enrolled in either the Group Health Cooperative of Puget Sound or the King County Medical plan were assigned at random to two groups. Both programs offered very comprehensive benefits. The two groups received free medical care and, in addition, one group received outreach services. Comparison of the families after 1 year of service revealed that the outreach group was significantly more likely to utilize and to report utilization, more likely to have physical examinations, and more likely to know about and to utilize support services, such as child care and transporation assistance. When the racial composition of the groups was considered, it appeared that the outreach-nonoutreach differences occurred for black enrollees and not for whites, possibly due to the largely minority racial composition of the outreach workers. Findings may not be applicable to other outreach programs for several reasons. First, the individuals enrolled in the program were not typical poverty individuals, since most were employed and had incomes above the poverty level, .¢,econd, specific aspects of outreach activities that were effective in increasing access were not identified. Third, the impact of outreach on the provider systems was not addressed. With these reservations, the data do support the concept that outreach services played a role in facilitating access to the medical care offered by the programs studied. Seven tables and 21 references are provided.
Descriptor(s): Prepaid plans, Demand/utilization of health care programs, Supply/availability of services_ Participants in health care programs.
I-2
This article summarizes the achievements and problems of medicaid, explaining the reasons for its high cost, the progress made over a decade of program operation, the problem of inequitable distribution of medicaid benefits, and areas for future reform of the program. Underlying reasons for the high costs of medicaid include the fact that the number of recipients of medicaid setvices has increased from 9 million in 1967 to 23 million in 1976; that medical care costs in the United States are generally high, regardless of medicaid coverage; and that medicaid has assumed the responsibility of meeting the health care costs of many elderly and disabled persons confined to nursing homes. Statistical evidence indicates that medicaid has succeeded in meeting its primary objectives of access to medical care by the poor: in 1964, persons with high incomes saw physicians about 20 percent more frequently than did the poor; by 1974, low-income persons were visiting physicians 13 percent more frequently than the rich. Dimensions of health status of the poor were improved: infant mortality declined as did the high death rates of low-income groups, rates that were attributable to certain diseases. The greatest deficiency in the medicaid program is that it does not treat people in equal circumstances equally. The inequitable distribution of medicaid benefits is caused by the joint Federal-State nature of the program and by the fact that a financing program is not effective in overcoming the nonfinancial barriers to medical care that certain disadvantaged groups face. Due to the program's complex restrictions and differences among states, it is estimated that as many as 40 to 50 percent of the poor population is not covered by medicaid at any given time, while 30 percent of medicaid recipients have incomes above the poverty level. Moreover, payments are lower for black recipients and rural residents, and data for all these inequities are inadequate for full documentation of their extent. Proposals for reform, whether they espouse broader State authority, federalization of medicaid, or its integration within national health insurance, should be debated in terms of the underlying causes of current problems in the medicaid program. Fifteen references are provided.
Earb'er version of this paper was presented as testimony before the Committee on Interstate and Foreign Commerce, Subcommittee on Health and the Environment (_.S. House), February 4, 1976.
Health Care Programs
Descriptor(s): Medicaid, Policy initiatives, Demand/utilization of health care programs, Present legislation/regulations, Participants in health care programs, Outcome/evaluation of quality
6. Achieving O0timum Utilization Annotated Bibliography.
assurance.
JoAnne DuCbez and Marion Torchia. National Health Standards and Quality Information Clearinghouse, Kensington, MD/20795 HCFA/PUB/HSQB-81/30044 Oct 1980, 99 pp.
5. Achieving Cost-Effective
Practice in a Prepaid Plan.
John K. TiUotson and Gerald B. Meier. • 1979, 4 pp. Availabih'ty: Medical Group Management p44,46,48,49 May/Jun 79.
v26 n3
Procedures for cost containment in a health maintenance organization (HMO) are described. Because HMO's guarantee comprehensive ambulatory and hospital benefits at a fixed price, cost containment is essential to the survival of an HMO. Many strategies exist for cutting HMO costs, including the selection of less expensive hospitals and other providers, the negotiation of discounts on hospital and other institutional charges, and the employment of ancillary professionals. The most significant savings in an HMO, however, are generated by changing the number and mix of hospital services, rather than by more efficiently producing given services. The major determinates of hospital use within an HMO focus on population characteristics, hospital operations, and physician practice patterns. An HMO can favorably impact its use of hospital services by either selecting a healthy subscriber population or by modifying the use decision and needs of the enrolled population. The extent to which a hospital operates cost effectively will also affect HMO hospital expenditures, In addition to selecting more cost-effective hospitals, HMO's may be able to modify hospital operating practices by negotiating discounts or risk arrangements, or by persuading a hospital to implement use review programs. Hospital use by HMO physi-
of Ancillary Services. An
Availability: National Technical Information field, VA 22161, PB81-147860.
Service, Spring-
This annotated bibliography is a collection of literature that (1) analyzes the problem of misuse of ancillary health services and (2) suggests solutions to the problem. It is intended for an audience directly involved in professional standards review organizations (PSRO's) and similar quality assurance activities, and also for persons with a more general interest in the underlying health policy issues. Included in the first category of literature are discussions of indications for various services, descriptions of utilization patterns, analyses of practitioners' motivations in prescribing services, and discussions about the effect of financial incentives. Included in the proposed solution category are models of quality assurance programs, descriptions of ongoing programs, criteria to be used in review, discussions of the value of education, descriptions of educational programs, and proposals for reform of pricing and reimbursement systems. In addition to a preliminary section containing general overviews of the subject, the bibliography is divided into three major sections, corresponding to three major settings where PSRO review is being implemented: the acute care inpatient setting, hospital-based outpatient facilities, and long-term care facilities. Within these settings, citations have been grouped according to categories of diagnostic and therapeutic services. Approximately 200 citations are made of literature published in the 1970's. Author and subject indexes are provided. (NTIS abstract)
Second F__'tlbn.
cians can be reduced through incentives to limit hospital use, such as a reward accruing to the HMO or the individual physician for controlling hospital use. Selecting cost-effective physicians for participation in an HMO is also an effective way for containing costs. The most effective ways for nurturing physician cost-containment behavior are peer interaction and the establishment of medical leadership with a strong cost-effectiveness orientation.
Dtm:riptor(s): Demand/utilization of health care programs, Diagnostic services, Outcome/evaluation of quality assurance, Therapeutic services, Facilities providing health care.
Descriptor(s): Cost containment efforts, Prepaid plans, Hospital services, Cost/benefit analyses, Demand/utilization of health care programs.
John K. Iglehart. 1978, 5 pp. Availability: National Jnl., v40 nl0 p1602-1606 Oct 78.
7. Adding a Dose of Competition try.
to the Health Care Indus-
I-3
This article reports on recent efforts by the Federal Trade Commission (F'I'C) to apply antitrust laws and tests to the health care industry. The FTC became involved in the health care field in 1975 largely as a result of a series of Supreme Court decisions which held that professional groups, such as the American Medical Society (AMA), are not exempt from antitrust laws and hence should not be allowed to limit competition through pricefixing and other schemes. The relentless rise in the cost of medical care added to the determination of the F-tiC. The FTC decided to treat the medical professions as businesses and to control costs in the health care sector by introducing competitive, marketplace influences into its practices. FTC efforts have been directed to three areas so far: physician advertising, medical fees, and domination of Blue Shield boards by physicians. Complaints have been f'ded against the AMA and the American Dental Association arguing that bans on advertising restrain free trade, The Antitrust Division of the Justice Department has joined in this effort. Physician fees have come under scrutiny through efforts by the FTC to ban relative value scales, which the FTC
protection against large absolute medical expenditures and protection against relatively large out-of-pocket expenditures compared to income. Most of the insured population is protected from large medical expenditures through private health insuranee or public programs. A smaller segment of the insured population is protected by limits on out-of-pocket expenses or by multiple forms of coverage. A public opinion survey conducted by the Health Institute found that the public is generally satisfied with health insurance. Seventy-three percent of respondents were satisfied with the promptness of claims payments, 72 percent were satisfied with the range of medical services and treatments covered by health insurance, and 71 percent were satisfied with the proportion of medical care costs paid by their health insurance. On the other hand, 57 percent felt there were serious problems with the health care system, and 2 percent felt that national health care or socialized medicine is the answer. Tables show distribution of health care expenditures, major medical coverage, and benefits. Seven references are provided.
claims to price Finally, setting by unit values for all medical lead procedures. the establishing FTC has moved to investigate the domination of Blue Shield boards by physicians, which, they claim, stifles competition. Each of these moves by the FTC is being contested strenuously, and the outlook is for a long-term controversy. Also, the FTC has taken the first step in a new direction by requesting information from health maintenance
Descriptor(s):
organizations regarding possible price fixing. Two tables summarizing the history of FTC actions are provided.
9. Administration's Program for Health Cost Containment.
Desc_ptor(s): Policy/changes re health care, Competition/interaction among third-party payors, Health insurance industry, Cost containment efforts, Physicians, Methods of payment determination.
8. Adequacy
of Private Health Insurance
Coverage.
Health Insurance Inst., Washington, DC 20006 1980, 9 pp. A vailabi/ity: Health Insurance Inst., Washington,
DC 20006.
This study discusses the adequacy of private health insurance coverage. It reports results of a previous study by the Congressional Budget Office (CBO) indicating that more than 90 percent of all Americans either had private health insurance coverage or were eligible for public programs that protected them to some degree from the financial losses associated with medical care. An estimated 5 to 8 percent of the population did not have such protection, and a higher percentage of those covered had "inadequate °' protection. The traditional measures of adequacy are
1-4
Health insurance industry,
Participants
in health
care programs, Private health care plans, Plan design/program provisions (under health plans).
Leonard D. Schaefer. 1979, 10 pp. AvMlability: Bulletin of the New York Academy v56 nl p9-18 Jan/Feb 80.
of Medicine
Reasons for lack of support of Government health care programs as well as responsibilities and activities of the Health Care Financing Administration (I-ICFA) in health care cost containment are discussed. The HCFA is charged with administering medicare and medicaid and with operating the Standards and Certification program, quality control programs, and others. In fulfilling this role, the agency has become the third largest in the Federal budget; 5 percent of the agency's costs go to administration and 95 percent to benefits. The goal of the agency is to facilitate appropriate interaction between people who need help and the providers of services in a timely and cost-effective manher. However, the work of the agency has become more difficult because of public scepticism about how major health programs are operated. The public in general lacks faith in Government, in part because many of the Government programs were created at a time of optimism about the Government's ability to solve problems; unrealistically high public expectations were subsequently disappointed. Public confidence has been further eroded by examples of fraud, waste, and abuse and by a slowing in the
Health
Care Programs
growth rate of tax receipts. Attempts to administer Government programs effectively are hindered by the uncoordinated health care delivery system and by the uncontrollable inflation rate. Legislation has sought to impose semimandatory limits on hospital growth, enforced by withdrawal of Government reimbursemerit funds. The HCFA has attempted to improve its program administration and cost effectiveness by combining medicare and medicaid administratively, by creating an Office of Health Regulations to review the impact of all regulations in the health care field and to identify problem areas, and by forming an Office of Professional and Scientific Affairs to maintain relations with professional organizations. Other proposed measure, include reform of the medicare physician reimbursement and assignment
in medicare administration. The combination of both findings indicates that the Plans are more efficient or had lower costs than the commercials. Further, both the Plans and the commercials were found to have experienced economies of scale in medicare administration. Although this fmding contradicts some previous study findings where only the commercials were observed to have economies of scale, the current finding appears to be more consistent with the Plans having lower administrative costs and with the proposal by previous authors for the merger of Blue Cross and Blue Shield plans in order to reduce costs and capture the economies of scale. Tabular data and 14 reference notes are provided.
systems, initiation of a system uniform financial reporting for all Government-funded health of institutions, and establishment of a new child health strategy to improve health care delivery to poor children. The need for involvement of the public and providers in the regulatory process is emphasized.
Descriptor(s):
Commercial health insurance plans, Service bene-
fit Cost/benefit of plans, health Medicare, administration.
analyses, Outcome/evaluation
This article was presented as part of the 1979 Annum Health Conference of the New York Academy of Medicine held May 10 and 11, 1979.
11. Age and Medical Care Utilization
Descriptor(s): Outcome/evaluation of health administration, Cost containment efforts, Publicly sponsored/mandated health plans, Policy/changes re health care.
Marie R. Hang. National Center for Health Services Research, Hyattsville, MD. 1980, 9 pp. Availabih'ty: Jnl. of Gerontology v36 nl p103-111 Jan 81.
10. Administrative Costs of Medicare Contractors. Cross Plans Versus Commercial Intermediaries.
Blue
Kuo-cheng Tseng. 1978, 8 pp. Availabih'ty: Inquiry v15 n4 p371-378 Dec 78. The efficiency of Blue Cross plans (Plans) and commercial intermediaries (commercials) in their administration of the medicare part A program is compared. The measures of administrative costs were net administrative costs per bill, claims-related costs per bill, service-related costs per bill, and provider audit and reimbursement costs/provider. Tests of equality of variances and means for the cost measures were conducted. Uncontrollable factors that have significant impact on costs were identified, and tests of equality between two sets of regression coefficients in two linear models were performed. It was found that during fiscal year 1976, the Plans had significantly lower net administrative costs per bill and claims-related costs per bill, but higher provider audit and reimbursement costs per provider than the commercials. Results also implied that the Plans and the commercials faced virtuallythesameuncontroUableenvironmentasexpected
Patterns.
This article reports a study investigating utilization patterns of older (over age 60) as compared to younger persons. Data were obtained from a random national sample of 1,509 persons aged 18 and above. Respondents were questioned on consumer attitudes and health care utilization appropriateness. They were asked to report visits for general checkups in the absence of symptoms, treatment of acute conditions, and treatment for new symptoms. Respondents were also presented with a list of 10 common ailments and asked if they had experienced them and contacted a doctor. Five of these involved symptoms which a physician panel had agreed would not require medical system contact; another five symptoms were deemed requiring medical attention. Respondents also dichotomized any reported syruptoms as serious or nonserious. In addition, utilization measures assessed the extent of preventive health care. Indexed responses to nonserious ailments categorized utilizers as appropriate or as overutilizers; responses to serious ailments categorized respondents as appropriate or as underutilizers. Control variables ineluded age, sex, marital status, family social class, and health knowlege. Also measured were attitudes questioning a doctor's authority, which indicate a consumerist approach to health care. Findings revealed that older persons are more likely than younger persons to overutilize the health care system for minor ailments, but they axe similar to the younger group in
I-5
underutilization
for conditions
which should receive a doctor's
ism treatment.
Increasing numbers of private insurance
carriers
attention. This finding of overutilization for trivial complaints among the older population, particularly women, whites, and those of higher social class and lower health knowledge, suggests that secondary gains may indeed account for some of the heavy load placed on the health system by the elderly. The analyses also point to the importance of lower health knowledge in both unnecessary physician contacts and avoidance of contact when it would be. advisable. A need to educate the aging puplic on the more common symptoms to reduce overutilization through selfcare is implied. Tables, footnotes, and 14 references are provided.
are providing coverage. Increasingly comprehensive alcoholism benefits, including treatment in special inpatient centers, are being offered by individual Blue Cross plans. In addition, 20 States have enacted legislation either mandating that alcoholism coverage be provided or requiring that it be available as an option. In the public sector, benefits include medicaid programs which often ignore treatment for alcoholism, the Supplemental Security Income Program (title XVI of the Social Security Act) that employs sanctions against the alcoholic who fails to stay in treatment, and provisions for alcoholism treatment in l0 States under title XX of the Social Security Act. A final chapter discusses research and prevention. Summaries are given for each
Revision of a paper presented at the Annual ScientitTc Meetings of the Gerontological Society, Washington, DC, Nov 1979.
chapter and tabular data are included.
Descriptor(s): Demand/utilization of health care programs, Medical/surgical services, Preventive service, Demographic features of population.
12. Alcohol and Health. Ernest P. Noble. National Inst. on Alcohol Abuse and Alcoholism, MD 20857 DHEW/PUB/ADM-78/569 Jun 1978, 98 pp. Availability: National Inst. on Alcohol ism, Rockville, MD 20857.
Rockville,
Descriptor(s): Mental health services, Publicly sponsored/mandated health plans, Private health care plans, Present legislation/ regulations, Trends in health status, Funding/financing of health cart; programs, Mandated benefits, Exclusions from coverage.
13. Alcoholism Program Management Through the Operation of a Computerized Information System. I. Actuarial Data on Utilization of Services.
Abuse and Alcohol-
This report incorporates the most significant findings of recent research in the field of alcoholism and outlines the growing trends of occupational alcoholism programming and the fmancing of alcoholism treatment services. Individual chapters cover alcohol use and alcohol-related problems; special population groups; biomedical consequences of alcohol use and abuse; interaction of alcohol and other drugs; psychological effects; genetic and family factors relating to alcoholism; alcohol-related accidents, crime, and violence; and treatment of alcoholism and problem drinking. The report states that between 1950 and 1973 the number of occupational alcoholism programs for early identification and intervention of alcoholic employees expanded from around 50 to an estimated 500. By mid-1977, however, nearly 2,400 public and private organizations had some type of program. Until recently, insurance carriers were reluctant to cover treatment of alcoholism, but the trend is changing. For example in 1972, approximately 25 percent of all Blue Cross plans specifically excluded treatment of alcoholism; by 1976, only 4 out of 60 plans responding to a survey excluded alcohol-
1-6
Third special report to the U.S. Congress from the Secretary of Health, Education, and Welfare.
Dick Gregory and Alfonso Paredes. National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD. 35 1977, pp. Availability: National Inst. on Alcohol Abuse and Alcoholism, RockviUe, MD 20857.
The State of Oklahoma has 56 alcoholism treatment centers; 28 of these programs are monitored by the Oklahoma Department of Mental Health through the Contract Management System (CMS), a computer information and management system. This paper describes the patterns of utilization of services observed among employed patients in programs monitored by the CMS between July 1974 and June 1975, the first year of CMS operation. For this study, a data base derived from 22 of the 28 facilities was used. The monitored programs rely primarily on State grant funds for support, as compared with nonmonitored facilities which depend on Federal funds. The eight major service modalities specified in the CMS manual include evaluation, referral, paraprofessional counseling, medical and nonmedical detoxification, residential care, professional individual and
Health Care Programs
group counseling, and followup. Monitored programs have a greater proportion of available services than nonmonitored groups, and patient to staff ratios are lower for monitored programs. Over 2,200 persons were contacted by the 22 programs during the study period. Of this number, 1,627 (71 percent) were admitted for treatment, and 29 percent of these admitted patients reported being employed at the time of admission. The 467 employed cfients included white males (63 percent), white females (7 percent), nonwhite males (26 percent), and nonwhite females (4 percent). The sample reported an average of 11.6 years of education and 9.5 years of heavy alcohol consumption,
family members affected by misuse of alcohol by one member. Other target populations include the employee and consumer groups that form the marketing effort of the plan. Prepaid group plans may also elect to establish their own occupational programs to assist their employees and membership in identifying and treating alcohol abuse manifested within the workplace. The varying modalities which may be used in alcoholism treatment include emergency care and detoxification, inpatient services, intermediate care services, outpatient services, residential treatment, followup and aftercare, outreach and prevention, and consultation and education. The evaluation of treatment
Concerning health insurance coverage, 36 percent indicate having no insurance, 53 percent reported having health insurance, and 11 percent were unsure of their insurance status. Craftsmen represented the largest occupational group, followed by service workers and laborers. Types of treatment services provided may be divided into the three categories of evaluative services, inpatient services, and counseling services. Evaluative services were the least used and counseling services were the most used of the three. Ten tables and appendices of related data are provided,
effectiveness should be included in the prepaid plan's quality control efforts. Data components likely to be used in any evaluation of treatment focus on characteristics of the treatment population, service use, and data for assessing program results. Planning for implementation of an alcoholism treatment program will involve determining treatment needs of the target population, establishing objectives, selecting a service defivery configuration, developing policies and procedures, and establishing staffing requirements and a training program. A glossary, footnotes, about 160 references, and appendices presenting a
National Inst. on Alcohol Abuse and Alcoholism Health Insurance Resource IO't.
sample needs assessment survey and other sample forms are included.
State Activity.
Descriptor(s): Demand/utilization of health care programs, Mental health services, Health information/data systems, Participation in health care programs.
Revision
o£an mrh'er ech'tion published
February
1977.
Descriptor(s): Prepaid plans, Mental health services, Outcome/ evaluation of quality assurance.
14. Alcoholism Services Handbook for Prepaid Group Plans. 15. Alcoholism Within Prepaid Group Practice HMOs. Group Health Association of America, Inc., Washington, DC 20036 National Inst. on Alcohol Abuse and Alcoholism, Rockville_ MD. Mar 1979, 83 pp. Availability: Group Health Association Washington, DC 20036.
of America, Inc.,
This handbook discusses areas of consideration for prepaid group plans in assessing the feasibility or necessity of developing alcoholism treatment services. It is written from the perspective of the prepaid group plan administrator. Alternate approaches to development are examined, as are the various treatment modalities themselves. Alcoholism is currently recognized by most professionals in the health field as a treatable disease. The necessity for a continuum of care which addresses medical, psychological, and environmental aspects of the patient's situation is emphasized. In a prepaid plan, the target population should be viewed in a broader perspective, taking into consideration all
Thomas G. Boyajy. Group Health Association 20036
of America, Inc., Washington,
DC
National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD. Dec 1978, 187 pp. Availability: Group Health Association of America, Inc., Washington,
DC 20036.
Results are reported from a 4-year research and demonstration project that (1) implemented and documented comprehensive alcoholism treatment serviees in three representative prepaid group practice plans in different regions of the country and (2) collected and analyzed socioeconomic and treatment outcome data, as well as patient health service-nse data on a 2-year retrospective and ongoing basis for identified alcohol abusers at each of the plans, including family members at one of the sites. The patient profile information was collected through a self-report
1-7
instrument administered at intake and at 6-month intervals throughout the project. Data items include basic demographics, referral source, quantity-frequency consumption of alcohol, number of years of heavy drinking, periods of abstinence, prior treatment, employment, and rates of absenteeism. The health plan use data collected at each site consisted of each encounter with the health care system up to 2 years prior to entering treatment and on a continuing basis throughout the study. Data items include provider type, place and type of encounter, presenting and associated morbidities, and treatment procedure if the encounter was specifically for alcoholism treatment. Additionally, the project documented the programmatic components of each treatment program, collecting information on such factots as staffing patterns, organization of services, patient flow, treatment philosophy, marginal staff and administrative costs, and descriptions of the overall health plan. Data show iml:,rovement in patients in a number of dimensions through the first 18 months following intake, such as a 75 percent overall reduction in alcohol consumption, 60 percent extension in longest period of abstinence, 55 percent reduction in absenteeism, and over 90 percent reduction in reprimands at work. The degree of improvement strongly correlated with the number of treatment encounters. Limitations on the generalization of the findings are discussed. Appended are data collection instruments, definite and related alcoholism diagnoses, a description of the Genesec Valley Group Health Association project (New York), a cost study summary, and a description of the technical assistance program. Tabular data and 37 references are provided, Desctiptor(_): Prepaid plans, Mental health services, Participants in health care programs, Evaluations/outcome of health care programs, Demographic features of population,
16. Allocation of Physicians' of-Visit.
Services.
Evidence on Length-
shift variables (insurance coverage, patient income, physician credentials, physician/population ratio, and demographic variables); (2) exogenous cost-function variables (the aggregated price of a standard group of medical office employees, the presence of children in the physician's household, and sources of physician income other than medical practice); and (3) standardizing variables ("dummy'" variables which limit the effects of diversity resulting from such differences as group versus nongroup practice). Two measures of the dependent variable were employed: (1) time spent per patient visit by the physician alone, and (2) a construct of physician equivalent time per patient created by combining physician time with weighted values of aide time. Data to test the general model and the explanatory power of the independent variables were derived from a 1973 mail questionnaire survey of office-based physicians conducted by the American Medical Association (AMA); supplemental items were drawn from _.heAMA's bibliographic file on U.S. physicians and from the 19/0 U.S. Census of Population. Statistical analysis of the data show that all three explanatory variables impacted positively, but to different degrees, on length-of-visit. Especially important were amount of insurance coverage, family income, physician credentials, and physician age, higher values of all of which were associated with increased physician time per patient visit. Of the cost-function variables, only the aggregated price of a standard group of medical office employees related positively with length-of-visit. Number of children in the physician's household was negatively correlated with the dependent variable, and other sources of income showed no correlation. Twentyfour footnotes, 36 references, and 2 tables are provided.
DesclT"ptor(s): tS:ost/benefit analyses, Physicians, Impact third-party coverage, Supply/availability of services.
17. Altering Medicaid Provider Reimbursement
of
Methods.
Fiank A. Sloan and John H. Lorant. Florida Univ., Gainesville, FL 32601 National Center for Health Se_ices Research, Hyattsville, MD. 1976, 19 pp. Availability: Quarterly Review of Economics and Busines,; vl6 n3 p85-103 Autumn 1976.
John Holahan, Bruce Spitz, William Pollak and Judith Feder. Urban Inst., Washington, DC 20037 UI-986/14 National Center for Health Services Research, Hyattsville, MD. Ford Foundation, New York, NY. Jun 1977, 215 pp. Availability: Urban Inst., Washington, DC 20037.
This study is concerned with patient length-of-visit in the physician's office as one variable of a general optimizing model of the allocation of physician's services. The model assumes that physicians' decisions on dependent variables, such as length-of-visit, are based on three explanatory variables: (1) exogenous demand-
This paper, focusing on provider reimbursement, is the third in a four-part series on alternative strategies for controlling the costs of State medicaid programs. The series is a systematic examination of State options which are permitted by Federal regulations and those which would improve the efficiency of the
I-8
Health
Care Program_
programs. It sets forth cost containment issues and options regarding medicaid eligibility, benefits, provider reimbursement, and utilization controls and addresses possible changes in Federal regulations and financing mechanisms which might improve State management of medicaid. This paper begins by providing an analysis of existing systems for reimbursing physicians, addressing both administrative difficulties involved with the iraplementation of alternative systems and the incentive effects generated by them. The two main reimbursement systems now used by State medicaid programs are customary and prevailing charge reimbursement and fee schedules. Options available to States include placing limits in the rate of increase of reasonable charge screens, defining prevailing charges as a lower percentile than the 75th, failing to update physician profiles, and freezing fee schedules. The effectiveness of such options clearly depends on provider response. The paper then examines the problems involved in payment to hospitals. Several potentially attractive cost control options are suggested, including a uniform fee schedule, a variable fee schedule, inclusive rate setting, and a fixed budget for all hospitals or cost-based reimbursement to a limited number of high-volume medicaid hospitals. A wide range of issues focusing on long-term care facility reimbursement are then considered. It is argued that systems of reimbursement can be logically divided into those which relate payment rates to the costs of the specific facility and those where reimbursement levels are independent ofthecost ofthe facility. Suchaelassification system is presented and it is recommended that Federal policy should not restrict States to a narrow group of reimbursement alternatives. Finally, analysis of medicaid policy with respect to health maintenance organizations (HMO's) is discussed. In this regard, it is suggested that States must first address the issues of HMO marketing, utilization of services, disenrollment of enrollees, and grievance procedures. Reference notes, total 215. (Author abstract modified)
Descriptor(s): Cost containment efforts, Medicaid, Long term care facilities, Methods of payment determination, Physicians, Outcome/evaluation of health administration, Reimbursement.
able change has taken place mainly in ratios of auxiliary personnel to dentists, the size of dental practices, and the source of fees through increased third party payments. However, serious gaps in the acc.e_ibility of dental care to many people and in the application of preventive dental procedures, as well as a desire to control costs, have stimulated the development of alternative delivery systems. Because oral diseases are almost universal, population-based rather than exclusively patient-based systems have been proposed to close some of the gaps. These include capitation or prepaid group practice and school-based programs. Individual programs have demonstrated that these systems can be both effective and efficient. School-based dental nurses have proven their worth in Canada. Other alternative systems include hospital-based programs using outpatient dental clinics, cornmanity health centers located mainly in urban areas, independent community dental care programs, as well as systems directed at the armed forces, veterans, Native Americans, and prisoners. One approach to the defivery of dental care is "den_udsm,' a practice which has become legal in several States. Denturists are nondentists who perform all services for the construction and fitting of full dentures. These professionals have been legal in Canada for several years. They practice independently and have their own standards of certification. The threat of widespread legalization of denturism in the United States has r_ulted in actions by organized dentistry to develop low-cost denture programs for the elderly. However, the long-term effects on both cost and quality of denturists' activities are still unknown. A total of 17 references are provided. (Author abstract modified)
Descriptor(s): Dental services, Outcome/evaluation of quality assurance, Comparisons regarding foreign health policies, Supply/availability of services.
19. Altea_ative Physician Payment Methods. Incentives, cieney, and National Health Insurance.
Effi-
Jon R. Gabel and Michael A. Rediseh. 1979, 22 pp. 18. Alternative
Oral Health Service Defivery Systems.
AvMlabih'ty: Milbank Memorial Fund Quarterly/Health Society v57 nl p38-59 1979.
and
Max H. Sehocn. 1980, 10 pp. A eailability: Family and Community Nov 80.
Health v3 n3 p71-80
The traditional private practice, fee-for-service system of dental care in the United States has done much to improve the oral health of the American public. In the past few decades, consider-
This article assesses the effect of alternative physician payment methods on the physician's specialty and practice location choice, on the utilization of services and treatment setting, and on the efficiency of the pl_ysician's practice. The paper begins with a description of the three major physician payment methods; i.e., fee-for-service, capitation, and salary. Physician pricing behavior is then reviewed. The implications of alternative payment methods are then explored with respect to five dimensions
1-9
of medical practice: utilization of physician and nonphysician services, specialty choice, treatment setting, location decision, and efficiency of an individual physician's practice. The present and future role of physician reimbursement within the current Washington health policy environment is then addressed. The analysis emphasizes the fact that incentives embodied within physician payment systems profoundly influence both the physician and nonphysician sectors of the health care system. The existence of perverse incentives under the fee-for-service method is highlighted. It is concluded that physicians' demonstrated ability to influence the demand for their services retards efforts to change specialty and geographic distributions and to control the growth in physician and hospital costs. The absence of risk sharing encourages expensive and intensive institutional care. National health insurance (NHI) affords policymakers an op-
hierarchies, and patient-imposed limitations to the acceptability of alternative therapies and therapists. In addition, strings attached to special grants can change the character of free clinics, their social composition, and the treatment they offer. The usefulness of the free clinic as a safety valve and training facility may actually legitimize the current organization of health care. Free clinics provide an alternative form of care but cannot, in the long run, be a base for radical social change. Footnotes and 61 references are given. (Author abstract modified)
portunity to reorganize the health care delivery system on a more efficient basis. However, the omission of an NHI proposal for restructuring of the physician reimbursement system constitutes a costly omission. Five footnotes and approximately 35 references are included in the article.
21. Alternatives
Earlier
version of this paper was presented
nomic Association 14, 197Z
Meetings,
Hartford,
at the Eastern Eco-
Connecticut,
on April
Descriptor(s): Reimbursement, Physicians, National health insurance (NHI), Methods of payment determination, Medical/ surgical services, Demand/utilization of health care programs.
Descriptor(s):
Policy initiatives,
Outpatient
facilities.
to Nursing Homes.
Russell W. Hereford. National Conference of State Legislatures, Denver, CO 80202 Health Care Financing Administration, Washington, DC. Oct 1980, 20 pp. A vailability: National Conference of State Legislatures, Denver, CO 80202.
The manner in which long-term care is provided and financed
Rosemary C. R. Taylor. 1979, 27 pp. Availabilitv: International Jnl. of Health Services v9 n2 p227253 1979.
has become a major public policy issue only in the past 10 years. Long-term care is heavily dependent upon public funding, and it appears likely that costs will continue to escalate in the forseeable future. The social implications of long-term care are perhaps of even greater importance than the financial ones. A number of studies show that many persons admitted to nursing homes are there for social reasons. Elderly people prefer to live outside nursing homes, but the support services which would allow them to continue to lead lives outside institutions either do not exist in the community or are provided by so many uncoordinated agencies that the elderly cannot arrange for the help that they need. In reality, the Nation's long-term care system is biased toward institutions: medicaid and medicare benefits for noninsti-
This article examines the achievements of free medical clinics in the United States and assesses the viability of a political mobilization and reform strategy based on the provision of care by alternative social service agencies. The development of genuine alternatives to the contemporary American health care system is viewed as limited by the monopoly of organized medicine, the scarcity of funds for preventive care, a class-based health insurance system, and the inadvertent role of free clinics in legitimizing existing structures. American medicine is seen as constraining and shaping clinic activities through its control of certification, its specialist divisions and privileges, and its pervasive ideology. Free clinics' responses to these constraints can engender high worker turnover, the reproduction of medical
tutional care are limited, reimbursement rates to providers are low, and no provisions are made for long-term care outside of institutions. The elderly poor who are ineligible for medicaid coverage within the community can become eligible in a nursing home where a different income standard applies. Congressional activity in long-term care has focused on two bills introduced during the 96th Congress, H. R. 6194, The Medicaid Community Care Act; and S. 2809, The Noninstitutional Long-Term Care Services for the Elderly and Disabled Act. Community-based alternatives to nursing homes are clearly needed and justifiable in terms of both social and financial reasons. Six key issues need to be resolved prior to establishing new programs or expanding existing ones: the level and source of funding, limits of service, administration, determination of need, case management, and
20. Alternative
1-10
Services. The Case of Free Clinics.
Health Care Programs
coordination with existing services. Eight State programs for alternatives to nursing homes are discussed in detail: the Arkansas In-Home Services Program, Connecticut's TRIAGE and Project SAIL, New York's Nursing Home without Wails, Oregon's Project Independence, Texas's Community Care Program, Utah's Alternative Program, and Virginia's Preadmission Screening Program. One diagram is given. Health
Descriptor(s): Source of premium Hospital services.
payment,
Policy initiatives,
23. Ambulatory Care Systems. Volume IV. Designing cal Services for Health Maintenance Organizatioml.
Medi-
Care Cost Seminar held by the Hawaii LegYslature and
Hawau" Department
of Social Ser_ces
and Housing.
Descriptor(s): Long term care facilities, Policy initiatives, Source of premium payment.
22. Alternatives vices,
to Prepayment
Finance for Hospital Set-
Paul N. Worthington. 1978, 9 pp. Availability: Inquiry el5 n3 p246-254 Sep 78.
The prepayment principle - which resembles insurance premium payments, but is not -- fosters a belief in potentially unlimited service consumption and indirectly influences the cost of the covered event. Under this arrangement, the individual hospital's reimbursement of services (and expenses)makes waste and inefficient use of resources tmdetectable and eostless to the hospital, Moreover, actual budget restraints ofindividnais are not considered. To illustrate how the principles of capital markets can be applied to counteract the deficiencies of prepayment schemes, this article considers arrangements for a major subscriber group composed of a working population, such as a national labor union. Rather than including health benefits in a labor contract, one could establish a form of credit union in which yearly health premiums are credited for each employee. The worker could draw or borrow on the balance in order to pay hospital bills, Upon retirement, termination of employment, or death, the eraployee or the estate could collect the balance. This fund could be managed to increase proceeds, pay administrative expenses and perhaps, in time, credit dividends to positive account balances. Under this alternative, hospitals would have to deal directly with patients in arranging for bill payment; implications for efficiency and competition are cited. This credit union scheme, with certain modifications, could be applied to current medicare/medicaid-type fiimneing. As long as members can satisfy any other want by postponing the use of their transfers, their total annual withdrawals or claims to pay for hospital expenses should be less than the tax appropriation for the procure. Over 30 references and notes are appended,
John R. Coleman and Frank C. Kaminsky. National Center for Health Services Research, HyattsviUe, MD. 1977, 444 pp. AvMlabib'ty: D.C. Heath and Co., Lexington, MA 48450.
Part of a series of volumes on ambulatory care, this book deals with the design of medical services for health maintenance organizations (HMO's). The purpose of the book is to make available to health planners and HMO planners new technology and data bases which can be used during the feasibility and planning stages of newly emerging HMO's. The focus of this presentation is on the mechanics and technology of the planning process, and it should be used in conjunction with other works defining the basic issues in formulating an HMO. Examined are the various choices that must be exercised in the designing of the benefit packages, the delivery system, and the methods of financing. The book details how existing HMO's are effecting their responsibilites to their members and identifies what are considered to be the most likely choices available, when an HMO intends to become federally qualified in accordance with the Health Maintenance Act of 1973. Addressing the issues involved, arguments are presented in support of the selection of one choice over another. In addition to contributing to planning technology, the book contains many data bases to assist HMO planners in executing their responsibilities. Much of the data are from first and second generation HMO's, while some data are from HMO's that have become operational since 1969. Among the specific issues considered are defining and sizing the service population of an HMO and the general framework of an HMO medical care program. Planning details are outlined for hospital care, mental health, dental care, vision care, and the prescription drug comportents of a proposed HMO programs. Appendice',; contain a listing of operative HMO's, a glossary, and an index. Tabular data and notes are provided with individual chapters.
Ambulatory
Care Systems Series.
Descriptor(s): Prepaid plans, Health care/services, Plan design/ program provisions (under health plans), Health information/ data systems.
1-11
24. Ambulatory Pharmaceutical Recipients. A Pilot Project.
Services for MedicarE;
Dennis L. Hefner and William Duwe. Paid Prescriptions, Burlingame, CA 94010 Health Care Financing Administration, Washington, DC. Ofrice of Policy, Planning and Research. 1976, 178 pp. Availability: National Technical Information Service, Springfield, VA 22161, PB-289 232.
This pilot project was designed to study the prescription drug utilization patterns in an elderly population in order to determine the feasibility of furnishing out-of-hospital prescriptions to the elderly. The effects on drug-use rates of various benefits and administrative costs were analyzed. Four benefit plans were offered to a sample of aged medicare beneficiaries in Sacramento and San Joaquin counties, Calif., for the period December 1974 to November 1976. The plans included complete prescription coverage, patient payment of $1 per prescription, 25 percent coinsurance per prescription, and 25 percent coinsurance per prescription after a $50 annual deductible. General utilization rates were lower than anticipated. Although cost sharing may be a barrier to using program benefits, it did not deter recipients from filling individual prescriptions. The average charges per person diminished as the level of cost sharing increased. Generally, higher prescription prices were found to be directly associated with the level of patient copayment. There was a tendency for pharmacies to charge higher prices to persons using drug cards issued by third-party carriers. Overall administrative costs were significantly higher with the use of a patient billing system to collect deductibles from beneficiaries. For a part of the project's second year, drug utilization review activities were initiated. Although administrative problems precluded the identification of any significant dollar savings, the potential for improving quality of care through use of centralized review procedures was demonstrated. It should be noted, however, that out-of-hospital prescription use should be higher for the two elderly population groups excluded from the study, medicaid eligibles and supplemental prescription drug plan enrollees. For the nonpoor elderly, changes in the copayment level did not significantly affect utilization rates of recipients. It is possible that the t:ost of adding outpatient prescription drug service to medicare may be less expensive than expected. Thirty tables are included, and five appendices provide related study materials.
25. American Attitudes Toward Health Maintenance zations.
Harris (Louis) and Associates, Inc., New York, NY 10Ill Henry J. Kaiser Family Foundation, Palo Alto, CA. Jul 1980, 128 pp. Availability: Harris (Louis) and Associates, Inc., New York, NY 10111.
This study focuses on aspects which members like and dislike about their health maintenance organizations (HMO's), factors that will shape the future of the HMO movement, and elements which encourage the growth of HMO membership. HMO managers and others involved in promoting the growth of HMO membership can use this research as a marketing study. The work is a national study; and does not provide information on individual HMO's. Three sample surveys provide the data base. These samples include a representative national cross section of 1,543 adults, a sample of 1,092 members of HMO's, and 991 individuals described as eligible nonmembers who live in the same locations as do HMO members. The personal interviews were conducted between January and June of 1980. Survey analysis indicates that members are generally pleased with HMO service, and the overwhelming majority of members renew their membership. Prospects for continued growth of HMO's are favorable. Notwithstanding their general satisfaction with HMO's, many members express some criticism. Thus HMO managers should be concerned about the perceived quality of physicians, impersonal service, and the length of time it takes to get an appointment with a physician. The survey identifies substantial barriers to the future growth of HMO's. The largest single barder preventing nonmembers from joining is concern about losing the freedom to choose physicians. Some of the clearest findings in the report are those relating to the communications methods which HMO's should use to reach potential new members most effectively. Specifically, HMO managers should note the crucial role played by employers, the importance of holding employee meetings for discussion of HMO's, and the advisability of directhag marketing efforts toward smaller businesses as well as larger firms. No significant difference between the health status of HMO members and eligible nonmembers was identified. Appendices and 75 tables are included.
Study No. 794021/Second
Descriptor(s).. Pharmaceutical services, Medicare, Demand/ utilization of health care programs, Deductible/coinsurance, Impact of third-party coverage,
I- 12
Organi-
Edition.
Descriptor(s): Prepaid plans, Demand/utilization programs, Participants in health care programs.
of health care
Health Care Programs
26. American Biomedical Network. Health Care Systems in America Present and Future.
The text introduces students and others to the American health care system and how it functions; it describes the components of the system and how they interact and outlines the issues and
Stacey B. Day, Robert V. Cuddihy and H. Hugh Fudenberg. 1977, 334 pp. A vMlability: Scripta Medica and Technica, South Orange, NJ 07079.
problems that affect that interaction. The basic elements of a health care system -- public health/preventive medicine, emergency medical care, inpatient hospital care, long-term care and rehabilitation, and other components -- are outlined, as are patient, provider, and community/social factors affecting the use
This collection of papers was presented at the 1976 Aspen Seminar on Biosciences Communications and Health Care Delivery. Disciplines addressed during the seminars included medicine and science, technology, cost and benefit analysis, management, and the politicization of science. The conference itself was an experiment in biomedical communications; emphasis was on the lack of perceptive and willing scientists who are capable of using collectively gathered, available knowledge. Conference participants included 100 individuals of diverse professional backgrounds and experiential philosophies. Categories of seminar topics focused on health and science policy; management, organization, and education in medicine; the quality of life; issues of health care costs; the role of industry in health care; and technology and technological information systems. Some of the topics addressed were the role of biologists in shaping national science policy, policy and evaluation in the health sciences, university health science curriculum nursing in an interdisciplinary health care team, Canadian health care delivery, and the "total patient" medical approach (acknowledging the effect of a patient's illness on his social, vocational, and emotional life). Remarks on health care costs dealt with regulation of the health care industry, the relevance of cost-benefit analysis, and measures for the social rate of return from drug innovations. Additionai subjects covered included American scientific policy as it influences drug development and clinical research, research management, computer-assisted medicine, and health information manaqement with automated systems. Footnotes, references, and figures are included in some position papers; a list of seminar participants is appended to the volume.
of a health care system. Also discussed are the issues and pressures currently influencing the health care system. The measure of health, the purpose of health care, the role of government in health care, technology in the health care system, and control of the system are all examined. Finally, the text outlines certain
Proceedings of the Aspen (CO) Interdisciplinary Symposium the USA Health Care Systems, October, 1976.
re health care.
27. American Health Care System.
Issues and Problems.
Paul R. Torrens. 1978, 120 pp. ArM/ability: Mosby (C.V.) Company,
St. Louis, MO 63141.
Descriptor(s): Characteristics of U.S. health care system, Economic/commerciai influences, Health care/services.
28. American Medical Association and Compulsory National Health Insurance. The Molding of Public Opinion, 19201965. Harold L. Walker. , 131 pp. Availability: University MI 48106.
Microfilms International,
Ann Arbor,
on
Descriptor(s): Characteristics of U.S. health care system, Medical technology impacts, Funding/financing of health care programs, Policy/changes
features of an "ideal" health care system. In creating the model, each health care worker is advised to consider the following three features: priority-setting and planning, financing, and delivery of personal services. The book recommends that basic fmanciai support come from a national health insurance plan that draws basically the same amount from all people and guarantees basically the same level of service. Supplemental support is recommended from taxes, voluntary private insurance plans, and out-of-pocket payments, the last at levels far lower than current ones. Chapter references and tabular data are provided.
This study investigates the controversy over national health insurance and the goals and strategies pursued by the American Medical Association (AMA) against proponents of national health insurance. In historical terms, four major factors have contributed to the lengthy forestallment of national health insurance: two major wars, the Whitaker-Baker public relations firm, the contented majority, and the reformers themselves. Prior to Worm War I, some form of compulsory national health insurance appeared imminent; today it is still the subject of debate. The prolonged success of organized medicine in resisting national health insurance is attributable to several factors, including influence flow and rhetorical devices. The AMA spent more than any other interest group from 1946 to 1966 in an effort to
1-13
insure acceptance of its legislative proposals. In addition, the public relations firm of Whitaker and Baker was hired in 1948 to wage war against the Truman health plan. Professional medicine also employed several motive appeals over the years of the insurance struggle. Thus, free enterprise and individual freeedom (as represented by the present system) were put forth as being symbolic of Americanism. Concern for the individual was emphasized in all AMA communications. The medical fraternity also reminded Americans that a system of national health insurante would deny them the personal attention to which they had been accustomed. Rhetorical devices employed in the AMA scheme included petition, promulgation, solidification, polarization, and substitution. Finally, reformers themselves unintentionally aided the AMA cause. By seeking to generate insurance policies rather than doctors, the reformers gave professional medicine an excellent issue for the creation and reinforcement of
and inadequate access to care for poor children, poor elderly, rural dwellers, and the handicapped. In addition, people with long-term chronic illnesses are not receiving the full benefit of medical knowledge that could improve their functioning and comfort. Some specific suggestions for improving the outlook for U.S. health care include restraining the costs of medical care by putting emphasis on improving ways to deliver care on an ambulatory basis and reduce hospital care; increase efforts to train more physicians for generalist careers, make such careers more financially rewarding, and train new physicians to better recognize the financial implications of care they render; and accelerate efforts to regionalize high technology, under used services, and services for special groups. Other recommended policies are that academic medical centers prepare for restricted growth and develop more cooperative linkages with other institutions; conduct collective research with government agencies; reach an
favorable public sentiment. A few notes and about 50 references are included,
agreement on number and kinds of health professionals needed, adjusting training opportunities accordingly. Because the number of students qualified to enter medical school will continue to exceed the number of openings, ways of reducing the stresses caused by this competition should be explored. Early admission, teaching of more human biology at the undergraduate level, broadening the selection criteria, and introducing human interaction skills earlier in the curriculum will characterize educational programs of the future. An index and 107 references are included in the book.
Submitted in partial fullTllment of the requirements for the degree of Doctor of Philosophy to the University of Texas at Austin,
1978.
Descn'ptor(s): Policy/changes
National health insurance re health care.
(NHI),
Physicians,
Descriptor(s): Supply/availability of services, Characteristics U.S. health care system, Physicians. 29. American
Medicine.
David E. Rogers. 1978, 151 pp. Avadabilitv: Ballinger 02138.
Challenges
Publishing
for the 1980s.
Company,
Cambridge,
MA
Beginning with a critical examination of the status of national efforts to bring modern medical care to all Americans, this book points out strengths and weaknesses of the major academic health centers where health professionals are educated and the role they fidfdl in the system. Finally, the manner in which we select, educate, and change the persons who become doctors is discussed as well as the problems they face. The author argues that we have the human resources and talents to solve remaining medical care problems if several conditions are met. First, we need to strive for apparently simplistic goals like equality in access to medical care and more considerate treatment ofthe elderly. S_ond, we must regain our confidence that we have the capacity to make appropriate changes. Third, we must precisely and objectively isolate and identify the problems and accurately target efforts to correct them. The two major problems that should structure future efforts are the rapidly rising cost of care
1-14
of
30. America's Health Care System. A Comprehensive trait.
Por-
LuAnn Aday, R. Anderson and G. V. Fleming. Robert Wood Johnson Foundation, Princeton, NJ. National Center for Health Services Research, Hyattsville, MD. 1978, 12 pp. AvMlability: Robert Wood Johnson NJ 08540.
Foundation,
Princeton,
This paper reports on the results of a national survey on access to medical care taken between September 1975 and February 1976 of 7,787 persons statistically representative of the U.S. population. The study focuses on many factors believed to affect access to care, and each indicator can be examined for subgroups defined by a number of important variables, including age, sex, race, income, region of country, education levels, and suburban as opposed to urban or rural residence. The survey investigates
Health Care Programs
five principle dimensions impinging on access to care: source of care, convenience of care, actual use of care, the need for care, and the patient's satisfaction with the care received. In the 1976 survey year, 76 percent of the population, or 160,000,000 persons, saw a doctor. In addition, the survey found that the population at large has better access to medical services today than in 1970 or 1963, largely due to medicaid and medicare. The study places special emphasis on whether persons have regular physiclans or regular sources of care. About 12 percent have neither and, although this represents a small proportion overall, it means that there are actually an estimated 24 million people who have no regular point of entry to the health care system. A new experimental approach was the symptoms-response ratio, developed to measure the appropriateness of medical care. This ratio
The Western Interstate Commission for Higher Education entered into a contract with the Department of Health, Education, and Welfare's Division of Nursing in March 1975 to carry out Analysis and Planning for Improved Distribution of Nursing Personnel and Services. This final report provides an ,overview of that project. The primary project goal was to significantly strengthen the nursing community's capability to analyze and plan for the improved distribution of nursing personnel and resources. The three specific objectives were to develop new methodologies for projecting nursing requirements and resources at National and State levels, develop a planning capability among nursing leaders throughout the nation, and to provide insights into ways of improving the distribution of personnel and services. Included are summaries of each of the activiti_s related
differentiates between the number of people with a given mix of symptoms who contact a physician at least once for the syruptoms and the number that a panel of medical professionals say should contact a doctor for those symptoms. Results varied depending upon whether specialists or primary care physicians, defined the symptoms. Results indicate that the total population sees physicians 6 percent less than recommended. Satisfaction with care was also measured. Cost is the main cause of dissatisfaction, although time spent waiting to see a doctor and the amount of information given to the patient by the doctor are also areas of dissatisfaction. Despite the survey data, which show a high level of satisfaction as well as increased access to the health system for Americans of all ages and races, 61 percent of the population believe there is a crisis in health care in the United States. Footnotes, 11 references, and 5 charts are provided,
to the development of analytical models, the development of the data base and improvement of data collection, new approaches used by nurses to improve delivery in education, and the three major activities that will increase the knowledge and participation of nurses in health planning, i.e., regional centers, training workshops, and national conferences. Separate reports and other publications produced during the course of the project which describe activities in greater detail are provided. Projeot results demonstrate that nurses can play a major role in health planning, and that nurses are already carrying out new approaches that improve care and education. The report concludes that there is an overall national shortage of nurses, particularly at the baccalaureate degree level and higher. It is up to the States 1Loensure that the impact of this project continues and that health care delivery will benefit from it. A glossary, appendices, fi)otnotes, 8 figures, and 17 tables are provided in the report. (Author
Robert
abstract modified)
Wood Johnson Special Report
Series nl p4-15 1978.
Descriptor(s): Characteristics of U.S. health care system, Supply/availability of services, Demand/utilization of health care programs, Providers of health care services, Demographic features of population.
Descriptor(s):
Supply/availability
of services, Nurses.
32. Analysis of Case Mix Complexity Using Information Theory and Diagnostic Related Grouping. 31. Analysis and Planning for Improved Distribution Nursing Personnel and Services. Final Report. Jo Eleanor
of
Elliott and Jeanne M. Kearns.
Western Interstate Commission for Higher Education National Center for Higher Education Management Systems, Boulder, CO 80302 Health Resources Administration, Hyattsville, MD. Div. of Nursing. Dec 1978, 214 pp. Availability: Health Resources Administration, Bureau of Health Manpower, Div. of Nursing, Hyattsville, MD 20782.
Susan D. Horn and Dale N. Sehumacher. Health Care Financing Administration, Washington, 1979, 8 pp. AvMlability:
DC.
Medical Care v17 n4 p382-389 Apr 79.
There is general agreement that hospital case mix complexity is a key determinant of hospital costs, and while case mix is difficult to quantify, this study shows that information theory has the potential to be useful in such quantification. Previous methods for quantifying ease mix are reviewed, with particular eraphasis on the approach in which degree of conc_mtration becomes the measure of complexity, and the AUTOGRP meth-
1-15
od in which hospital discharges are partitioned into medically meaningful classes with similar patterns of average length of stay. The information theory measure of case mix complexity developed in this paper uses the 383 Diagnostic Related Groupings of AUTOGRP to provide a convenient summary index of the degree of concentration. The analysis presented here is based on 216,000 live discharges during the period of October 1976 to March 1977 from 45 hospitals in Maryland. By State law, all 50 acute general hospitals in Maryland have been required since July 1976 to provide uniform discharge data on all discharges in a format similar to the Uniform Hospital Discharge Data Set. While the information theory approach using the 383 DRG's gave a good picture of the complexity of the diagnoses, 167 included intuitive disagreements. To alleviate these problems, those 167 DRG's were collapsed into a new set of 56 DRG's and their complexity numbers recomputed; this approach is shown to agree well with clinical complexity and mortality. The information theory measure of case mix complexity has several advantages. It is easy to compute once distributions of diseases are known, and it is less easily influenced by the hospital. If more procedures are done or patients kept longer, complexity measures based on cost per case or length of stay can be influenced, Furthermore, it can be used as an independent variable in a regression equation with average cost per case for each hospital as the dependent variable. Two tables and 16 references are provided,
Descriptor(s): Methods of payment determination, Outcome/ evaluation of health administration, Hospital services.
cine, pediatrics, general surgery, and obstetrics/gynecology. Survey instruments included a questionnaire completed during a face-to-face interview with the groups' chief medical executive, a revenue and expense form, and scheduling questions on hours worked, numbers of patients seen, and waiting times. Individual physicians also completed questionnaires. Following an overview of descriptive statistics on group practices are separate chapters examining responses to financial incentives by individual members of the groups, surgical output in group practice, and the ownership of medical laboratory and x-ray facilities. The final discussion concerns prepaid medical practices, the composition of their patients and physicians, and practice styles. The study discovered substantial variations in weekly hours worked by physicians, in numbers of patients seen, and in medical fees. Great diversity was also found in income distribution policies. Analysis suggested that financial incentives had some effect on numbers of patients seen and hours devoted to patient care. Because financial rewards of owning equipment did not appear to be large, the report suggests that criticisms of the prescription of diagnostic tests focus on utilization patterns, rather than ownership of equipment. This investigation failed to uncover any marked differences between prepaid and fee-for-service groups and questioned whether HMO's really do contain costs. Figures and extensive tables are provided. The appendices contain staffstieal tables, an analysis ofnonresponse bias in the survey, and the analytical framework for analysis of group practice efficiency. An annotated bibliography is provided.
Project Report Descriptor(s): plans.
33. Analysis Practices.
of Economic Performance
Physicians,
Medical/surgical
services,
Prepaid
in Medical Group
Philip J. Held and Uwe E. Reinhardt. Mathematica Policy Research, Inc., Princeton, NJ 08540 National Center for Health Services Research, Hyattsville, MD. Jul 1979, 440 pp. A vailability: Mathematica Policy Research, Inc., Princeton, NJ 08540.
This report describes the results of a nationwide survey of group medical practices conducted in 1978 that was known as the Group Practice Study (GPS). The basic sample for the GPS was derived from the 1969 American Medical Association (AMA) list of groups, a list of health maintenance organizations (HMO) supplied by the Department of Health, Education, and Welfare, and an AMA list of groups believed to have been formed after 1969. The study was limited to general practice, internal medi-
1-16
79-05.
34. Analysis of Programs to Limit Hospital Capital Expenditures. Draft Final Report. ICF, Inc., Washington, DC 20006 National Center for Health Services Research, Hyattsville, MD. Apr 1980, 112 pp. A vMlability: ICF, Inc., Washington, DC 20006.
This report examines the potential impact of alternative hospital capital investment ceilings and allocation formulas. The Department of Health, Education, and Welfare (DHEW) has proposed the use of a limit on hospital capital investments as one way of reducing the increase in hospital operating costs. A major concern is whether capital limits can significantly reduce operating costs at all, especially labor costs, given the wide range of possi-
Health Care Programs
ble investments by hospitals. However, other important questions include how capital limits will affect the relative condition and age of facilities, the distribution and accessibility of beds and services, and the capital structure of the hospital industry. The study approach included a review of the underlying theoretical basis for capital investment limits; site visits to New York and California; selected telephone interviews with State officials in Rhode Island, Michigan, and Maryland; and the development of a Hospital Cost Model (HCM) for use in analyzing tradeoffs under alternative regulatory proposals. In addition, the impact of alternative approaches over the next 10 years was estimated, using a number of key measures such as operating costs, access to care, condition of facilities, and capital structure. Major findings of significance to DHEW resulted from the study: (1) if used alone, capital limit programs are likely to require relatively stringent ceilings to achieve a meaningful impact on operating costs; (2) under the population-based allocation approaches examined, capital limit programs have significantly different effects on different States; and (3) several important questions need to be addressed in future studies. Recommendations to DHEW are that (1) it should consider the implementation of capital investment limits only in concert with broader forms of hospital regulation; (2) it should evaluate more thoroughly the potentially adverse effects of a capital investment limit; and (3) if DHEW does not select a comprehensive regulatory strategy for hospitals, capital investment limits could still be considered as one way to augment individual State regulatory efforts. Appendices give 10-year forecasts for each alternative and a description of the hospital cost model. Tables are provided,
Descriptor(s):Cost cy initiatives,
containment efforts, Inpatient facilities, Poli-
35. Analysis of Prospective Payment System
in Upstate
New York.
The upstate New York program is described as unique in that a formula, rather than individually negotiated budgets, was used to set rates for all hospitals, thus providing a comparative test of the superiority of this particular form of PR. In order to develop testable hypotheses of hospital reaction to PR, a model of hospital behavior under price regulation was required. The model presented suggests that certain crucial variables needed to be examined in addition to costs, including net revenues, volume (patient days, length of stay), productivity, scope of services, intensity, ca_mix, quality, and skill mix. Skill mix is most likely to affect the average wage in the short run. A brief description of the New York PR system is provided, along with art analysis of the incentives to encourage hospitals to respond in a particular way. Two genetic forms of PR that currently exist are discussed: budget review (or negotiation) and formula. The first is based on the premise that hospitals are unique and require review on an individual basis; the second, on the assumption that hospitals treating similar kinds of patients should be reimbursed the same amount, adjusting for legitimate differences in factor prices. The New York State legislature mandated formulary PR participation for all Blue Cross and medicaid patients. The New "York rate -- setting system is reviewed, with an analysis of the formula and its associated incentive structure. Also included is an analysis of penalty size and incidence by hosptal size, type, location, and level of efficiency. For all 145 hospitals in the program in upstate New York, routine ceiling penalties were incurred atmually by approximately 20-24 percent of the institutions while occupancy penalties were incurred twice as often (approximately 44 perten0. A breakout of penalty incidence by bedsize class shows a consistent decrease in incidence with increasing bedsize. Teaching hospitals incurred routine penalties more often than nonteaching ones, while the opposite was true of occupancy penalties. An appreciably larger percentage of rural hospitals incurred occupancy penalties; nearly one-half of all rural hospitals are penalized for low occupancy every year. The report then briefly outlines methods and empirical results of actual hospital behavior in the areas of cost and revenues, volume, productivity, scope of services, factor prices and skill mix, and quality. Twenty-nine annotated footnotes and 11 references are provided.
Jerry Cromwell, Craig Coelen, Lee Edlefsen, Diane Hamilton and Jan Mitchell. Abt Associates, Inc., Cambridge, MA 02138 Social Security Administration, Washington, DC. Office of Research and Statistics. Nov 1976, 59 pp. Availability: Abt Associates Inc., Health Care Systems Area, Cambridge, MA 02138.
Prospective reimbursement (PR), or the setting of fixed rates of payment to hospitals for periods of time without automatic admustments, has recently achieved a certain popularity; this paper tests the impact and appropriateness of PR in upstate New York.
Presented at a conference on Prospective Reimbursement and Hospital Cost Inflation in Waslu'ngton, DC, on November 10, 1976. Discussion Paper No. HCSA-3.
Descn'ptor(s): Cost containment efforts, Methods of payment determination, Hospital services.
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36. Analysis of Requirements for a Cost Benefit Structure for the Military Medical System With Initial Focus on CHAMPUS.
Trapnell (Gordon R.) Consulting Actuaries, Falls Church, VA 22044 1974, 84 pp. Availabib'ty: Trapnell (Gordon R.) Consulting Actuaries, Falls Church, VA 22044.
37. Analysis of the Effects of Prospective Programs on Hospital Exl_enditures.
Reimbursement
Craig Coelen and Daniel Sullivan. Health Care Financing Administration, Washington, DC. 1981, 40 pp. A vailabilRy: Health Care Financing Review v2 n3 p 1-40 Winter 1981.
Prospective reimbursement programs attempt to restrain increases in hospital expenditures by establishing, in advance of a Results and recommendations are reported from an analysis of requirements for a cost-benefit structure for the military medical system, with initial focus on the Civilian Health and Medical Program for Uniformed Services (CHAMPUS). The health benefits provided to active and retired servicemen and their families through the military medical system, including CHAMPUS, are an important part of the compensation paid to servicemen, However, CHAMPUS outlays are now around half a billion dollars a year and growing rapidly, leading to demands that the program be reduced and limits placed on the benefits. Such circumstances require that a cost-benefit structure be developed for CHAMPUS and the military medical system. Specifically, it is essential to be able to determine (1) who the CHAMPUS beneficiaries are and where they reside; (2) how those eligible use the CHAMPUS program and the services available through the individual service medical corps; (3) how much it costs to provide services through CHAMPUS or direct medical programs (by age, sex, grade, etc.); and (4) how much is spent for each type of service and how expenditures compare to other population groups, especially Federal employees and employees covered by typical group insurance programs. Currently, no formal method for reliably projecting the cost of the CHAMPUS program has been instituted. A 1 in 1,000 (or other small-sized sample) "observation model" should be assembled from the existing data on active and retired servicemen and their families. This model would assemble and match enrollment data from finance files,
hospital's fiscal year, limits on the reimbursement the hospital will receive for the services it provides to patients. This study used data compiled from a sample of approximately 2,700 cornmunity hospitals in the United States for each year from 1969 to 1978 to estimate the effects of prospective reimbursement programs on hospital expenditures per patient day, per admission, and, to a lesser extent, per capita. The statistical evidence indicates that some prospectivehospital reimbursement have been successful in reducing expendituresprograms per patient day, admission, and perMaryland, capita. Eight programs -- in Arizona, New per York, Counectieut, Massachusetts, Minnesota, and New Jersey -- have reduced the rate of increase in expenses by 2 percentage points or more per year and, in some eases, by as much as 4 to 6 percentage points. There are indications, although less strong, that prospective reimbursement programs also reduced expenses in Indiana, Kentucky, Washington, Western Pennsylvania, and Wisconsin. There are no indications of cost reductions for programs in Colorado and Nebraska. An analysis of the relative effectiveness of the various programs suggests that mandatory programs have a significantly higher probability of influencing hospital behavior than do voluntary programs. Some voluntary proqrams, however, are shown to be effective. and tabular graphic material are supplied. reference Footnotes list of 26 items is included. (Author abstract modified)A
Descriptor(s):
Cost
containment
efforts,
Methods of payment health administration.
Descriptor(s): Cost/benefit analyses, Publicly sponsored/mandated health plans, Policy initiatives,
A vMlability: National Technical Information field, VA 22161, PB81-134991.
I- 18
determination,
Inpatient
personnel files, the application files for identification cards, and from special surveys of servicemen in the sample; merge CHAMPUS claims data with such enrollment data for servicemen in the sample and their families; supplement claims information available by requesting additional information from carriers and providers as to services furnished to sample members and their families; develop a suitable format for maintenance of this data base for purposes of analysis by the staff of the Assistant Secretary of Defense for Health and Environment; and develop algorithms to project the enrollment, use, and cost of health services for future years. Tabular data are provided.
facilities,
Outcome/evaluation
of
38. Analysis of the Potential Impacts of National Health Insuranee Programs on Collective Bargaining. Final Report. ICF, Inc., Washington, DC 20006 Department of Labor, Washington, and Welfare Benefit Programs. Aug 1980, 130 pp.
DC. Office of Pension
Health
Service, Spring-
Care Programs
This study explores the possible impact of national health insurance (NHI) on employers and employees covered by negotiated health benefit plans. The study identifies how NHI will alter past trends in collective bargaining and identifies areas where major adverse impacts might occur. Five major issues are examined: what persons will receive health plan coverage who were not previously covered, how NHI will improve benefits for persons already covered by negotiated plans, how the increase of health plan costs will affect employer contributions and future wage and other fringe benefits, and how adverse financial impacts on employers or workers need to be addressed by NHI. For the purpose of evaluating the effects of NHI, the study evaluated three general NHI programs: a catastrophic NHI program, an intermediate NHI program, and a comprehensive NHI program. All three programs would mandate coverage of all full-time employees and their dependents and at least some part-time employees and their dependents. Analysis of these three programs found that each program will have a significant impact upon some negotiated health plans. To reduce financial liardship due to NHI, some approaches allow plans to phase in benefits,
delineate the statutory employment coverage requirements and portray the status of legislation on the coverage of occupational diseases. They cover income or cash benefits payable under elther temporary total or permanent total disability, maximum amounts payable in cases of "scheduled" injuries, benefits payable in the event of fatal injuries, medical benefits and waiting periods, and specific rehabilitation provisions. An administration section includes charts on the topics of statutory provisions relating to administration, provisions for employers' reports of accidents, second-injury funds, administration expenses, and appeal provisions. The final chart gives a directory of the administrators, boards, and commissioners for all jurisdictions reported. A list of abbreviations and chart computations are included.
subsidize health plan costs, and establish wage-related premiurns. The report presents a detailed discussion of study methodology, including data sources and analysis of 75 negotiated health plans. In addition, an overview of the characteristics of negotiated health plans and a discussion of significant trends are presented. Finally, implications of the study findings for the design of NHI programs and for the regulation of health benefit plans are detailed. Tables and footnotes are provided, and study methodologies are appended. (Author abstract modified)
40. Ancillary Services Review and PSROs. Demonstration Programs Tell Us.
Descriptor(s): National health insurance (NHI), Source of premium payment, Cost/benefit analyses, Participation in health care programs,
Discussions of alternative methods of ancillary services; review (ASP,) and problem identification highlight certain aspects that must be addressed by Professional Standards Review Organization (PSRO's) in designing an ASR system. The ASR demonstration sites should consider the following design factors in documenting their experience: (1) focused review, (2) development of criteria and screens, (3) appropriate intervention, (4) data to support the review, and (5) cooperation of providers. PSRO's must decide which ancillary services and diagnostic
39. Analysis
of Workers' Compensation
Laws.
Eric J. Oxfeld. Chamber of Commerce of the United States, Washington, DC 20062 1980, 45 pp. Availability: Chamber of Commerce Washington, DC 20062.
of the United States,
This analysis of workers' compensation laws presented in 15 charts provides a ready reference to the statutory provisions found in the Federal, State, and territorial laws of the United States and the Federal, provincial, and territorial laws of Canada. American Samoa, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands are included. In part 1, charts
De_riptor(s): Workers compensation, lations, Health care/services.
Judith L. Wagner. Urban Inst., Washington, DC 20037 Health Care Financing Administration, Aug 1978, 41 pp. Availability: Urban Inst., Washington,
Present legislation/regu-
What Can the
Washington,
EtC.
DC 20037.
categories to review. Selection criteria should ensure that the services reviewed have significant impact on the cost or quality of health care. Further, every review method needs some criteria on which to base the identification of problem cases. Thus, the development of criteria is a necessary condition for all types of review. For ASR, simple criteria may be more productive than comprehensive listings of all possible justified uses of a procedure. The alternative intervention strategies available will depend partially on the kind of ASR chosen, but in general, PSRO's must choose between noncertification for payment and educational strategies. The appropriateness of the intervention will depend on the particular problem being addressed and the source of the use problem. Although the types of data needed differ with the kind of review, the ASR demonstration sites will
1-19
have achieved considerable experience in designing and using data collection instruments, particularly medical record abstracts which include information on ancillary service use. Whether ASR is conducted directly by the PSRO or is delegated to hospitals, the hospitals must be willing to cooperate if any positive impact is to be expected. Several ASR demonstration sites have not been able to implement ASR as intended because of the resistance of area hospitals. Issues bearing upon eventual formal evaluation of ASR systems are also discussed° A few tables and footnotes are furnished,
Worka'ng Paper 1251-00. Descriptor(s): Diagnostic services, Evaluations/outcome health care programs, Methods of payment determination,
41. Annotated 1979, 3 pp. Availability:
of
Bibliography of Health Economies.
Kyklos v32 n4 p826-828
1979.
This bibliography is divided into eight main sections: general works, demand/need for health, supply of health services, evaluating the contribution of health services, finance and organization of health services, planning whole systems, utilization studies, and bibliographies. All publications are numbered consecutively, in alpabetical order by author, by year within each section or subsection (mostly early 1960's until 1974). There is extensive cross-referencing and a complete author index, but no subject index. Almost all items mentioned are annotated, in some cases extensively. Each section includes an introduction. A companion volume also has been published, entitled "An Annotated Bibliography of Health Economics -- European Sources, 1978." (Author
abstract
modified)
Descriptor(s): Supply/availability of services, Demand/utilization of health care programs, Economic/commercial influences, Funding/financing of health care programs.
42. Assessing Quality of Care and Oral Health tion With Dental Insurance. Howard L. Bailit and Melvin N. Raskin. 1978, 11 pp. Availability: Inquiry v15 n4 p359-369 Dec 78.
1-20
in a Popula-
A preliminary study of the quality of services received and the oral health of a population eligible for prepaid dental benefits is described in this paper. Specifically, the investigation sought to determine the technical quality of restorations and crowns within the insured population. The study sample was selected from among 6,000 employees of the Blue Cross and Blue Shield Plan of Greater New York. Over the past 5 years, this nonprofit insurance carrier has provided a comprehensive dental plan for its employees and their dependents. To collect clinical data, three licensed dentists were trained in the use of various quality assessment and oral health indices. Subjects examined totaled 163. In addition to the examination, information regarding patient attitudes was collected through questionnaires. Results indicate that the technical quality of care was reasonable for amalgams, composites, and inlays. In contrast, single crowns and bridge crowns did not meet a reasonable standard for adequate care. More importantly, this study raised questions about the relationship between technical quality and oral health outcomes. The major area of restoration inadequacy was gingo-cavo surface margins within the range of quality variation seen in this study, many of the gingo-cavo surface criteria have not been directly related to increased disease. Thus, it is legitimate to question the value of developing sophisticated and expensive systems for monitoring the quality of restorative services if a quality assurance system does not lead to improved health or lower costs. The study results offer some evidence that oral hygiene levels may be more important in determining oral health than the frequency of dental visits. Twelve tables and 13 reference notes are included. (Author summary modified)
Descriptor(s): Service benefit plans, Dental services, Outcome/ evaluation of quality assurance.
43. Assessing the Utilization and Productivity of Nurse Praetitioners and Physician's Assistants. Methodology and Findings on Productivity.
Robert C. Mendenhall, Paul A. Repicky and Richard E. Neville. Health ('.are Financing Administration, Washington, DC. 1980, 15 pp. Availability: Medical Care v18 n6 p009-623 Jun 80.
A national study conducted in 1976 to 1977 analyzed the productivity of nurse practitioners (NP's) and physician's assistants (PA's) by comparing primary care practices which employed these personnel with ones which did not. Although formal training programs began for NP's and PA's in 1965, little empirical research on their effectiveness has been implemented. This pro-
Health Care Programs
ject selected 455 practices which employed formally trained NP's/PA's; were eligible to treat medicare patients; and whose supervising physician specialized in general practice, family practice or general internal medicine. A matched group of cornparison practices were subjected to the same eligibility criteria except that they did not use NP's/PA's. A comprehensive diarytype instrument was used to collect detailed data on each practitioner's daily professional activities. This questionnaire recorded all patient encounters for a 6-day period and solicited personal and professional data from participants. Surveys were conducted in segments throughout the time period to minimize the effects of seasonal variations in patient volume. Productivity of PA's, NA's, and physicians was measured by variables relating to patient volume, time in patient care, and revenue generated, Rural and urban health care services were also compared. Interpretation of the survey data indicated that PA's were more productive than NP's, although the latter spent more time with individual patients. NP's and PA's were equally productive in remote and nonremote areas. Contrary to expectations, NP's and PA's in urban areas spent more time with each patient than did practitioners in rural locations. Both groups charged more per patient visit in resource-poor areas. Generally, NP's were more productive in single speciality groups and partnerships, while PA's were most effective in solo practices. Tables and 26 references are provided.
Descriptor(s): Allied health professionals, Supply/availability services, Health care/services.
of
and perceptions of competency, courtesy, and efficiency. Of the 743 survey questionaires mailed, 538 (72.4 percent) returns were received prior to the cut-offdate. Ingeneral, satisfaction with the plan was high and the results of the survey indicated strong membership support. Getting care at the site before HMO enrollment was significantly related to reports on general courtesy and efficiency. Reported satisfaction on all dimensions is related to the length of time one received previous care at the service site. The longer one received care at the site prior to joining the HMO, the greater the tendency to report favorably. Satisfaction was not significantly associated with residence, educational level, marital status, race, sex, or membership status. The study highlights those aspects of services on which administrators might act or monitor to improve member satisfaction. These include strategies to increase attendance at orientation.,; by new members and to maximize access and understanding of procedures for obtaining emergency after-hours care. Tabular data and references (43 items) are provided.
Descriptor(s): Prepaid plans, Participants in health care programs, Outpatient facilities, Evaluations/outcome of health care programs.
45. Attempts to Control Health Care Costs. The United States Experience.
John F. Newman, Helen C. Gift. 44. Assessment
of Member
Satisfaction
in an I-IMO. Under-
standing the Interaction of Variables and Their Implications. Jane M. Zapka. 1979, 17 pp. Av_dlability: Jnl. of Ambulatory p29-45 Nov 79.
Care Management
v2 n4
Results and implications axe reported from a study of consumer satisfaction with a health maintenance organization (HMO). The study was conducted in a small, newly organized, semirural, federally-qualified HMO. This HMO has two service delivery sites -- one is a large State university health center and the other is a large formerly fee-for-service group practice. A major proportion of members are State professional employees, predominantly university-classified. At the time of the study, the 6,898-person HMO had been in operation for 13 months. The membership included the 4,311 adult members from whom the study sample was selected. The membership survey examined consumer dimensions of accessibility, acceptability of services
William B. Elliott, James O. Gibbs and
1979, 12 pp. Availabih'ty: Social Science and Medicine vl3A Aug 79.
n5 p529-540
Trends in U.S. health care costs and efforts to control those costs are assessed. Costs of medical care services in the U.S. have been rising faster than costs of other basic consumer items (135 percent from 1967 to 1978). The most rapidly rising component has been hospital room charges. Utilization of health care services has also increased as the result of demographic shifts, such as aging of the population and medical practice patterns. Health care financing is characterized by multiple sources of payment, with a strong trend toward intermediary financing for hospital payments and out-of-pocket payments for other services. The proportion of the population with third party coverage for medical expenses had grown to 90 percent in 1978. No comprehensive policy of cost containment has been developed. Piecemeal cost containment efforts affect health care organization and delivery, planning and development, and reimbursement. Effective cost containment efforts include programs to encourage increased individual responsibility for health and programs to set limits on
1-21
total allowable resources, thereby forcing choices by dectsionmakers between alternatives. Health Maintenance Organizations (HMO's) illustrate the approach which encourages limits on total expenditures and definition of service responsibilities. Certain organizational structures also result in more efficient programs, as demonstrated by the HMO's use of provider reimbursement to create incentives for efficient practitioner decisionmaking as well as peer review to define norms of appropriate treatment. Cost containment may have negative effects, such as reduction of access to services for medicaid patients. Evaluation of the impact of cost-containment measures on other health goals, particularly access and quality, is recommended. Tables, footnotes and a bibliography of 64 references are supplied.
Descriptor(s): Health care cost trends/projections, Cost containment efforts, Demand/utilization of health care programs, Prepaid plans.
Spnnger
Series on Industry
and Health
Descriptor(s): Private health care plans, Plan design/program provisions (under health plans), Voluntary initiatives, Prepaid plans.
47. Benefit Recovery in Medicaid. An Examination of the Development and Implementation of a Benefit Recovery Systern in the State of Minnesota. John C. Anderson. Minnesota Univ. Management
Richard H. EgdahL Boston Univ. Health Policy Inst., Boston, MA 02215 1977, 198 pp. Availability: Springer-Verlag, New York, NY 10010.
Information
Systems Research
Center,Services Minneapolis, MN 55455Washington, Medical Administration, Mar 1977, 255 pp. Availability: National Technical Information field, VA 22161, HRP-0028557. Benefit recovery or third-party
46. Background Papers on Indnstry's Changing Role in Health Care Delivery.
Care, No. 3.
DC. Service, Spring-
liability in the Minnesota
medi-
caid program (title XIX) is discussed. Benefit recovery within title XIX is broadly defined as a function that attempts to recover resources due the medicaid program. It may include insurance, workrnen's compensation, tort recoveries, and many other kinds of recoveries, where a medicaid recipient has received medical services and some third party is responsible for paying part or all of the related costs. Minnesota's medicaid program is one of the most liberal in the Nation, but the State has followed a conservative policy with regard to administrative costs. Back-
Based on a conference on industry-sponsored health programs held in June 1977, this volume explores industry's varying roles as a provider of health services. One paper addresses a corporation's experience with the individual practice association (IPA) model of the health maintenance organization (HMO). It gives a brief history of the company's IPA-HMO, describes the Health Protection Plan, notes results achieved under the Plan, and com-
ground and historical information on benefit recovery activities in Minnesota deal with the utilization of third-party recovery, providers' concerns over third parties, third-party liability, requirements in benefit recovery (coordination and functional requirements), collection responsibility, obtaining necessary legislation, and benefit recovery validation of case information files. The organizational structure of the benefit recovery system
pares the Health Protection Plan with the traditional Universal Plan. Other papers discuss corporate health care management as a solution to employee health care dilemmas; the impact of the Government, new technology, and the work force on (_eupational medicine; union health clinics, the United Mine Workers Appalachia Program, and the activities of other unions; and one company's comprehensive care system involving the services of physicians in both corporate and private practice. Further, the results of a survey of seven industrial clinics in the greater Boston area and the classification scheme developed by level and type of services are discussed. Other papers address corporate mental health benefits, cost containment through benefit plan design, corporate reaction to the Occupational Safety and Health Act of 1970, legal liability in corporate health clinics, and the economic implications of employer-provided health care Notes, tables, footnotes, and an index are supplied.
is described, along with the authority for benefit recovery, legislative considerations, benefit recovery in relation to other health coverage, medicare crossover claims, and the benefit recovery interface with the State's medicaid management information system. Illustrations and data are included. (NTIS abstract)
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Descriptor(s): Medicaid, Competition/interaction among thirdparty payors, Reimbursement, Private health care plans, Cost containment efforts, Present legislation/regulations.
48. Benefit Rights and Privacy. The Insurance Fertility Control.
System
and
Charlotte F. Muller.
Health
Care Programs
City Univ. of New York Graduate New York, NY 10036
School and Univ. Center,
Ford Foundation, New York, NY. Rockefeller Foundation, New York, NY. 1977, 183 pp. Availability: Research Foundation of the City University New York, NY 10036.
of
The research reported here is an attempt to determine the extent of change in insurance protection that occured following the 1973 Supreme Court decision to legalize early abortion and the • ensuing increase in legal abortion services. In addition, the study sought to assess the feasibility of a mechanism for assuring privacy in l'fling insurance claims for abortion services. Respondents to the abortion coverage inquiry were 37 insurance companies accounting for 49.1 percent of all private health insurance business, 66 Blue Cross regional plans, the National Association of Blue Shield, the Civil Service Commission on Federal Employee Plans, the Civilian and Health Programs for the Uniformed Services, a sample of abortion provider organizations, and a set of group health plans (HMO's). The questionnaires investigated conditions of coverage for maternity and abortion, methods of abortion, immediate and delayed complications, contraceptive services, tests in early pregnancy, location of service, classes of insured women eligible for fertility control coverage, coverage statistics, and payment basis. Results indicate that group health insurance has made an incomplete adaptation to legalization of abortion and has done little to promote or underwrite contraception. Some of the limitations brought out in the survey include policies in which maternity (or abortion) benefits are not the same as nonmaternity benefits, those in which dependent minors are covered only by separate riders or under State requirements, policies covering complications of pregnancy or abortion only under major medical insurance, and policies which use a cap on coverage of preventive tests for high-risk pregnancies equal to the fiat-rate maximum maternity benefit. Policies were also found differentiating benefits according to the reason for the abortion. The Aetna plan for Federal employees was found superior to many policies of commercial carriers and service benefit plans because no special limitations are attached to pregnancy-related care. However, the Aetna plan excludes coverage for both sterilization and contraception. The abortion and contraceptive services offered by health maintenance organizations (HMO's) were found to be superior, especially in combination with the infant and child health care supplied. Since privacy assurance is considered crucial to the equitable accessibility of abortion services, 83 private carriers and 73 HMO's were asked to express their reactions to the feasibility of participating in a privacy insurance pool that would enable women, particularly adolescents, to obtain abortion services while retaining eonlidentiality. A total of 36 replies were received with 1 qualified posi-
tive response to possible pool participation. It is recommended that the advent of national health insurance be viewed as an opportunity to correct the present shortcomings of insurance coverage and practices regarding fertility control. Tabular data, footnotes, and 17 references are supplied. The appendix contains the study questionnaire, correspondence, and supplementary material. Descriptor(s): Plan design/program provisions (under health plans), Limitations on coverage, Exclusions from coverage, Present legislation/regulations, Medical/surgical services, Prevenfive services, Private health care plans, Comparisons care programs.
of health
49. Benefits in Medical Care Programs. Avedis Donabedian. Carnegie Corp., New York, NY. Milbank Memorial Fund, New York, NY. 1976, 436 pp. A vnilabib'ty: Harvard University Press, Cambridge, MA 02173. This book is a comprehensive treatment of the problems assoeiated with prepayment for medical care. The work begins with an analysis of assumptions about the social mandate for medical care benefits, the objectives of medical care programs, and the magnitude and distribution of the unmet needs that these programs are designed to alleviate. The problem of defining and measuring the need for care is considered within the context of the data yielded by alternative definitions. Analysis then shifts to the impact of benefits on certain key features of the medical care system. These features (i.e., use of medical care services, price of services, service substitution and redistribution of costs and purchasing power) are used to specify the objectives that should be sought in any medical care program and the side effects that should be avoided. Criteria used to test benefit design are financial protection, access proportionate to need, efficiency of allocation, efficiency of production, and equity. These factors are examined in detail in relation to the groups whose interests they serve, including clients, organizations, providers, and the collectivity of all those associated with health care Program benefits are weighed against program objectives, and policy implications are drawn from this comparison. Although the author advocates a thorough reform of existing systems, he is skeptical about the possibility of designing a perfect system, and he emphasizes the importance of recognizing that increased access to care increases exposure to both positive and negative aspects of the medical care system. Appendices of related data, 45 tables, 280 references, a subject index, and an author index are provided in the book. (Author abstract modified)
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DesaHptor(s): Demand/utiiization of health care programs, Third-party payors, Health care/services, Plan design/program provisions (under health plans).
51. Bibliography on Health Policy and Lifestyle Behavior Change. Milton J. Huber. Jan 1979, 28 pp. Availability: Vance Bibliographies,
50. Better Services at Reduced Costs Through an Improved "Personal Care" Program Recommended for Veterans.
Comptroller General of the United States, Washington, DC 20548 Jun 1978, 35 pp. Availability.. General Accounting Office, Distribution Section, Washington, DC 20013.
This report by the General Accounting Office (GAO) advocates better services at reduced costs through an improved "personal care" program recommended for veterans. As long ago as 1951, the Veterans Administration (VA) began a foster home program to provide care for patients able to live in the community but who had no homes. Studies show that the medical and psychiatric conditions of veterans improve and costs reduced after placement in personal care residences (PCR's). Personal care residences allow former patients to assume nonpatient roles in the community and provide support during the adjustment process. Today, thousands of institutionalized veterans are capable of being cared for in such residences. They remain in hospitals for various reasons: inability to pay for such housing, unsuitable community facilities, resistance to placement efforts, or unavailability of personal care programs. Attention needs to be directed at improving overall personal care program management and administration, expanding this health care alternative, and assuring quality of care. Congress should provide specific legislative authority to the VA to provide PCR care and authorize patient subsidy if needed. The VA needs to clearly define program goals, evaluate program effectiveness, establish a budget for the program, and make it an integral part of the VA health care delivery system. Tables and figures comparing institutionalized patient populations and their reasons for remaining hospitalized are provided. Appendices display statistical data on VA hospitals included in the study and a proposed legislative bill providing for personal care services. (Author abstract modified)
Comptroller
General's
Report
to the Congress, HRD-78-10Z
DescHptor(s): Policy initiatives, Publicly sponsored/mandated health plans, Cost containment efforts, Evaluations/outcome of health care programs, Home health services.
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Monticello,
IL 61856.
This bibliography on health behavior change brings together 67 articles concerning selected research findings and theories demonstrative of the increasing awareness among social scientists and health professionals about the kinds of practice and research challenges in health behavior changes. Publication dates range from 1966 to 1977, and direct quotations from each contribution have been included to show the style of the writer. Individual articles discuss the philosophy of health behavior change, including the methods and effectiveness of health education, the importance of changing lifestyles to improve health, and consumer health education; goals of health behavior change, such as a policy assessment of preventive health practice, the conceptualization of health and social well-being, and the measurement of prevention effectiveness; and social and psychological factors of health behavior change, including health and social factors related to life satisfaction and modification of health beliefs. Other categories include arranging the environmental situation to facilitate change, the practical value of health behavior change, and strategies deserving further investigation. Price and availability information are given. (Author abstract modifled)
Public Administration Descriptor(s):
Series Bibliography
No. P-161.
Preventive services.
52. Blue Cross. What Went Wrong.
Sylvia A. Law. Pennsylvania Univ., Philadelphia, PA 19104 Office of Economic Opportunity, Washington, DC. Department of Health, Education, and Welfare, Washington, DC. 1974, 246 pp. Availability: University Univ. Press, New Haven, CT 06520. This book consists of two parts. The first contains an analytical description of Blue Cross, its history, its status under State laws, its relationship to State regulatory agencies, and its internal governance; a discussion of the relationship between local plans, the national Blue Cross Association (BCA) and the American Hospital Association (AHA); and an investigation of the legal
Health Care Pro_;l,,.ls
role and status of Blue Cross under the Federal health insurance programs. The second part considers in detail the role of Blue Cross with respect to two major problems: reimbursement for hospital services and review of the medical necessity of hospital services provided to individuals. These issues are important to any health services delivery system, and their resolution involves major public and social questions. Confusion as to the proper role of Blue Cross is common and pervades the organization itself, the State regulatory agencies, Congress, and Federal agenties. This book finds that Blue Cross is most accurately characterized as the financing arm of American hospitals. It argues that money for both hospital care and health care generally should be administered by Blue Cross or some other agency which is primarily responsive and accountable to the public interest, and • particularly the interests of the individuals who use and pay for health care services. The book examines the extent to which Blue Cross is an independent power affecting the institutional autonomy of hospitals in regard to financial and ethical decisions, Alternatively, the book investigates the extent to which Blue Cross is affected by subscribers, State and Federal regulatory agencies, hospitals, competitors, and countervailing forces within the organization. Throughout the discussion the fundamental powerlessness of the consumer of health and hospital care is emphasized. Finally, it is maintained that there has been amassive failure by the Public regulatory agencies to control Blue Cross or the hospitals in the interests of consumers. Additional problems considered briefly include the role of Blue Cross in promoting and monitoring high quality services; Blue Cross rate structures in terms of uniform rates to all subscribers (community rating) versus favorable rates to statistically healthier groups (experience rating); and the proper role of Blue Cross in developing lower cost alternatives to hospitalization. Extensive chapter notes, a subject index, and a table of contents are provided. (Author abstract modified) Descriptor(s): Service benefit plans, Evaluations/outcome of health care programs, Characteristics of U.S. health care system, Funding/financing of health care programs, Health insurance industry, Policy/changes re health care.
53. Brown Lung Disability. Costs, Compensation and Controversy. An Exploratory Policy Study. Joseph T. Hughes and Elizabeth Scott. Carolina Brown Lung Association, Chapel Hill, NC 27514 Assistant Secretary for Policy, Evaluation and Research (Labor), Washington, DC. Jun 1979, 58 pp. A vailability: National Technical Information Service, Springfield, VA 22161, PB80-218340.
Very little research has been undertaken on either the economic status of work-related disease victims or on the adequacy of State and Federal compensation systems set up to serve disabled workers. Data on work history, health status, medical expenses, insurance coverage, income sources, and program experience with State workers' compensation and Federal social security disability were collected on 300 disabled cotton textile workers through the Carolina Brown Lung Association. There are significant economic and health costs which are a result of disabling byssinosis, including premature disability, lost wages, and medical expenses. The Federal Government was the source of 82 percent of the income maintenance benefits for the study Ix_pulation, while only 5.5 percent of the sample were receiving ongoing workers' compensation payments. Data indicate that the costs of work-related disability have been shifted from responsible employers to the Federal Government. Tabular material and chapter notes are included with the text; additional tables are appended along with a discussion of the study methodology and related correspondence. (NTIS abstract)
Descriptor(s): Workers compensation, Trends in health status, Present legislation/regulations, Publicly sponsored/mandated health plans.
54. Build Study 1979.
Society of Actuaries, Chicago, IL 60604 Association of Life Insurance Medical Directors of ?u-nerica, Philadelphia, PA 19103 Mar 1980, 255 pp. A vailabih'ty: Society of Actuaries, Chicago, IL 60604.
This is the fifth in a series of comprehensive studies of mortality among insured persons according to variations in body weight. It concerns the mortality experience between 1954 and 1972 on nearly 4,200,000 policies issued to men and women aged 15-69. About 450,000 of the policies were on men and women with borderline and definite underweight or with borderline and deftnite overweight. The study was confined to individuals in ostensibly good health who did not have any significant health impairments other than underweight or overweight. The total experience included some 106,000 deaths. Insured men were found to be consistently heavier than in the previous study, which covered the period 1935 to 1954. Insured women weighed more at the younger ages but less at ages 30 or older. Findings are expressed largely in terms of mortality ratios that: compare the actual deaths with the expected deaths on the basis of contemporanenus mortality rates on the policies. The mortality among overweights was somewhat lower than in the earlier
1-25
study, notably for short men 15-35 percent overweight, for medium height men 35-55 percent overweight, for short women 5-25 percent overweight and for medium height women 25-45 percent overweight. Tall men 5-35 percent overweight show slightly higher mortality in the present study. The mortality ratios among overweights generally increased with time elapsed since issue of insurance, especially among men moderately and markedly overweight. The mortality among underweights were highest in the present study. The mortality ratios among underweights were highest in the years immediately following issue of insurance and declined thereafter. Among overweight men, death rates from heart and circulatory diseases, coronary artery disease, hypertensive heart disease, diabetes, digestive diseases and vascular lesions of the central nervous system were all significantly higher than among men close to average weight, Among overweight women, heart and circulatory diseases regis-
(NHI) or even a non-NHI long-range cost containment strategy is the need to reach agreement on how much money the Nation should allocate to the broad category of health. Health problems cited in the volume include the lack of health education m the schools, the lack of good nutritional eating habits, and the lack of medical insurance coverage of mental health problem_ The volume offers discussions on these issues and others, such as health planning and resource allocation, redefinition of the industrial health program, dimensions and issues in industrial health programs, and models of industry involvement (Goodyear Tire and Rubber, R.J. Reynolds, Gillette, and New York Telephone). Recommendations are presented for the areas of health education, reimbursement, planning, quality assurance, and insurance. Notes and an appendix of conference participants are provided.
tered excess mortality. Among women 50 percent or so overweight, mortality from malignant neoplasms was distinctly higher. Generally, the lowest mortality ratios were found among those somewhat below average weight. A bibliography, methodological appendixes, and 145 tables are included. (Modified author's summary)
Based on a conference aided by a grant from the Robert Wood Johnson Foundation, held in Boston, MA, June 4-5, 1977. Springer Series on Industry and Health Care, No. 2.
Descriptor(s): Cost containment efforts, Voluntary Source of premium payment, Preventive services.
initiatives,
Descriptor(s): Demographic features of population, Trends in health status, Premium determination/underwriting, Participants in health care programs. 56. California Health Facilities Commission. of Government Regulation.
55. Business Perspective
Willis B. Goldbeck. Boston Univ. Health Policy Inst., Boston, MA 02215 1978, 70 pp. Availability: Springer-Verlag, New York, NY 10010.
Albert J. Lipson. Rand Corp., Santa Monica, CA 90406 RAND/R-2220-HCFA Health Care Financing Administration, Washington, Div. of Health Insurance Studies. Nov 1977, 250 pp. Availability: Rand Corp., Santa Monica, CA 90406.
This second volume of a series on industry and health care describes present and future ways in which industry can influence the Nation's health care system in the direction of greater efficiency and effectiveness. Although the term "industry" refers to private sector employers of all kinds, the monograph focuses on the very large firms whose policies concerning health care benefits affect the economics of the entire health delivery system, The cost of health care has forced examiners to investigate the health industry in greater detail than ever before. Three themes have emerged from the examinations: (1) health care programs and insurance are concerned mainly with curative medicine, not health; (2) health, far more than medical care, is inextricably linked with many other social policy sectors, such as transportation, housing, the environment, employment, and individual lifestyle; and (3) basic to the design of national health insurance
The political dynamics of health facility regulation in California are described as an aid to future policymaking. The history of health facility regulation in California primarily reflects the respouse of a diverse and sophisticated hospital industry and allied health provider groups to changing cost-containment and political pressures in the State. Cost-containment pressures prompted the California hospital industry to sponsor legislation, enacted in 1971, creating the California Health Facilities Commission and empowering it to implement a mandatory accounting, reporting, and public disclosure system for hospitals. Efforts to expand the commission's regulatory authority over health facilities, launched by both the Reagan administration in 1973 and the Brown administration in 1977, were defeated largely because of effective industry lobbying. The legislature has also been unwilling either to dismember the commission or to expand the rate-
1-26
on Industry and Health Care.
A Case Study
Health
DC.
Care Programs
regulatory powers of the department of health, with both moves being opposed by health provider groups. It is unlikely that California will enact major cost-containment legislation in the near future; however, the State can play a major role in developing and disseminating health facility data, conducting studies of hospital productivity, experimenting with alternative cost-containment strategies, and focusing public attention on cost-containment issues. The appendices contain organization charts of the executive branch of the State government and the California Health Facilities Commission, a chronology of important events, an interview list, and quotations from interviews,
introduction of comprehensive and universal health insurance. The evidence shows California's medicare and medicaid services increased during the Federal stabilization program. Furthermore, there were definite constraints on physician's ability to manipulate demand. Also, physicians responded to relative reimbursement rates in making choices among patients. An increase in medicare or medicaid fees relative to private charges resulted in increases in the services provided to medicare or medicaid patients. The paper concludes that policies such as areawide fee schedules might be more in accordance with the arguments that physicians can create demand, but only within limits, and that physicians react to market signals. On the other
Descriptor(s): Cost containment efforts, Inpatient facilities, Present legislation/regulations,
hand, because the evidence also suggests that utilization may increase in response to general limitations on fees, the Canadian practice of trying annual fee incomes to growth in physicians' incomes is proposed. Six tables and 21 references are given.
57. Can Fee-for-Service mand Creation.
Reimbursement Coexist With De-
Jack Hadley, John Holahan and William Scanlon. Urban Inst., Washington, DC 20037 Social Security Administration, Washington, DC. Health Care Financing Administration, Washington,
DC.
1979, 12 pp. Availability: Inquiry v16 n3 p247-258 Fall 1979.
This paper suggests that the extreme forms of demand-creation hypotheses and the standard economic model donot describe the medical marketplace adequately. The concept of physiciancreated demand or demand-inducement refers to physician's alleged ability to shift patients demand for care at a given price; that is, to convince patients to increase health care usage without lowering the price charged. This ability is based on the fact that patients generally lack the medical knowledge required to assess the quality, need, and efficiency of care and that the physician takes on both the role of medical care adviser and provider. It follows that if the physicians' income is threatened by some event, he can restore order by some combination of increasing the quantity of services or raising fees. The standard economic model, however, maintains that increases in the supply of physiclans (one of those events threatening a physician's supply and thus his income) will reduce prices of health care and induce an increase in the quantity of services demanded and in an upgrading of the quality of services offered, to which consumers respond by increasing the demand for services. This paper examines both contentions and presents evidence on physicians' prices and medicare service delivery in California to do this. The California data reflect the period of the Federal Government's Economic Stabilization Program of 1971. In addition, data are provided on physicians' incomes in Canada before and after
IMscriptor(s): Supply/availability of services, Physicians, Demand/utilization of health care programs, Policy/changes re health care, Publicly sponsored/mandated health plans.
SS. Can Health Be Planned. Or, Why Doctors Should Do Lem and Patients Should Do More. Forecasting the Future of Health System Agencies.
Aaron Wildavsky. 1976, 15 pp. AvMlability: Univ. of Chicagn, Chicago, IL 60637.
The delivery of health care services must be radically reevaluated. Health is not delivered, but rather involves fundamental human behavior which is the product of innumerable daily decisions about the food we eat and the exercise we do or do not get. Medical services and medicines can be delivered, but health must be lived. The relationship between medicine and health is not automatic, and health is determined by factors over which doctors have little control. People invariably want more medical service than any system is willing to provide, perhaps because medicine is only partially and imperfectly related to health. Medicine is an uncertain science, and there is always one more thing that might be done. Patients seek care up to the level of their insurance or subsidy. Medical expenditures rise to whatever that level is, so the only solution is to keep that level down. The 1974 National Health Planning and Resources Development Act established Health System Agencies (HSA's), mandated to reduce costs and improve delivery of health services. However, HSA's do nothing to prevent costs from rising to the level of insurance or subsidy, so they will actually increase costs and transfer ineffective service delivery from the "have-littles"
1-27
to the "have-nots." Every decision HSA's make will be paid for by patients, insurance, or taxpayers. Old services will not give way to new ones. Rather, when it becomes clear that HSA's do not work, the conclusion is likely to be that private, pluralistic medicine has failed -- not that collective regulation has failed, The conclusions should be that doctors should do less and individuals more about their own health, 1976 Michad M. Davis Lecture, deh'vered at the University Chicago on April 23, 1976.
of
Descriptor(s): Demand/ut'dization of health care programs, Health care costs, Present legislation/regulations, Economics of third-party payors, Preventive services.
nat¢ guidelines for designing quality assurance programs and implement procedures for reviewing compliance with quality assurance requirements and obtain additional staff with needed experience. Congress should defer action on proposals intended to stimulate medicare and medicaid enrollments until effective administration begins. Congress should enact the proposed financial disclosure requirements for third-party relationships and the proposed training program for HMO managers. Appendices and a few tables, charts, and footnotes are provided. (Author abstract modified) Comptroller
General's Report
to the Congress, HRD-78-125.
Desc_qptor(s): Prepaid plans, Plan design/program provisions (under health plans), Present legislation/regulations, Policy initiatives, Comparisons of health care programs, Premium determination/underwriting.
59. Can Health Maintenance Organizations Be Successful. An Analysis of 14 Federally Qualified HMOs. Comptroller General of the United States, Washington, DC 20548 Jun 1978, 72 pp. A vMlability: General Accounting Office, Washington, DC 20548.
Findings and conclusions reached following review of the operations of 14 federally qualified health maintenance organizations (HMO's) are discussed in this report. HMO's serve as alternatives to traditional fee-for-service health care delivery systems by providing health care to members based on prepaid rates. Operations review reveals that the Department of Health, Education, and Welfare (HEW) has not defined specific methods for trailslating the community rating requirements of the Health Maintenance Organization Act of 1973 into subscriber rate structures. Some subscriber rates of some organizations did not appear to be equivalent. In addition, some HMO's may not meet the act's financial soundness requirement, and membership is not broadly representative of service areas, including few indigent or elderly persons. None of the 14 HMO's has held open enrollment periods, and none has implemented planned quality assurance programs. The dual choice requirement of the act has not had a significant effect on employer costs. Problems with regard to implementation of the act include fragmented responsibility and uncoordinated efforts in operating the program, insufficient staff, and slow issuance of final regulations and guidelines, It is recommended that the Secretary of HEW issue final regulations and guidelines for defining how a community rating system should work, for evaluating requests for waiver of the open enrollment requirement, and for governing third-party relationships. Furthermore, the Secretary should develop and dissemi-
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60. Can Primary Care Deliver. Elliot J. Sussman, Harry M. Rosen, Arthur J. Siegel, John M. Witherspoon and H. Richard Nesson. 1979, 11 pp. Availability: Jnl. of Ambulatory Care Management v2 n3 p29-39 Aug 79. This study analyzes the claim that primary care leads to higher quality of care, increased satisfaction, and a more careful and restrained use of health care resources. The primary care concept stresses continuity, comprehensiveness, and responsiblity for appropriate referral when needed. Two health care facilites at Peter Bent Brigham Hospital in Boston, Mass., were compared. The Pearl Primary Care Center (PPCC) was established within the framework of the existing outpatient department as a pilot program in primary care. The General Medical Clinic (GMC) retained its traditional hospital outpatient structure. The study followed 2 matched cohorts totaling 182 patients for 3 years and indicated that a primary care system can provide health services effectively and efficiently. The two groups experienced almost identical utilization, but GMC patients made significantly greater use of the emergency room, suggesting that the primary care group may have had more preventive and fewer acute care visits. However, there was a suprisingly low rate of utilization of both medical and surgical subspcclalty clinics by both PPCC and GMC patients, and there is no apparent explanation for this. Diagnostic testing for PPCC patients was high in the first year, but subsequently declined, while testing for GMC patients increased. The increase for GMC patients may be caused by duplicate testing resulting from provider turnover, or possibly
Health Care Programs
physicians in training tend to order more diagnostic tests. The study indicates a substantial saving in hospital days for PPCC patients, with fewer hospital admissions and shorter lengths of stay. Patient satisfaction with services was high for both PPCC and GMC groups, but PPCC patients were more confident that they could contact their physicians when needed and felt more strongly that their physicians were experienced enough to decide what their medical problems were. A significantly greater numher of PPCC patients than GMC patients reported seeing the same physician each time. Continuity is a fundamental component of good medical care, increasing efficiency and patient sarisfaction. However, some of these observed differences between the two groups might be explained by the fact that PPCC senior staff physicians were committed to a primary care career. Seven tables and 20 references are provided, This article is adapted from a presentanbn at the annual meetings of the Amezfwan Federation of Clinical Research, San Frsncisco, CA, April, 1978.
Descriptor(s): Cost/benefit analyses, Comparisons of health care programs, Demand/utilization of health care programs, Providers of health care services, Medical/surgical services.
The voluntary, autonomous hospitals at the local level and independent physicians providing medical service will continue as buffers between the financing government and the consuming pubfic. If this pattern is followed, Canada may be faced with an overhaul of the system that could move in the direction of the health maintenance organizations (HMO's) in the U.S. The provincial and regional bed matrix programs for determining the type and number of required hospital beds should be continued. Although regionalization of health facilities should continue, it will remain difficult, especially in light of historical development and local pride. A system of consumer hospital charges or regional tax levies could supplement Provincial hospital revenues. The broadest challenge is to abate consumer demand through consumer planning and education, deterrent fees, coinsurance charges, percentage sharing, and similar mechanisms to instill self-discipline. Brokerage politics should permit a carefully monitored private system of health insurance and care alongside the government ones. This paper is adapted from the author's speech delivered seminar sponsored by the American Medical Associan'on held in Toronto (CAr) in November, 1978.
at a and
Descriptor(s): Health care cost trends/projections, Cost containment efforts, Comparisons regarding foreign health policies.
61. Canada's Thirty Years of Health Care Through Government. Where to From Here. 62. Canadian Approaches to Health Policy Decisions. Lloyd F. Detwiller. 1979, 7 pp. Availabih'ty: Inquiry vl6 n2 p101-107 Summer 1979.
tionl
The state of the Canadian health care system, the role of govern. ment, and client expectations are reviewed, and cost-containment measures and historical and political considerations are discussed. Additional revenue needs to be found to help pay for the health care system and to counteract escalating cost and decreasing quality. In part, the principle of the citizen's right to health care is responsible for the escalating cost. Business and insurance mechanisms must be reintroduced to make national health plans more self-adjusting and responsive to local conditions. Canadians are not prepared to alter their living patterns to the extent of giving up high-powered cars and alcohol to help hold down subsequent health costs related to reckless habits and pleasures. Government has been frustrated in its attempts to control costs by limiting research funding, by closing hospitals, or by limiting the number of doctors (the latter two having been declared ultra vires and/or discriminatory by the courts). The majority of social capital necessary to run the health system will continue to come from the Federal and Provincial governments,
Availability: Sep 78.
Na-
Health Insurance.
Gordon H. Hatcher. 1978, 9 pp. American Jul. of Public Health v68 n9 p881-889
This article examines five Canadian health policy decisions and their relevance to the implementation of national health insurance in the United States. Universal coverage of the population was one of the Canadian Federal requirements both for hospital insurance and for physicians' services insurance. In a sense, the Provincial Governments bargain with the hospitals and doctors on behalf of all their citizens to set rates for hospital and medical services, ensuring that patients are not overcharged and insurance premiums are subsidized by progressive income and other taxes. All physicians' services, including all office visits and hospital care, are covered in Canada, with virtually no copayment. Administrative costs in Canada, with a single government health insurance agency in each province, are only one-fourth those in the United States. The data base enables program managers to monitor utilization and costs of health c_re services
1-29
to improve regional health planning and contain costs; productivity of physicians and institutions also can be measured and analyzed by characteristics of providers and patients. Overservicing and overcharging can be detected easily. At the Provincial Government level, an integrated health cost containment policy had evolved from administrators' experience with universal comprehensive health insurance. However, one problem with Canada's program has been excessive use of hospital inpatient services, due to a failure to limit high technology care to a few widely separated regional hospitals in each Province. Recent Federal renegotiation of health insurance financing arrangements encourages the Provinces to deemphasize hospital care and to use the savings for alternative modes of care. In addition Canadian medical manpower policy has now become restrictive instead of expansionist, and increased supply is targeted to geographic areas defined as in short supply. Having equal fee schedules through a Province enables market forces to attract physicians to rural and underserved areas. Tables, footnotes, and 24 references are included,
across the landscape has long been regarded as a problem in the United States. This study suggests that adoption of a Canadian style of program would exacerbate this problem. The study indicates genuine cause for alarm as to who actually pays for the insurance. Both the hospital and medical care parts of the program are financed by displacement in the budgets of other social welfare programs. For every dollar spent on Canadian NHI, the government reduced by 60 cents program budgets for worker's compensation, aid to the blind and disabled, and family allowances. The middle classes, holding the marginal, decisionmaking votes, are likely to benefit from new programs at the expense of the poor. While it has been shown that low-income groups seem to get somewhat more care than they would have been able to obtain before NHI, they are not the only groups consuming care under the program. If the burden of financing the program falls too heavily on the poor, then the result may be the sort of perverse redistribution which improves the lot of the middle and upper classes at the expense of the poor. Initial thinking suggests that in the United States those effects would not differ greatly from those experienced in Canada. Fifteen tables, five figures,
Otiginaily presented at the 105th Annum Meeting of the American Pubhc Health Association, Washington, DC, 1977.
two appendices, and a bibliography Descdptor(s):
Descriptor(s): National health insurance (NHI), Comparisons regarding foreign health policies, Outcome/evaluation of health administration, Cost containment efforts, Health information/ data systems.
63. Canadian National Health Insurance. Lessons for the United States.
Cotton M. Lindsay, Health Issues, New Roche Lab., Nutley, 1978, 43 pp. Availability: Health
Steven Honda and Benjamin Zycher. York, NY 10019 NJ. Issues, New York, NY 10019.
The Canadian national health insurance (NHI) system is frequently presented as a model upon which a U.S. system might be based. To a certain degree, the Canadian approach has been to develop not a single system, but a network of different provincial plans, each organized and financed according to the dictates of the individual provinces. But for the most part, these differences are superficial. The coverages provided by the different plans are virtually identical, and the plan is indeed an NHI system. This study reveals that most Canadians pay more for their medical care now that it is free: they first pay taxes and then spend time waiting for the services which are frequently of a debased quality. The geographical imbalance of physicians
1-30
are provided.
National health insurance
(NHI),
Comparisons
regarding foreign health policies, Supply/availability of services, Source of premium payment, Participants in health care programs, Plan design/program provisions (under health plans).
64. Cancer Insurance. Exploiting Fear for Profit. An Exami. nation of Dread Disease Insurance.
Select Committee on Aging (U.S. House), Washington, DC 20515 Mar 1980, 292 pp. A vailability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 052-071-00609-5.
Based on a congressional committee's investigation of cancer insurance, this report concludes that insurance policies which pay for medical expenses relating to cancer are not a good buy, that sales tactics used to promote such policies are highly questionable, and that cancer insurance is unnecessary for elderly beneficiaries of medicare. Data on the numbers of cancer policies, the insurance companies involved, and sales strategies are presented. The discussion notes that the cause of widespread abuse is the fear of senior citizens concerning escalating health costs and decreasing medicare coverage. Major investigations conducted since 1971 of companies that sell cancer insurance are summarized, followed by descriptions of market conduct studies
Health Care Programs
undertaken by Massachusetts of 4 principal cancer insurers: American Family Life Assurance Co., American Income Life Insurance Co., Union Fidelity Life Insurance Co., and Washington National Life Insurance CO. The results of a questionnaire sent to 50 State insurance commissioners by the committee are also detailed. Most agreed with the committee's conclusions about the ineffectiveness of cancer insurance. A poll of the Nation's largest health insurance companies showed that most shared this view but were unwilling to comment on fear tactics nsed to sell the insurance. Few of the top 50 companies, however, sell cancer insurance. An examination of mail order insurance
included along with summaries of its capital requirements and capital fmancing covering the past 15 years. The following suggested changes in methods of reimbursement of group practice prepayment plans and other health care providers are included in the discussion: (1) medicare should recognize and include appropriate earnings in computing the amount of payment due group practice prepayment plans and other providers of services for medicare beneficiaries; (2)retrospective cost reimbm'sement systems of payment should be changed to payment of fixed prospective rates; and (3) title XVIII, section 1876, and title XIX, section 1903, should include payment provisions that per-
companies indicated that consumers do not save money by putchasing policies in this manner. Great opportunities for abuse exist in mail order schemes because States do not have the authority to regulate any policy sold through interstate mail. Finally, 33 major findings of the investigation are presented. The committee recommended that policies sold to the elderly who have medicare provide only broad coverage and not be limited
mit health maintenance organizations to be paid for medicare and medicaid enrollees in accord with established fixed prospective prepayment principles, including appropriate earnings. Footnotes and tabular data are included. A description of the Kaiser-Permanente Medical Care Program is appended. (Author abstract modified)
to one disease. Federal assistance to States in regulating cancer and mail order insurance was also suggested. The appendices contain questionnaires sent to State insurance commissioners and insurance companies and information materials on advertising used to promote cancer insurance.
Descriptor(s): Prepaid plans, Policy initiatives, Methods of payment determination, Publicly sponsored/mandated health plans.
96th Congress second session, Committee
66. Care of the Aged. Old Problems in Need of New Solutious.
Pub. No. 96-202.
Descriptor(s): Non-employment related plans, Limitations on coverage, Policy initiatives, Health insurance industry.
65. Capital Requirements and Capital Financing in a Hospital-Based Group Practice Prepayment Plan.
Pittsburg Univ. Dept. of Health Services Administration, Pittsburg, PA 15260 1977, 20 pp. Availability: Kaiser Foundation CA 94612.
Health Plan, Inc., Oakland,
To provide a base for a discussion of capital requirements and capital financing of hospital-based group practice prepayment plans, this paper describes the general characteristics of such plans. It focuses on the long-term capital-financing requirements of health care institutions and systems including hospital-based group practice prepayment plans. Government purchasers of health care from the Kaiser-Permanente Medical Care Program and the bases of payment are identified, with particular emphasis on the program's community rate as the foundation for such payment arrangements except lbr medicare. The capital fmancing policy of the Kaiser-Permanente Medical Care Program is
Robert L. Kane and Rosalie A. Kane. 1978, 7 pp. Availability: Science v200 n4344 p913-919 26 May 78.
This article describes the nursing home in the context of other long-term care alternatives, the population found in nursing homes, some of the nursing home issues, and a suggested formula for nursing home reimbursement that might provide more effective care. In 1973, there were over 21,834 nursing homes in the United States with over 1.25 million beds. A total of $12.5 billion was spent for nursing home care in fiscal 1977 of which $4.0 billion came from Federal sources and $2.9 billion from State and local governments, primarily from the medicare and medicaid programs. Most nursing homes are owned by private proprietors and have residents who vary enormously in physical impairment and mental disorientation. In contrast, some European countries have long-term care programs under government sponsorship, provide more adequate funding for their nursing homes, and offer alternatives to institutional living such as the Scotland sheltered housing projections which call for developing 50 such units for every 1,000 persons over age 65. Even countries with well-developed long-term care systems experience problems of rising costs, lack of agency coordination, variable style of care, scant program data, and high staff turnover. The article recommends (1) subsuming the provision of health care under a social
1-31
plan, (2) developing a geriatrics specialty for physicians, (3) using other forms of primary health care providers, and (4) developing alternatives to institutional care such as sheltered housing. In addition, the article proposes that nursing homes be paid on the basis of the actual incomes of their patients, using available data collection and review mechanisms. Tabular data and 28 references are given.
Descriptor(s): Cost containment efforts, Comparisons regarding foreign health policies, Present legislation/regulations, Voluntary initiatives, Policy initiatives.
68. Case for a National Health Service. Descriptor(s):
Long term care facilities, Policy initiatives, Com-
parisons regarding foreign health policies.
Milton Terris, Paul B. Comely, Henry C. Daniels and Lorin E. Kerr. 1977, 3 pp. Availability: American Jnl. of Public Health v67 n12 p1183-
67. Carter Administration, Congress and Health Policy,. A National Leadership Conference.
1185 Dec 77. This article delineates
National Journal, Wa_shington, DC 20036 1978, 81 pp. Availability: Government Research Corp., 20036.
Washington,
DC
This publication presents an edited transcript of the proceedings of the National Leadership Conference on current health policy issues, held May 22 and 23, 1978, in Washington, D.C. The first panel discussed national health policy directions and analyzed four perspectives: health and the environment, disease prevention, veterans medicine, and health financing. Next, a congressional health priorities survey was reviewed, evidencing congressional concern over rising medical costs but disagreement over the role that the Government should play. A cornparative study of the health plans of Australia, Canada, France, and West Germany with those of the United States presented ways in which other nations provide low-cost health care. Following an address by Health, Education, and Welfare Secretary Joseph A. Califano, Jr., working groups met to discfiss health planning, Federal drug regulation, cost containment through volunteerism, and the relationship of medical technology and health policy. Proceedings on the second day concerned legislarive matters -- the role of health regulations as they impact the economy and society. The need to coordinate the proliferation of data on which the health care system depends for planning, budgeting, rate review, and insurance was addressed. White House health policy views were expounded and the role of State governments in providing regulatory initiatives were assessed. The concluding session explored the many dimensions of health planning in terms of regulation, consumerism, fmance, medicine and HMO's from participants' data are included,
divergent
viewpoints.
Tabular
National JournM Conference Proceedings, held May 22-23, 1978 at the MayrTower Hotel, Waslu'ngton, DC
1-32
the features and differences of two con-
cepts: national health insurance (NHI) and national health service (NHS). The crucial features of NHS are that all health workers are government employees and that all care is provided in government hospitals and health centers. In addition, by definition, NHS covers the whole population. In Canada and the United States, the crucial feature of NHI is that the health providers, whether professional or institutional, are independent entrepreneurs who enter into a contractual arrangement with the government to provide services. Both in the NHI program operating in Canada and in every NHI bill in the U.S. Congress, the right of physicians and other professionals to be paid by fee-forservice is assured. However, this type of system will not be effective in meeting the Nation's health needs. This conclusion is based on the disillusioning experience with voluntary health insurance and with more than a decade of NHI for the aged, namely medicare. The medicare program has a number of flaws, all of which are inherent in fee-for-service NHI. These include the rapid escalation of costs, accompanied by extraordinarily high incomes of practitioners; the rise in premiums for the aged, cuts in covered services, and an increase in out-of-pocket expenses; further commercialization and corruption of the medical profession; and a strengthening of the archaic system of fee-forservice solo practice and independent hospitals by the influx of public funds. In addition, medicare has enabled members of other health professions, such as physical and occupational therapists, to leave hospitals where they are badly needed and to develop highly lucrative private practices. Medicare, considered a trmancing program, has emphasized paying bills rather than providing services. Thus, Government regulation has proved ineffective in containing costs while increasing paperwork and bureaucracy. The Nation's health services must be reorganized to meet the needs of the public instead of the providers. This can be done only by establishing NHS. Other health insurance patterns are also discussed, including those in Scandinavian countries, Spain, Chile, Mexico, Turkey, and Great Britain. Eight references are provided.
Health Care Programs
Descriptor(s): National health insurance (NHI), Supply/availability of services, Providers of health care services, Policy initiatives, Methods of payment determination.
70. Case-Mix Difference Between Nonprofit and For-Profit Hospitals. Carson W. Bays. 1976, 5 pp. Avafflabih'ty: Inquiry v14 nl p17-21 Mar 77.
69. Case for Negotiated
Rates.
Anne R. Somers. 1977, 4 pp. Avsil_bi_ty: Hospitals v52 n3 1)49-52 1 Feb 78.
This paper presents data on differences in case mix within a sample of 41 short-term general hospitals composed of for- profit hospitals and nonprofit types. Specifically, the data relate to the issue of "cream skimming," the alleged tendency of hospitals organized for profit to treat conditions with the highest pricecost margins, thus leaving less lucrative conditions to be treated
Negotiated rates are described as a promising method of controlling health care rates. There are different approaches to price determination in the health care field. The marketplace method reties entirely on consumer-provider interactions, and the provider determination method is unfettered by any other factors than provider decisions. Both are inflationary and uncontrolled, Government rate setting would be difficult to impose on the health professions and on the health industry, and consumer or public regulatory bodies are not feasible. The weaknesses of these methods point to the possibility of a fifth method, negotiated rates. Formally organized, officially recognized bilateral negotiations would take place among representatives of health care providers, especially physician and hospitals, the major organized consumer groups, such as those responsible for financing medicare and medicaid, and subscribers to private health insurante, and third-party payers. Also needed is a social, political, and structural framework that will permit the parties to work together toward solution of the problem and will take into account two circumstances - the near universalization of third party payments and limited resources. The mission of the negotiators would be to arrive at firm, prospective, all-inclusive, national, regional, and State rate schedules. Rate variations would correspond to geographic, specialty, and other significant factors, and the rates would be binding for a specificed time period, perhaps 2 years. Medical fee setting would require extensive use of relative value schedules; hospital rate setting could be on the basis of itemized charges, per diem costs, capitation, and patient stay by diagnosis. Negotiated rates would be reviewed by an independent neutral review board. Statutory changes required for such negotiations would include amendment of Federal antitrust laws and State health insurance laws as well as repeal of "reasonable costs " and "reasonable charges" provisions of the Social Security Act. Six references are provided.
by nonprofit hospitals by default. Data were obtained from Carlfornia hospitals for patients admitted during 1971 and 1972.
Adsptedfromapspvrpresentedataspeci_dconfer_atDuke Univ. Medical Center, Septemher 10, 1977.
National Center for Health Statistics, Hyattsville, MD 20782 Nov 1980, 61 pp. Availabih'(y: National Center for Health Statistics, 3700 EastWest Highway, Hyattsville, MD 20782, DHHS Pablication No. (PHS) 81-1213.
Descriptor(s): Cost containment efforts, Policy initiatives, Methods of payment determination,
Information analyzed includes the average number of beds in use during the year, the number of patient days, the estimated value of the input of admitting physicians, payroll data, assets, and number of outpatient visits per year. Variables focus on the proportions of admissions in broad diagnostic categories and indicators of case severity. Analysis indicates that for- profit hospitals admit significantly more cases of infective diseases, respiratory diseases, skin diseases, and trauma cases than do nonprofit hospitals; they admit significantly fewer diagnosed cases of neoplasms, maternity, and central nervous system disorders. For- profit hospitals also admit significantly fewer older patients and have lower average costs per operation, length of stay, and proportion of medicare admissions than do nonprofits. Available data do not provide answers regarding quality of care issues. However, cream skimming is not a quality issue but one of allocative and distributional efficiency. The data analyzed in this study are consistent with the eream-skimming hypothesis. Future research should address the reasons that for-profit hospitais produce only certain types of care, as well as the relative of the profit motive on prices, quantity, and quality of care. Two tables and 10 reference notes are included.
This paper is derived from a portion d/ssertation.
of the author's
Desc_'ptor(s): Health care costs, Hospital facilities, Supply/availability of services.
dactoral
services, Inpatient
71. Catalog of Public Use Data Tapes from the National Center for Health Statistics.
1-33
This publication catalogs data tapes made available to the public by the National Center for Health Statistics (NCHS), sets forth exclusions on their use, and indicates ordering information. The NCHS is the primary source of statistical data on vital events, health, and related matters pertaining to the American people, While the published report remains the predominate means used by the NCHS to disseminate this data, it also releases the 'standardized microdata tape transcripts' described in this catalog, Numerous data sets are available for purchase, including those having to do with data on health facilities (hospitals, nursing homes, and family planning units), those dealing with data on health resources utilization (the National Hospital Discharge Survey, the National Ambulatory Medical Care Survey, and the National Nursing Home Survey), data on vital events (natality, mortality, marriage, and divorce data), data from the National Survey of Family Growth, data from the National Natality and Mortality Surveys, and data from the National Health Interview Survey. Finally the data sets from the National Health and Nutrition Examination Surveys are available. Assession num-
have three major sources of assistance in meeting the cost of health care: private insurance, public programs, and tax subsidies. Collectively, these sources significantly reduce the percent of medical expenses paid directly by the consumer; however, the lack of adequate basic insurance coverage for almost a third of families with incomes below the national median and the failure of public and private health insurance programs to cover certain types of services result in two kinds of catastrophic out-of-pocket expenses: the cost of long-term care for the aged and average or normal expenses that consume an unreasonable proportion of low-income families' resources. Approaches proposed to deal with the problem of catastrophic medical expenses are a traditional insurance plan, an income-related plan with fixed maximum liability, a mixed traditional and income-related plan, and a uniform mid universal plan to deal with the specific catastrophic expense problems of both low-income and middle-income families through a single program. Tabular data and estimates of induced costs are appended.
bers, cost, and order forms are included with each description, as is a tabular summary of the data presented and a technical contact person. Twenty tables are provided,
Descriptor(s): Private health care plans, Publicly sponsored/ mandated health plans, Plan design/program provisions (under health plans), Long term care facilities, Health care/services, Policy/changes re health care.
Descriptor(s): systems.
Trends in health status, Health information/data
73. Catastrophic Illness Expense. Implications Health Policy in the United States. 72. Catastrophic
for National
Health Insurance.
Susanne A. Stoiber. Congressional Budget Office, Washington, DC 20515 Jan 1977, 61 pp. A failabih'ty: Superintendent of Documents, Government Printing Office, Washington, DC, order number 052..07003882°9.
Michael Schwartz, Naomi Naierman and Howard Birnbaum. Abt Associates, Inc., Cambridge, MA 02138 National Center for Health Services Research, HyattsviLle, MD. 1978, 10 ppo Availability: Social Science and Medicine v12 nlc/2c p13-22 Jun 78.
The frequency and origins of "catastrophic" medical expenses, the extent to which they are currently met through public programs and private insurance, and various proposals for insuring "catastrophic" costs are discussed. Two methods have been used most commonly to gauge whether a medical event is catastrophic: (1) the level of large absolute expenditures and (2) medical costs in proportion to a person's income. In fiscal year 1978, an estimated 2.4 million persons under the age of 65 will incur expenses that exceed $5,000. An estimated 21.4 million families will incur medical expenses exceeding 15 percent of their income in 1978. The most significant catastrophic expense problem, however, is long-term care. In fiscal year 1978, an estimated 1.3 million persons will be residents of nursing homes for 6 months or longer at an aggregate cost of about $14.7 billion. Consumers
Accurate statistics on expensive illnesses are generally unavailable. Catastrophic illnesses, those involving more than $5,000 in medical expenses per year, contribute significantly to overall medical care inflation. The actual costs of these illnesses are often hidden in hospital bad debts, increased insurance premiurns, and indirect public subsidies. In this report, preliminary data on incidence rate, average cost per episode, number of individuals, and total national cost of catastropic illnesses were collected and the results disaggregated by age, sex, income, and geographic region. Analysis reveals that the average expenses varied considerably. Furthermore, it is commonly believed that low-income people have greater health problems, but this study reveals that middle-income people had higher per capita catastrophic expenses. A disproportionately large number of catas-
1-34
Health Care Programs
trophie expenditures are incurred by long-term institutions, ineluding nursing homes, psychiatric hospitals, and tuberculosis hospitals. What is more, a disproportionately large amount of these expenses belonged to the aged population over 65. No information is available on the effectiveness of this care. The large amounts of money spent to treat a few individuals might yield greater benefits if spent on preventive care or health education. Catastrophic illnesses have been consuming increasingly large shares of medical expenses, and there are few constraints, National health insurance proposals providing unlimited coverage of catastrophic conditions may be expected to increase these large medical expenditures. Additional research on the determinants of catastrophic expenses is vitally important. Public poficy b3ward these illnesses clearly relates directly to American public policy toward aged and institutionalized individuals. A figure of population partitions, 7 tables comparing data, and 11 references are provided,
Descriptor(s): Trends in health statns, Health care costs, Demographic features of population, Policy/changes re health care.
percent of their family income. Females had a higher incidence of reaching the low threshold level of utilization, while males were more likely to reach the highest threshold level. In general, older persons (especially those 60 and older)experienced higher rates of catastrophic illness than younger persons. Of the total value of services, 38.3 percent were inpatient services, with 44 percent of that figure attributable to the basic per diem fee, 32 percent to surgery, 9 percent to physician visit and consultation charges, and 14 percent to other services. Inpatient care represeats 15 percent of the total utilization by persons using less than $1,000 worth of care, compared with 77 percent for persons using more than $1,000 and 88 percent for those using $5,000 worth. Although there were eight different general disease categories represented, neoplasms, diseases of the circulatory system, and diseases of the digestive system represented more than 65 percent of the catastrophically expensive cases. Future analyses will focus on the subscriber unit, the membership's experience over a 4-year period, and the distribution of high utilization among socioeconomic groups in the population. Tabular data and 18 references are appended.
Descriptor(s): Trends in health status, Demand/utilization of health care programs, Prepaid plans, Health care costs, Participants in health care programs. 74. Catastrophic
Illness in an HMO.
David R. Lalrson, Ron N. Forthofer and Jay H. Glasser. National MD.
Center for Health Services Research, HyattsviUe,
1979, 12 pp. Availabih'ty: Inquiry v16 n2 p119-130 Summer 1979.
This paper presents preliminary findings on the incidence and distribution of catastrophic illness among members of the Kaiser Foundation Health Plan of Portland, Oregon. By applying a fee structure to known medical care utilization by the 6,208 individuals in the sample, the study estimated the rate of catastrophie illness by using 5 alternative economic definitions. These definitions included three levels of dollar utilization $1,000, $2,500 and $5,000 as well as two income-related measures (dollar utilization grcater than 15 percent ofthe total family income and greater than 50 percent of per capita family income). The estimated rate of catastrophic illness in this population varies from a low of .129 percent for the $5,000 threshold definition to a range of from 3.318 percent to 4.320 percent for the 15 percent of family income definition. While representing less than 1 percent of the population, the $2,500 catastrophic group accounted for more than 15 percent of the total utilization. As expected, a relatively high proportion of persons who died during the year experienced catastrophically expensive medical care use. More than 62 percent nsed $1,000 or more; more than 32percent nsed $2,500 or more; and more than 80 percent used at least 15
7S. Challenge of Primary Care.
David E. Rogers. 1977, 23 pp. Availability: Daedalus v106 nl p81-103 Winter 1977.
During the last decade, the ability of readily available medical care to improve or maintain health has been oversold. In most instances, medical intervention is relatively ineffective in preventing disease or preserving health. Clearly, more medical care will not in and of itself produce better health. Nonetheless, actess to a more effective primary care system is a profound human need, especially in light of the fragmentation of families and social organizations. In response to these needs, the training of family practitioners will be expanded and the training of specialists such as internists will be modified to prepare them more adequately for new generalist roles. In addition, an enlarged corps of new health professionals will enable individual physieians to manage more patients, enhancing their capacity to serve as personal physicians without sacrificing the exposure: to tomplex diseases that keeps their technical skills up to date. With the focus of primary care on health and care groups, new skills in epidemiology, demography, and the behavioral sciences now rarely employed by physicians in their praetices will be used, and
1-35
consequently, general medicine will become intellectually richer, more exciting, and more challenging. Inequalities in availability and quality of medical care will continue, but these gaps can be reduced to acceptable dimensions without totally dismembering the medical establishment. Tabular data, 19 references, and 4 figures illustrating proportions of specialists to generalists, distribution, and increasing costs of medical care are also provided. Descriptor(_9: Supply/availability health care services.
of services,
Providers
Health Polky
Program Discussion Paper.
Descmptor(s): Health information/data systems. Health care cost trends/projections, Cost/benefit analyses, Medical technology impacts, Diagnostic
services, Medical/surgical
services.
of 77. Changing Health Care. Perspectives cal Care Setting.
From a New Medi-
Gerald T. Perkoff. 76. Changes in the Costs of Treatment of Selected Illnesses. 1951-1964-1971.
Anne A. Scitovsky and Nelda McCall. California Univ. School of Medicine, San Francisco, CA 94143 National Center for Health Services Research, Hyattsville, MD. Aug 1975, 72 pp. A vnilability California Univ., School of Medicine, San Francisco, CA 94143.
This update of an earlier work comparing the treatment costs of selected illnesses in 1951 and 1964 suggests that the net effect of changes in medical treatment tend to be cost raising rather than cost saving. The report points out that the only significant trends toward lower costs are the reduction in length of hospital stays and the increased tendency to treat patients with selected illnesses in an ambulatory setting. Every other shift in the care of these selected illnesses -- the use of tests, the level of physician training, the nature of the medical or surgical therapy -- tends to increase costs. The selected illnesses include otitis media (middie ear infection) in children, acute appendicitis (subdivided into simple appendicitis and perforated appendicitis), maternity care, cancer of the breast, and forearm fractures in children (subdivided into cases requiring a cast only, cases requiring a closed reduction without a general anesthetic, and cases requiring a closed reduction with a general or regional anesthetic). The new study also includes pneumonia, duodenal ulcer, and myocardial infarction for the years 1964 and 1971, investigates the Bureau of Labor Statistics medical care price index for the period 1964 to 1971, and analyzes the effects of changes in treatment on costs for both the 1951 to 1964 and the 1964 to 1971 periods. For both studies, the study population consisted of patients treated by doctors at the Palo Alto Medical Clinic, a multispecialty, largely fee-for-service group practice of about 140 physicians in Palo Alto, Calif. Tables are included. Data tables and footnotes are appended,
1-36
Washington Univ. School of Medicine Div. of Health Care Research, St. Louis, MO 63110 Robert Wood Johnson Foundation, Princeton, NJ. National Center for Health Services Research and Development, Rockville, MD. National Fund for Medical Education, New York, NY. Kellogg (W.K.) Foundation, Battle Creek, MI. Bureau of Health Manpower, Hyattsville, MD. Washington Univ., St. Louis, MO. Metropolitan Life Insurance Co., Washington, DC. Henry J. Kaiser Family Foundation, Palo Alto, CA. 1979, 160 pp. A vnilability: Health Administration Press, Ann Arbor, MI 48109.
This book, written especially for medical school faculty, practicing physicians, and social scientists interested in health services and medical politics, describes and interprets the development of the Medical Care Group (MCG) of Washington University, a teaching and research prepaid group practice. Designed to be a continued and defined experiment in prepaid group practice, MCG was 10 years into the project by 1968 and had enrolled 24,000 people. Difficulties encountered during the early development of MCG included physician resistance to the plan, the complexity of arranging for specialty services, and the problems of recruiting and managing staff, marketing the plan, and providing an appropriate teaching and research model for primary care. The original goals included construction of a rational system of medical care within a major medical school which would provide the needed evidence on cost, utilization, and effectiveness to encourage change. MCG was an attempt to adapt the ideal of convenient, one-stop, patient-oriented primary care services to academic teaching and research services and programs which had their own goals, methods of operation, and needs. MCG had to pay higher salaries than had been hoped, and the productivity of almost everyone was lower than in fee-for-service settings, partly because of increased paperwork within the organization and partly because MCG physicians resisted delegating patient care to allied health professionals. The MCG experience
Health
Care Programs
confirmed that academic leadership in clinical departments is often critical of those who pra_ice in outpatient settings. Having almost never worked in such settings on a continuing basis, academicians have little respect or understanding of the day-today demands a physician faces in caring for his patients. If the rational reorganization of medical care is to occur, physicians must reemphasize their human service commitment and conduct their work for the patients' benefit rather than for the sake of high incomes. MCG is now being gradually excluded from the mainstream of the medical school and is on the way to becoming an independent corporation. Although organization of medical care into an effective group with prepayment did lead to reduced hospital and increased ambulatory services utilization, in and of itself this did not reduce medical care costs. Data suggest that high expectations for cost savings from this method of medical
status. When viewed at various points in time during 1977, the medicaid population appears to be fairly stable at about 13 million, except for the January through March 1977 period, when it was 15.6 million. The apparent stability, however, disappears when the medicaid population is viewed in terms of full-year coverage and part-year coverage. Estimates indicate that only 9 million are covered all year as contrasted with 11.8 million covered by medicaid part of the year. Of the 11.8 millions. 6.5 million were uninsured during the whole time they were not on mcdicaid; 4.3 million were insured the entire time; and t3:wer than 1 million were insured and uninsured part of the time they were not on medicaid. Discussions of the sample design and edits performed on the medicaid estimate are appended. Tabular data are provided.
care delivery may need to be modified. An appendix provides a summary of data and an explanation of methodology; an index is also supplied.
Presented at the 1980 Annual Meeting of the American cal Association, Houston, TX, August 11, 1980.
Descriptor(s): Prepaid plans, Providers of health care services, Evaluations/outcome of health care programs, Outpatient facilities.
78. Changing Medicaid Population. Gall R. Wilensky, Daniel C. Walden and Judith A. Kasper. Aug 1980, 23 pp. Availability: National Center for Health Services Research, Hyattsville, MD 20782.
Results are reported from a study that examined movements on and off of medicaid during 1977 and the insurance status of the part-time medicaid population during the periods they are not on medicaid. Data also compare the medicaid population at various points in time with the privately insured population according to selected characteristics. The data used were ohrained from the National Medical Care Expenditure Survey, specifically rounds 1 through 5 of the household interviews, Interviews were conducted during the approximate periods of January through March 1977, and April through June, July through September, October through November, and December through March 1978. Questions on insurance coverage were limited to events occurring during calendar year 1977. Using only direct report data, 20.4 million persons reported receiving medicaid sometime during 1977. Using adjusted data, 20.8 raillion reported receiving medicaid. The medicaid population is younger, less educated, more likely to be female, and more likely to be nonwhite than the privately insured population; the medicaid population is also more likely to report a poorer health
Statisti-
Descriptor(s): Demand/ut'flization of health care programs, Medicaid, Participants in health care programs, Non-participants in health care programs, Demographic features of population, Competition/interaction among third-party payors.
79. Changing Patterns and Implications for Cost znd Quality of Dental Care.
Israel L. Praiss, Kenneth A. Tarmenbaum, Cheryl A. GelderKogan and Christiane B. Hale. Health Programs Research, Inc., Ann Arbor, MI 48107 Kellogg 0V.K.) Foundation, Battle Creek, MI. American Fund for Dental Health, Chicago, IL. 1979, 10 pp. Availability: Inquiry el6 n2 p131-140 Summer 19'79.
This paper is the report of a survey of 230 third.-party payer programs which describes the trends and patterns of dental care insurance growth between 1970 and 1976; identifies third-party payer characteristics in terms of their use of cost-sharing mechanisms, claims management, and review procedures; and assesses the implication of these characteristics on costs and their potential for monitoring quality of dental care. Of the programs identified and approached, 19 did not offer any dental coverage. The remaining 211 programs represented Delta plans, Blue Cross and Blue Shield, medicaid, and commercial plans. Based on figures showing that 68 million people had dental coverage in 1976, current projections for 1980 appear to be low. The commercial carriers currently write the greatest share (twothirds) of dental coverage because they can offer a wider range of other types of insurance. Blue Cross and Blue Shield plans
1-37
have a similar competitive advantage enhanced by their nonprofit status. Commercial carriers emphasize cost-sharing mechanisms and use fewer pre-treatment and post-treatment mechanisms than other payer groups. Since these review procedures are essential to decisions about quality, the absence of such mechanisms seemingly preclude a payer from doing anything other than paying claims. Moreover, a strong emphasis on costsharing mechanisms may impose a barrier to claims, services, and treatment pattern evaluations. Blue Cross and Blue Shield plans use pretreatmeut review mechanisms more frequently than commercial carriers but slightly less than the Delta programs, Medicaid post-treatment review mechanisms approximated those used by the Deltas. The Delta and medicaid programs both appear to have a broad range of mechanisms with potential for use as quality indicators; Deltas should consider the marketing potentials of their procedures. Blue Cross and Blue Shield plans and commercial carriers less frequently use such reviews but it is unclear whether this indicates less concern with quality of
change is critical if the hospital industry is to evolve into a stronger industry which meets the needs of the changing population. In addition, a hospital has little control over whether change occurs, but it does have some control over how it occurs. Change activities will involve selecting and implementing specific role options. In selecting appropriate options, tasks will include discussion by the change management team; assessment of the hospital's present position compared with earlier times; selection of role categories to be studied; creation of a structure and process for study; selection of leadership; completion of study; and assimilation, testing, interpretation, and communication of results. Once these steps are completed, the hospital is ready to implement them to realize desired goals. Role options considered include hospice, ambulatory care, health promotion, and organizational options. Service options, the health needs of industry, and closure and conversion are also addressed. Thirty tables, notes, and sources of information are included.
care. Tabular data and 17 references are provided.
AHA
Descriptor(s): Third-party payors, Commercial health insurance plans, Service benefit plans, Medicaid, Dental services, Outcome/evaluation of quality assurance, Plan design/program provisions (under health plans).
Descriptor(s): Hospital services, Inpatient facilities, Outcome/ evaluation of health administration.
No. 1186.
81. Charges and Sources of Payment for Dental Visits With Separate Charges. Data Preview 2. 80. Changing Role of the Hospital. Options for the Future.
Mara M. Melum, Fern Z. Liang and Sheryl Locke McInerhey. Minnesota Hospital Association, Minneapolis, MN 55414 1980, 322 pp. Availability.. American Hospital Association, Chicago, IL 60611. This text is based on the Minnesota Hospital Association's 1979 workshop which focused on the changing role of the hospital. Proceedings of the workshop sessions are provided, along with other information pertaining to hospital role options. The purpose of the workshops and the text is to develop hospital leadership that is strong enough to manage change for positive results, Many alternatives are explored, providing a wide range of options that can be implemented by hospitals committed to meeting people's changing needs. Options range from relatively isolated service changes to fundamental changes in the hospital's mission. Contributors to the conference are experts from throughout the United States who have had direct experience in implementing role options. Descriptions of these experiences are emphasized. The text focuses on why hospitals should change, how they can change, and what options are available. Positive
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Louis F. Rossiter and Walter R. Lawson. National Center for Health Services Research, Hyattsville, MD 20782 DHHS/PUB/PHS-80/3275 1980, 12 pp. A vailability: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782.
Differences in charges for dental care according to population characteristics and to the extent of third-party payments from private health insurance or Government programs are reported. The report is based on dental care data from the National Medical Care Expenditure Survey for the period between January 1, 1977 and March 31, 1977. Data were obtained from about 14,000 randomly selected households, physicians and health care facilities providing care to household members, and employers and insurance companies. Data indicate that a separate fee was charged for about 66 percent of all dental visits. The average reported charge was $31.71 per visit, and of this amount an average of $24.42 was paid by the patient or the patient's family. The average proportion of the charge paid by the family increased with age; the lowest proportion paid by the family was
Health Care Programs
for children 12 years of age or younger. A larger proportion of charges was paid by public sources for nonwhites. In addition, the average charge for dental visits did not vary significantly by the education of the patient, although the average proportion paid by the family increased with educational level. Moreover, the average charge for dental visits was higher in the West than in the South or the North Central region. More than 90 percent of all dental visits with separate charges involved only one source of payment. Two tables are included. NCHSR
NationM Health
Care Expenditures
Study.
Descriptor(s): Demographic features of population, Dental set• vices, Health care costs, Impact of third-party coverage, Source of premium payment,
82. Charges and Sources of Payment for Visits to Physician Offices. Data Preview $. National Center for Health Services Research, Hyattsville, MD 20782 DHHS/PUB/PHS-81/3291 Mar 1981, 8 pp. A vailabih'ty: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782. Charges and sources of payment for visits to a physician's office are examined. Particular attention is given to differences in charges and the extent of third-party payments for different groups in the population. The findings are based on preliminary data from the National Medical Care Expenditure Survey for the period between January 1, 1977, and March 31, 1977. The mean charge for physician office visits during the first quarter of 1977 was $21.29, and of this, the patient paid an average proportion of $14.69; the remainder was paid by other sources such as private health insurance ($3.41), medicare ($0.85), and medicaid ($1.49). Differences in charges were found according to age, education, location of residence, and region of the country. Differences in sources of payment were observed for each of the population characteristics examined. Two tables are provided. (Author abstract modified)
NCHSR
National Health Care Expenditurvs
Study.
Descriptor(s): Demographic features of population, Medical/ surgical services, Impact of third-party coverage, Health care costs, Source of premium payment.
83. Checkbook's Guide to Health Insurance Plans for Federal Employees. For District of Columbia, Maryland, and Virginia (Also covers D.C. Government Employees). Walton Francis. Washington Center for the Study of Services, Washington, DC 20005 1980, 58 pp. Availabih'ty: Washington Center for the Study of Services, Washington, DC 20005. Designed for Federal civilian employees and retirees, both postal and nonpostal, and District of Columbia Government employecs, this book covers 30 Federal health plans available to executive, legislative, and judicial branch employees in the District of Columbia, Maryland, and Virginia. The book may enable employees to save as much as $300 or more by choosing the fight health plan. Every employee in the area has at least 22 plans from which to choose; 7 are new this year (1980). To help employees decide which plan is best for them, the book provides estimates of likely and not-so-likely costs under each of the plans available and compares special features of the various plans. In addition, the results of a recent survey show which plans pay their bills promptly and without redtape, which health maintenance organizations (HMO's) schedule appointments quickly, and which HMO's have doctors that take the time to talk with their patients. Tables show total medical expenses under each plan, including both premiums and out-of-pocket expenses, and show what each plan will cost in an "average" year and in years in which medical expenses are much better or worse than average. Information is also given on special features of plans, such as benefits for skilled nursing care and mental hospital care, and factors to consider in finally selecting a plan. Appendices describe what health insurance is, what financial factors to consider in choosing a plan, data related to the cost tables, and how the survey results should be interpreted. Tables and footnotes are included.
Descriptor(s): Comparisons of health care programs, Governmerit employee plans, Health care/services, Plan design/program provisions (under health plans), Source of premium payment.
84. Child Health. America's Future. George A. Silver. National Center for Health Services Research, Hyattsville, MD. National Inst. of Health, Bethesda, MD. Fogarty C,mter. Commonwealth Fund, New York, NY. Ford Foundation, New York, NY.
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1978, 267 pp. Availability: Aspen Systems Corp., Rockville,
MD 20850.
This text relates to evidence that U.S. child health services are not at peak performance. It discusses some reasons for this failure; other countries' approaches to child health services; lessons from experiences abroad and their adaptation; and long-term benefits of a meaningful child health program. The major factors in America's failure to provide adequate health care for its children are a neglect of children's social needs that relate directly to the quality of their health, insufficient preventive services, inadequate curative services, and administrative and financial impediments. Holland, Sweden, and Finland, which have the best records for child health care, manifest the following cornmon system characteristics: separate preventive services reasonably well linked to the curative; nurses playing an important role in the preventive services and in the linkage of the preventive and curative; national standards with local control; and powerful national health department supervision. Recommended for the United States are community child health programs that are to be preventive units. These programs would be supported in part from Federal and in part from local tax funds and operate under the supervision (if not direct control) of local health departments. A national child health service should plan programs and set standards, assist States in meeting standards and staffmg clinics, and provide a locally-based supervision and inspection service for evaluation and quality control. Services provided must include prenatal and well-baby care, nurse visitations to the home, home help during and after childbirth, scheduled immunizations of children, a modest maternity allowance to pregnant women upon registration, family planning services, preschool screening examinations of children, assessment centers for evaluation of screened referrals, school entrance and exit examinations, medical and psychological care in the schools, and school health education programs. Tabular data and references are provided with individual chapters.
Information about who currently pays for dental care of children under 20 years of age in the United States is provided. Data were taken from the National Medical Care Expenditure Survey, which included a survey of about 14,000 randomly selected households from the civilian noninstitutionalized population. The data provided are estimates intended to show current U.S. trends regarding the cost and use of children's dental services by various characteristics of children. Findings show that children from families whose most educated member had a low level of education (9 to 11 or 12 years of school completed) were less likely to have had one or more dental visits in the first quarter of 1977, compared to children from families with more education. This trend was most significant when the type of dental service performed was preventive. Data also showed that State medicaid programs were more likely to pay the entire charge for a child's dental visit when the child came from a family whose most educated member had a relatively low level of education. Although less educated families pay a lower percentage of the total charge for their children's dental visit because of medicaid and other Government assistance programs, their children receive less preventive care than children from more educated households. Further multivariate analysis of the complete survey data should help in understanding these phenomena and assist policymakers in formulating national health care policy, particularly the dental component of the Child Health Assurance Program. Tabular data are provided.
Prepared for presentation at the 107th Amebean Public Health Association AnnuM Meeting, DentalHealth Section, New York, _ November 7, 1979. Descziptor(s): Health care costs, Medicaid, Participants in health care programs, Dental services, Source of premium payment, Demographic features of population.
DesctT"ptor(s): Demographic features of population, Preventive services, Home health services, Policy initiatives, Comparisons
86. Chip Commission. Final Report.
regarding
Mar 1980, 98 pp. A vailabih'ty: State of Rhode Providence, RI 01908.
foreign health policies.
85. Children and Dental Care. Charges and Probability of a Visit by Individual Characteristics.
Walter R. Lawson. 1980, 6 pp. A vailability: Journal of the American Dental Association, vl01 n7 p32-37 Jul 80.
1-40
Island, Div. of Health
Insurance,
Costs and modes of review and evaluation are examined for Rhode Island's Catastrophic Health Insurance Program (CHIP). The data examined cover 1978. The service areas incurring the largest increase in CHIP costs were inpatient psychiatric hospitalization, nursing home care, prescription drugs, and hemodialysis. The diseases most responsible for the cost increases were mental illness, diseases of the nervous system, diseases of the musculoskeletal system, and kidney failure. To
Health
Care Programs
restrain such cost increases the report recommends (1) that the CHIP program be administered by the Department of Health, which will review and evaluate the appropriateness of medical treatment; (2) that covered care in skilled nursing homes be limited to 100 days of care per benefit period beyond the 100 days covered by medicare and that medicare guidelines be used to determine the eligibility of skilled nursing home care for CHIP coverage; and (3) that inpatient psychiatric hospitalization be covered for 100 fullor partialdays perbenefit period and that additional inpatient days be covered at the rate of 50 percent of eligible costs. The primary recommendation of the Subcommittee on Review and Evaluation is that additional and more stringent review procedures be developed for psychiatric cases, Dissenting positions of commission members and commission minutes are appended, and tabular data on CHIP costs and illnesses covered are provided,
presents some theoretical results on the variance of plans for any family. For example, if the coinsurance rate is zero, the variance of payments by the insured is higher with individual deductibles than with equivalent family deductibles. Finding that tl_Leoretical calculations -- such as those for insurer payouts under family plans and for insured out-of-pocket payments under both family and individual plans -- do not necessarily apply to actual conditions, researchers conducted an empirical study of family and individual plans. A national sample of 3,700 families was surveyed. Results indicated that when upper limits for out-of-pocket expenses consistent with various national health insurance proposals are imposed, the variance of payouts by families under individual deductible plans is higher than the variance under equivalent family deductible plans for all deductibles and coinsurance rates that were tried. However, when the upper limit was raised to $I0,000 or more per family per year, the estimates of variance changed substantially. Tables, footnotes, graphs, ap-
Report ofthe SpecialLegislative Commission ic Health Insurance Program (CHIP).
pended tables, and eight references are included. (Author stract modified)
on the Catastroph-
Descriptor(s): Health care costs, Cost containment efforts, Policy initiatives, Evaluations/outcome of health care programs, Mandated benefits.
This report summarized in "Empin'eal Study between Family and Inab'vidual Deductibles
of the &;fferences in Health Insur-
ShOe'" Descxiptor(s): Deductible/coinsurance, Economics party payors, Impact of third-party coverage.
87. Choice Between Family and Individual Deductibles Health Insurance.
ab-
of third-
in
Emmett B. Keeler, Daniel A. Relies and John E. Rolph. Rand Corp., Santa Monica, CA 90406 RAND/R- 1393-HEW
88. Chronic Illness and Health Services Use. A Before-After Study of Canadian National Health Insurance.
Department of Health, Education, and Welfare, Washington, DC. Oct 1975, 37 pp. Availability: Rand Corp., Santa Monica, CA 90406.
David M. Weiss. National Center for Health Services Research and Development, Rockvilie, MD. Public Health Service, Washington, DC. Maurice Falk Medical Fund, Pittsburgh, PA.
This report focuses on the question of whether deductibles should apply on a per-family or a per-individual basis. The resuits are also relevant to the choice of accounting period, since the pooling of family members is formally equivalent to aggregating time periods - where, for example, "per year" is analogous to the family deductible and "per quarter" to the individual deductible. The report studies how individual deductibles should be combined to make a family deductible with the same expected expense for the insurer, and how the choice of deductible type affects the variance of insurance payouts and alters the individuals' incentives to economize on medical care. The variance of policies is of interest because a major point of medical insurance is the reduction of risk. Altered incentives are problems for policyholders because they require higher premiums. The report
1977, 248 pp. A vailabib'ty: University MI 48106.
Microfilms International,
Arm Arbor,
This dissertation focuses on the use of health services by the chronically ill before and after a major health policy change; i.e., the introduction of national health insurance in Canada. The research studied the factors that influence the use of health services among the chronicafly ill derived from a more comprehensive survey series. The sample of direct concern to this disserration, was chosen from those respondents in the general survey who responded affirmatively to inquiry of existence of long-term illness. The number of subjects potentially available for analysis was: phase I = 995; phase II = 897. Information was obtained
1-41
through questionnaires and interviews. Among the major topics addressed by the survey instruments were the seeking of health care, attitudinal dimensions toward health practices, use of medical personnel and facilities, perceived symptoms, health status, and general demographic information. Measures of the dependent variables concerned physician and hospital use. Several hypotheses regarding use were developed and tested. The goal of the Canadian medicare insurance program was to eliminate one of the assumed major economic barriers to health care. For the chronically ill target population of this study, the exami-
of any upward trend in the use of physician services. The overall use rate was much the same for both years and the use rates by demographic subgroups and types of visits were similar or slightly lower. Equally important was the finding that the plan had become relatively unattractive for families in the lowest socioeconomic groups, which constituted a smaller proportion of the 1972 plan membership than of the pre-coinsurance membership. Tabular data and footnotes are provided. (Author abstract modifled)
nation of the cost factor appeared to be particularly important, since health care use was a necessary routine for those learning to live with long-term illnesses. Analysis of data reveals unmistakable potential benefits derived from medicare and other such health programs. Medicare's removal of a major economic obstacle to health care, increased the chances for the chronically ill to establish contact with additional health providers, thus significantly improving the quality of life for those with long-term illnesses. A bibliography, a few footnotes, nine tables, and appendices are included in the dissertation.
A version of this article was presented at the 104th annual meeting of the American Public Health Association in Miami Beach, FL., October 1976.
Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy to University of Pittsburgh, 1977.
90. Conmmnity Mental Health Centers. The Federal Investment.
Descriptor(s): Comparisons
National Inst. of Mental Health, Rockville, MD 20857 DHEW/PUB/ADM-78/677 Sep 1978, 65 pp. A vMlnbility: Alcohol, Drug Abuse and Mental Health Administration, Rockville, MD 20857.
Demand/utilization of health care programs, regarding foreign health policies.
89. Coinsurance and the Demand for Physician Four Years Later.
Descriptor(s): Demand/utilization of health care programs, Deductible/coinsurance, Evaluations/outcome of health care programs, Medical/surgical services.
Services.
Anne A. Scitovsky and Nelda McCall.
This report summarizes the growth and development of the Community Mental Health Centers (CMHC's) program. Passed in 1963, Public Law 88-164 was the first of many acts designed to initiate a network of CMHC's. In the 11 years from the
Social Security Administration, Washington, DC 20203 HEW/PUB/SSA-77/11700 1977, 9 pp. Availability" Social Security Bulletin May 77.
program's first awards in fiscal year 1966 through Fiscal Year 1976, Federal funds have assisted in the initiation of 650 CMHC's, which, when fully operational, will make services available to an estimated 90 million persons, some 43 percent of the U.S. population. CMHC's, it was believed, could more effec-
Results are presented from studies that examined the effects of coinsurance on the demand for physician services. In 1971, a study was made of the effects of a 25-percent coinsurance provision on the demand for physician services under a comprehensive prepaid plan for medical care. Comparisons of physician use rates in 1966 (the first calendar year after the change) showed that coinsurance led to a 24-percent decline in the per capita number of all physician visits. This held true regardless of whether the data were examined, by demographic characteristics of the study population, physician specialization, or place of visit. It was hypothesized that this effect of coinsurance could be temporary, and a followup study comparing physician use rates for 1972 and 1968 was used to test it. Results showed no evidence
tivly treat the mentally ill than the institutional programs of State and county mental health hospitals, which separate the mentally ill person from family and other potential community supports. The legislative history of the program is provided, from the original idea of simply providing seed money for startups, to regular Federal funding, to a comprehensive plan providing an organizational network throughout the country. The quantity and kinds of services provided are discussed, along with an analysis of the recipients of care and their pathways to CMHC's. In addition, staffing and funding are reviewed. The report notes that the comprehensive community health care concept has been expanded to include 12 essential services, such as special children's programs and services relating to alcoholism
1-42
Health Care Programs
and addiction. The essential issue for the future concerns how services will be made available throughout the Nation, especially with the emergence of increasing financial constraints and demands on the CMI-IC's. Annotated chapter footnotes, graphs,
92. Comparative Experiences in Controlling Expenditures Prescription Drugs in State Medicaid Programs.
and tabular data covering 1971 to 1975 are included.
Gordon R. Trapnell. Dec 1975, 41 pp.
Descriptor(s): Mental health services, Outpatient fac'flities, Present legislation/regnlations, Outcome/evaluation of quality as-
A vailability: American Univ., College of Public Affain_, School of Justice, Washington, DC 20016.
for
suranc._.
9i. Comparative Absence Experience Among Employees Coyered by a Prepaid or a Blue Cross/Blue Shield Health Insurance Program.
J. H. Mitchell and J. P. Dunn. 1978, 4 pp. A vailability: Jnl. of Occupational Dec 78.
Medicine v20 n12 p797-800
Health maintenance organizations (HMO's) report lower hospitalization and surgical experience than fee-for-service practice. If this is true, then sickness absence should be less. Because many companies pay no more for the prepaid HMO insurance premium than they pay for other coverage, such as Blue Cross and Blue Shield or commercial insurance, the employer can realize direct savings only from a reduced rate of absence among employees participating in HMO's. This pilot study compared the morbidity experience of 247 pairs of Mountain Bell Telephone Company employees: HMO-enrolled employees matched with employees covered only by Blue Cross and Blue Shield. The study period extended before and after enrollment of the HMO subjects. Rates for the HMO group for hospitalization and surgery decreased after enrollment, whereas rates for the Blue Cross and Blue Shield group increased. The absence disability rate for the HMO group remained constant but increased for the Blue Cross and Blue Shield group. It is concluded that differences in absenteeism may exist due to the type of medical insurance and that the potential impact of such a difference upon absence costs is considerable. Five references and 11 tables are given. (Author abstract modified)
Presented at the American Occupational annual meeting, April 1978.
Medical
Association
Descriptor(s): Service benefit plans, Prepaid plans, Demand/ utilization of health care programs, Impact of third-party coverage, Health care costs,
Results are reported from an analysis of data generated from the 25 State programs that pay about 90 percent of medicaid benefits to determine ff the relative efficiency of the programs in delivering prescription drugs can be ascertained by data analysis. The Federal policy of letting States decide on the design and administration of medicaid programs has produced a variety of approaches in the way prescription drugs are made available to medicaid eligibles. This provides the opportunity to contrast and compare the different approaches to determine the effect of different benefit designs, administrative systems, regulatory polides, and enforcement actions. The adjusted spending per capita for prescription drugs in each State in fiscal 1973 is compared; the adjusted comparisons of spending per capita for prescriptions and for both physician and physician substitute services are also given. Moreover, the total spending per capita for hospitals, physicians, clinics, home health agencies, and prescriptions are compared. The only conclusions that can be supported by the evidence is that the adjustments for age, sex, race, and area differentials are not adequate to explain the variation in spending of medicaid services from State to State. The primary problem appears to be the enormous variation in reported spending under medicaid programs. This variation suggests major differences exist between the populations eligible for medicaid services in these States. Also, the data reported by some States may neither be accurate, nor timely, nor reported in a manner consistent with the reporting of the number of persons efigible for cash assistance. Finally, eligibility requirements are very complex and the administration of the requirements varies greatly, leading to the hypothesis that eligibility determination processes are a primary cause of variation in the characteristics of the population coyered. Tabular data and footnotes are provided.
Paper no. 4 from the Third Seminar on PhatTnaceutical Public Policy Issues Impact of Public Policy on Drug Innovation and Pricing, December 15 and 16, 1975, The Statler Hilton Hotel, Washington, DC
Descriptor(s): Health care costs, Pharmaceutical services, Medicaid, Comparisons of health care programs, Eligibility requiremerits, Outcome/evaluation of health administration.
1-43
93. Comparative
Milton
National Policies on Health Care.
sons regarding foreign health policies, Preventive Facilities providing health care, Source of premium Providers of health care services.
services, payment,
I. Roemer.
1977, 252 pp. Availability: Marcel Decker Inc., New York, NY 10016.
This volume analyzes all major aspects of health care systems in a complete range of countries throughout the world. The health care systems are analyzed according to seven major components: economic support of health services, health manpower resources, health care facilities, patterns of delivering medical care, patterns of cldivering preventive services, regulation of health care, and methods of health administration and planning. In addition, countries have been grouped into five general categories according to the country's political structure and level of economic development. These categories are free enterprise, welfare states, underdeveloped, transitional, and socialist. Concerning economic support of health services, the book discusses broad classifications of financial payment which include personal payment, charity, payment by industry, voluntary insurance, social insurance, and general revenues. A chapter on health manpower provides a brief overview of the current health manpower situation and specifically focuses on the supply of doctors in relation to the population of different countries, the trends in this supply, and the distribution of doctors between urban and rural areas. In addition, the main features of the nursing profcssion are summarized, and dental personnel, pharmacists, and other secondary personnel ate examined. Other chapters analyze the history, functions, and organization of hospitals and other health facilities in various countries; examine the delivery of health care, including primary care, specialties and hospitalization, payment methods and medical performance, and rural health care delivery; and describe the delivery of preventive services, such as communicable disease control and family plan-
94. Comparing
ning. Regulation of health personnel, other health care resources, and health care performance is considered, aiong with factors involved in health service administration and planning, The final chapter illustrates each of the five general categories of countries by presenting one country for each classification, These are the United States, Norway, Peru, Ghana, and the Soviet Union. Observations on general trends in the provision of health care services throughout the world point out that eeonomic support for health services is, on the whole, becoming more collectivized; the supply of doctors relative to the population in all countries is increasing; and the patterns of delivery of all levels of medical care are becoming increasingly systematized, Chapter readings of over 330 references, tables, and an index are supplied.
number of routine procedures were about the same. A significant difference appeared in extensive procedures, with the capitation program showing 62 percent fewer such procedures. In addition, the study showed that although the comparative value of routine services provided for fee-for-service patients was 12 percent less than the value of routine services provided to capitation patients, the value of extensive services was 88 percent greater. Furthermore, the value of extensive services provided to fee-for-service patients exceeded the value of all services provided to capitation patients by 11 percent. Overall, the comparative value of all services provided to fee-for-service patients was 47 percent greater than the value of all services provided to capitation patients. A chart is provided.
Descriptor(s): Trends in health status, Supply/availability of services, Funding/financing of health care programs, Compari-
Descriptor(s): Comparisons of health care programs, Dental services, Private health care plans.
1-44
Dental Care Systems in California.
1979, 2 pp. Availability: Employee Benefit Plan Review v35 n8 p34,36 Feb 80.
In 1977, California Dental Service (Delta Dental Plan of Callfornia) completed a study comparing the benefits received during 1976 under their dual choice dental care programs in California. Under the program, patients could choose either the California Dental Service (CDS) or a panel capitation program. Those who selected CDS's fee-for-service program could select their own dentist from 14,000 participating dentists. Those who chose the capitation program were required to visit a panel dentist. A dental capitation program is similar to an individual practice association health maintenance organization in that the employer pays a fixed dollar amount monthly for each eligible employee; diagnostic and preventive services are performed by a panel of dentists and each dentist is paid a fixed amount based on enrollment. Most of the panel dentists are also participating members of CDS and have their own private practice patients. A table compares the frequency of procedures under the capitation program to those under the fee-for-service program. Data show that the capitation program performed more x-rays but had a reduced number of restorations and extractions. Total
Health Care Programs
95. Comparing the Medical Utilization and Expenditures of Low Income Health Plan Enrollees With Medicaid Recipients and With Low Income Enrollees Having Medicaid Eligibility,
Richard E. Johnson and Daniel J. Azevedo. 1979, 14 pp. A vnilability: Medical Care v l 7 n9 p953-966 Sep 79.
This 1977 study compares group medical care ill nonrnaternity insurance benefits with claimants' charges. Similar data from a 1967 study are also examined. Results were analyzed for all insurance plans combined, and by (1) type of insurance plan, (2) diagnosis, (3) type of claimant, and (4) age of claimant. Of the $14 million in total covered nonmatemity expenses, 84.9 percent were reimbursed by benefit payments. (In 1967, the proportion was 80.1 percent). The proportion of expenses reimbursed by benefits was highest among claimants who had combined basic and major medical benefits through the same carrier (87.2 per-
This study examines the medical care (hospital, physician, drug, diagnostic) utilization and expenditures of low-income persons enrolled in a prepaid health plan with a matched group of medicaid recipients. The study also examines the medical care utilization of low-income persons enrolled in a prepaid health plan but also eligible for medicaid benefits. Utilization and population-atrisk data were obtained from the Kaiser Permanente Medical
cent). In two other types of plans (basic or major medical), the proportions were slightly lower. By type of expense, persons with basic plus major medical coverage by the same carrier had the highest degree of reimbursement of expenses for hospital care, surgery, anesthetists' services, and diagnostic x-ray and laboratory services. Claimants with accident causes had the highest proportion of covered expenses paid by benefits (88.2 percent). Such
Care Program of Portland, Oreg., and from the State of Oregon Welfare Division. A hypothesis of lower hospital utilization by low-income enrollees compared with Medicaid recipients was accepted. A hypothesis of higher ambulatory care utilization was accepted for diagnostic care procedures and prescription use but rejected for office visit utilization. An analysis of the findings appeared to implicate the medicaid program for differences observed. The hypotheses of no significant differences in inpatient and ambulatory medical care utilization of low-income health plan enrollees with and without medicaid eligibility were generally rejected. Low-income enrollees with concurrent medicaid had consistently higher utilization rates for all services, resulting in substantially higher medical care expenditures per person. The findings contribute some useful information with regard to planning or establishing policy for medicaid prepayment programs or other programs enrolling low income persons in prepaid health plans or health maintenance organizations: Four tables and 25 references are provided. (Author abstract modifled)
proportion was lowest for claimants with a dental diagnosis (70.1 percent). Average covered expenses were highest among claimants with mental or nervous conditions. Average covered expenses ranged from $236 per dependent child claimant to $434 per dependent husband claimant. More than half the total benefits were paid to persons 40 to 64 years of age, though they represented about two-fifths of all claims. In the proportion of covered expenses reimbursed by benefits, very little variation was shown among the six age groups. Of the 39,710 c_aimants, three-fourths had g0 percent or more of their expenses reim-
Descriptor(s): Prepaid plans, Medicaid, Medical/surgical services, Diagnostic services, Pharmaceutical services, Hospital services, Comparisons of health care programs, Demand/utilization of health care programs.
96. Comparison Charges.
bursed. (In 1967, two-thirds of claimants were reimbursed for 80 percent or more of their expenses). Coordination of' benefits (COB) savings, a provision found in some group health insurance policies, was realized from 821 claims (72.6 percent of secondary claims and 2.1 percent of the total). (COIl savings provide a method of integrating benefits payable under more than one group plan so that the insured's benefits from all sources do not exceed 100 percent of allowable medical expenses). As a result of COB provisions, the savings to insurers amounted to 3.8 percent of the total benefit payments in the study. Tabular data and an appendix with a description of claims are included. Descdptor(s): Medical/surgical services, Diagnostic services, Dental services, Mental health services, Reimbursement, Deductible/coinsurance, Participants in health care programs, Health care costs, Private health care plans, Hospital services, Health insurance industry.
of Group Medical Care Insurance Benefits to
Health Insurance Association 20006
of America,
Washington,
Feb 1978, 27 pp. A t.ilabi]ity: Health Insurance Inst., Washington,
DC
DC 20006.
97. Comparison of Organizational Sponsorship and Service Arrangement Variables Among Prepaid Medical Group Praetiees in the United States. Doman Lum.
1-45
Aug 1974, 141 pp. AvMlability: University Microfilms MI 48106.
International,
Ann Arbor,
98. Comparison of the Hospital Cost Experience of Three Competing HMOs. J. William Gavett and David B. Smith. !978, 9 pp. Availability: Inquiry v15 n4 p327-335 Dec 78.
This study
explored
the relationship
between
organizational
sponsorship and services arrangement among prepaid group practices in the United States. It sought to identify crucial variables to assess how prepaid group practices are organizing themselves and serve as a taxonomic base to develop criteria of organizational effectiveness. The study framework was derived from interorganizational theory which was relevant to sponsorship and service arrangement between complex health institutions. An exploratory-descriptive survey research design of' organizational aspects of prepaid group practice was used. A directory of 173 prepaid group practices throughout the United States was obtained through the Department of Health, E_lucation, and Welfare. Subjects taken from the directory were health administrators who were engaged in operations and who represented a large and diverse sample. A self-administered questionnaire was designed to gather data on organizational operations, sponsorship, and service arrangement variables. Data analysis of the 66 usable respondents' information consisted of identifying emerging organizational profiles on sponsorship and services arrangement and constructing a taxonomy which categorized these profiles in a systematic manner. Several trends emerged among provider, insurer, consumer, and independent sponsors, First, providers owned more hospitals and had the largest boards compared with other sponsor types. Second, insurers invested the fewest responsibilities with their governing boards and made arrangements with other institutions for health facilities and medical services. Third, consumers granted their boards full policy and decisionmaking as well as funding control, had their own staffs and facilities, and offered a full range of comprehen-
The hospitalization costs experience of three competing health malntanance organizations (HMO's) are examined in this paper. Five factors directly affect the hospitalization costs of each plan. These include hospital service mix used, admission rate, hospital mix used, length of stay, and intensity of resources used within a particular hospital service. Data for this analysis were obtained from Blue Cross claim files for 1974 and 1975; Blue Cross is the fiscal intermediary for all three plans. Both hospital billings and per diem payments were examined. In order to summarize the relative impact of the five factors on hospitalization costs, an elaboration of the equation specifying total hospital costs per member year equals admission rate x average length of stay x average per diem is required. Service mix, hospital mix, and service intensity were factored into the standard formula. Results indicate that none of the plans experienced the degree of hospital cost savings that have been generally attributed to HMO's. There appear to be three reasons for this result. First, serious adverse selection was incurred in the maternity and psychiatric areas, as there were no waiting periods for those previously enrolled in the Blue Cross plan. Second, one of the HMO's considered is located in a city with a substantially lower bed population ratio than most other metropolitan areas in the United States. Third, in none of the three plans were physicians at risk for the hospitalization experience of their plan. It is concluded that assessing the hospitalization cost control potential of HMO's is a complex process. Six tables and eight reference notes are provided.
sive services. Fourth, independents served predominantly unemployed groups. It is concluded that the prepaid group practice health system has yet to become a viable competitor in the
Also See "Note on the Comparison of the Hospital Cost Experience of Three Cbmpeting HMO's. ""
existing health care market. However, with the proper guidance from the Government, it has the potential to meet the health care needs of the medically underserved. Footnotes, 11 tables, a bibliography of about 75 references, and an appended questiormalre are included. (Author abstract modified)
Descriptor(s): Prepaid plans, Hospital services, Demand/utilization of health care programs.
99. Comparison of the Quality of Maternity Care Between a Health-Maintenance Organization and Fee-For-Service PracSubmitted in partial fultTllment of the requirements for the degree of Doctor of Philosophy in SociM Welfare to Case W_tern Reserve Univ, 1974.
Descriptor(s): Prepaid plans, Comparisons grams, Facilities providing health care.
1-46
of health care pro-
tices. Alfred L. Frechette and Pearl K. Russo. Massachusetts Dept. of Public Health, Boston, MA 02215 Kellogg (W.K.) Foundation, Battle Creek, MI. National Center for Health Services Research, Hyattsville, MD. National Foandation-March of Dimes, Washington, DC.
Health Care Programs
Harvard Community Health Plan Special Projects Fund, Boston, MA. 1980, 4 pp. Availsbility: New England Jnl. of Medicine v304 n13 p784787 26 Max 81.
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Participants in health care programs, Hospital setvices, Medical/snrgical services, Outcome/evaluation of quality assurance.
Using multiple indicators of process and outcome, this study compared the quality of maternity care for members of a Bostonbased health maintenance organization (HMO), the Harvard
100. Comparisons of Prepaid Health Care Plans ht a Competitive Market. The Seattle Prepaid Health Care Project.
Community Health Plan (HCHP), and for patients of private fee-for-service (FFS) practices. Obstetric hospitalizations account for over 30 percent of all hospitalizations at this HMO. A review of 5,003 consecutive deliveries at the two study hospitals between September 1975 and June 1976 found some variations between the HMO and FFS systems in the process of care, but
William C. Richardson, Paula K. Diehr, James P. LoGerfo, Kenneth M. McCaffree and Stephen M. Shorte_l. Washington Univ. Dept. of Health Services, Seattle, WA 98195 l National Center for Health Services Research, Hyattsville, MD.
outcomes were similar. Patients in the FFS group were more likely to be white, married, and college-educated, whereas more women in the HMO group either had never had children or were pregnantforthefirst time. The HMO population included more women youngerthan 20,whereasthe private patients include more women 35 yearsofageorolder.Patients withan underly-
Aug 1980, 46 pp. Availabih'ty: National Center for Health Services l_esearch, Publications and Information Branch,Hyattsville, MD 20782.
ingmedical condition (including any cardiac problem, asthma, epilepsy, hereditary anemia, or prior history of hypertension) were equally represented in the two groups. Admissions for premature labor not resulting in delivery were more frequent among HMO patients, whereas the rate of inductions was significantly lower for HMO patients. More FFS women than HMO patients had a primary cesarean section. The overall average maternal duration of HMO patient hospitalization was 4.4 days, slightly shorter than the FFS patients' average stay of 4.8 days. HMO infants were admitted to the special care nursery at about the same rate as FFS neonates. Finally, the two groups had comparable outcomes with respect to the following measures: the occurrenceof stillbirths, neonataldeaths,l-minuteApgar scores less than 6, low birth weights, short gestation, mean birth weights, and mean gestational age. This study reveals a higher prepartum admission rate among HMO members -- a practice that could be considered costly for the HMO. However, this is probably more than offset by the shorter average length of stay for delivery (249 days saved). The HMO's higher rate of admissions for premature labor may be a consequence of the lower rate of inductions. In turn, fewer inductions may lead to a reduction in cesarean sections by avoiding the problem of failed inductions, The HMO in this study may have been able to reduce the costs of medical care without any apparent sacrifice in the quality of that care. Tabular data and 15 references are provided,
Results are reported from a Seattle, Wash., 4-year (1971 through 1975) comparative study of an established prepaid .group pracrice and a fee-for-service arrangement in which services were paid for through Blue Cross and Blue Shield. The two plans were compared in the areas of ambulatory care, hospital use, service costs, quality of care, access, and patient satisfaction. The plans differed basically only in method of organization; neither plan required copayments. The plans were compared by using existing data systems wherever possible. Baseline data on social and demographic characteristics of enrollees, their health status, and their prior use of health services were obtained through household interview surveys administered after enrollment but beforeservices began.Afterenrollment, eachfamilywas reinterviewed once a year. C_--nerally, the prepaid group practice appeared to be more efficient and less costly, while the fee-for-service patients indicated greater satisfaction with services. The average cost for the fee-for-service patient group was 33 percent higher than the corresponding cost to the prepaid group enrollees. A significant proportion of this difference was due to the higher rate of hospital admissions and the higher costs per admission for the fee-for-service group. In outpatient care, the overall average cost per visit was slightly lower in the prepaid group setting, with much of the difference attributable to the greater use of less costly professional personnel; however, the cost savings accruing from greater use of less expensive professional personnel were largely offset by the significantly greater costs for care by specialists in the prepaid group practice. Outpatient use was about the same for both groups overall, but the older and sicker enrollees in the fee-for-service setting used disproportionately more visits per person than their counterparts in
Presented in part at the 107th Annual Meeting of the AmeMcan Public Health Association, November 1979, New York, NY.
1-47
the prepaid group practice, while younger and healthier enrollees in the prepaid group practice had disproportionately more visits than their counterparts in the fee-for-service setting. Tabular data and 19 references are provided. NCHSR
Research
Summary
Paper discussed at the Conference on the Economics sation, November 21-22, 1980.
Series.
_,iptor(s): Cost/benefit analyses, Prepaid plans, Health care/services, Comparisons of health care programs, Competition/interaction among third-party payors, Service benefit plans, Participants in health care programs.
101. Compensation Physicians.
appropriate objective for public policy would be to constrain physicians' fees. Three tables, 27 footnotes, and 28 references are provided.
Arrangements Between Hospitals and
of Compen-
Descriptor(s): Inpatient facilities, Physicians, Impact of thirdparty coverage, Health care costs, Methods of payment determination.
102. Competing for Acute Care Dollars. The Economics Risk Reduction.
of
K. Michael Peddecord. Roger Feldman, Frank A. Sloan and Lynn Paringer. National Bureau of Economic Research, Inc., Cambridge, MA 02138 Health Care Financing Administration, Washington, DC.
1980, 16 pp. ArM]ability: Family and Community Health v3 nl p25-40 May 80.
Jun 1980, 31 pp. A vailabih'ty: National Bureau of Economic Cambridge, MA 02138.
Discussion centers on the economic benefits of individual risk reduction (IRR) programs. Although each program differs from the others, all IR__ programs deal with primary and secondary prevention. As with any innovative health care technology, considerable resources must be devoted to development and evaluation of IRR. Aggressive leadership will be required to assure that IRH will be adequately funded during developmental and evaluation stages. There is no more rationale for third party payers to exclude IRR from plans that cover preventive services than there is a rationale to exclude reimbursement for selected new drugs or therapy from acute care coverage plans. Some insurers, such as Blue Cross/Blue Shield, are nonprofit and have a history of provider participation in development of innovative benefit packages; alteration in benefit structures for preventive services may follow the pattern that was observed for prepaid health care plans. However, it appears that restructuring ofbenefit packages in the short term may be accomplished at the local rather than the national level. If IRR programs can demonstrate the efficiency of their activities to large purchasers of insurance coverage, third parties are likely to include preventive services in their packages to keep themselves competitive. The majority of health care innovations are clearly classifiable into either personal health care or public health activities. However, this classification scheme may not work for IRR programs. Developers of IRR programs may wish to market their activities as a combination of community and personal services, or as one or the other. As IRR continues to develop continued experimentation, innovation, and evaluation are essential. Care should be taken to avoid overselling it as a cure-all or preventive panacea. Recognition of the competitive nature of the health care field and of the
Research, Inc.,
This paper investigates the pattern of compensation arrangements between hospitals and physicians. Data from two hospital surveys are used to estimate an equation explaining the percentage of a hospital's physicians on salary. Generally, it is assumed that hospitals choose a combination of salary and incentive or outpatient-based compensation to maximize utility from profits and physicians' nonpatient care activities. It is suggested that medical care prices have implications for the choice of compensation method when risk and the costs of supervision are held constant. Earlier theoretical analyses of contractual arrangements have focused on the implications of risk, imperfect information, and the cost of supervision. The model developed here takes these results as given and concentrates on the consequences of changes in prices of medical care and grants to hospitals. The model describes circumstances under which the price of medical care induces the hospital to provide more patient services. The hospital does this by increasing the amount of incentive compensation for staff physicians. It appears that salary arrangements are less frequent where the price of physicians' patient care services is high and revenues from grants and the medicaid program are low. Medicare seems to have had a neutral effect on choice of salary versus incentive payment. Prohibiting percentage-of-revenue arrangements for hospital-based physicians will probably lead to more fee-for-service billing, rather than salary, as long as physicians' fees continue to be high. Thus, if it is determined that salaried compensation is preferable, the
1-48
Health
Care Programs
origin of the demand for the services, as well as an understanding of factors that regulate the development of new technologies, will aid IRR program directors in securing resources and tailoring their programs to those segments of the population who are likely to benefit from them. A total of 60 references are provided.
104. Competition in the Delivery of Medical
Descriptor(s): Competition/interaction among third-party payors, Preventive services, Impact of third-party coverage, Plan design/program provisions (under health plans).
1978, 47 pp. Availability: InterStudy,
103. Competition and Regulation. The Consumer Choice Health Plan Alternative. F. Kenneth
Ackerman.
1980, 5 pp. AvMlab_'ty: Medical Group Management 64 Jul/Aug 80.
v27 n4 p58, 60, 62-
The Consumer Choice Health Plan (CCHP) is proposed as a means of developing incentives for competition in health care delivery. The resulting competition should help constrain costs, The CCHP is an alternative to the current system of health care financing which provides few incentives for cost containment. In the CCHP, each employee is presented with a multiple choice of health plans. Each employer pays a fixed amount toward the premium of the health plan selected by the employee. The employee pays the balance and any copayments charged by the selected health plan. For each plan, a group of health care providers agrees to offer services at prices that will make the plan's premiums competitive with other plans. The employee benefits by selecting the most cost-effective plan. It behooves each competing health plan to attract consumers by controlling premiums and passing savings on to customers. Each plan is in a position to control costs because each has the authority not to.buy from expensive providers. By shifting some decisionmaking about resource allocation to those demanding the services and away from those supplying the services, the CCHP significantly alters and redirects current economic incentives in the health care system. Any proposal for increased Federal involvement in health care delivery must stimulate competition in service provision; otherwise, the current noncompetitive system will continue to escalate costs, regardless of who handles the payments. Eleven references are provided.
Jon B. Christianson and Walter McClure. InterStudy, Excelsior, MN 55331 McKnight Foundation, St. Paul, MN.
Descriptor(s): Cost containment efforts, Private health care plans, Source of premium payment, Policy initiatives, Competition/interaction among third-party payors.
Excelsior, MN 55331.
This paper discusses the way in which organized systems might compete in the delivery of medical care, describes a market in which competition is actually taking place, and outlines possible policymaking decisions that the Government could take to facilitare effective choice and competition in medical care. An area with a diversity of health care plans and traditional provider/ insurer plans is imagined. The hypothetical case stipulates that each year, employees, medicare and medicaid recipients, and other individuals are offered a multiple choice among several or all of these plans. A competitive system in practice is then described using the Minneapolis-St. Paul metropolitan area (Minnesota) which now has seven health maintenance organizations (HMO's) with an enrollment totaling 11.6 percent of the population. The report concludes that this HMO development supports the feasibility of the organized system-market approach to medical care delivery reform. The paper suggests that Government policymakers should support competitive medical care systems by redefining a health care plan to broaden the prepaid group practice model; giving a multiple choice of health care plans to State and Federal employees and to medicare and medicaid beneficiaries; supporting the enforcement of antitrust laws, cornpetitive bidding by hospitals, and Certificate of Need recommendations at the State and local level; and enacting specific legislation that would encourage an organized system-market approach. In addition, the decreasing relative price of health care plans, their greater acceptance by physicians, and the increased willingness of employers to provide multiple choices have the potential to effect a major reform of the medical care delivery system. A total of 12 tables and 34 notes are given.
Dt_riptor(s): Prepaid plans, Competition/interaction third-party payors.
105. Competition Contents of this paper were presented to the HospitM Admire'strators Study Society, Cancun, Mexico, March 6, 1980.
Care.
among
in the Health Care Sector. Past, Present
and Future. Federal Trade Commission Bureau of Economics, Washington, DC 20580 1978, 403 pp. Av_lability: Aspen Systems Corp., Rockville, MD 20850.
1-.49
In 1977, a conference on the role of competition in the health care industry was conducted by the Federal Trade Commission (FTC). This book presents the conference proceedings in four sections. In the introductory section, the FTC Chairman remarks that health care caan be classified as a business and that the idea of competition in the health field should be explored by the FTC. Points made by other speakers include assertions that competition in the medical sector differs from the classic economie concept of the term, that lack of information of appropriate price-quality level is the most important difference between medical care and material goods, and that insurance reduces competition. The second part of the book reviews competition in specific sectors. Views on competition in the physicians sector range from a contention that doctors have monopolistic powers in the medical marketplace to a rejection of this idea. The subject of competition among hospitals elicits a suggestion that changes in insurance would lead to price competition. One speaker warns tht emphasis on price-oriented competition among health insurers brings the finding tht regulatory advantages of Blue Cross plans increase its market share and that market power raises hospital prices. In part three, insurance and alternative delivery systems are the topics. A study supporting the view that services heavily covered by insurance are less price competitive than those that are not is presented, and an examination of the health maintenance organization as an alternative delivery system is provided. The final section addressed the policy alternaatives of competition and regulation in the health care field. Observations include the ocntention that quality care at low cost will result from a large-scale cooperaative effort between public and private sectors, not of either competition or regulation. Notes and references are provided at the end of each section. (Author abstract modified)
Descriptor(s): Characteristics of U.S. health care system, Health care costs, Economic/commercial influences, Cost containment efforts, Competition/interaction among third-party payors, Policy initiatives.
106. Competitive Response of Blue Cross and Blue Shield to the Health Maintenance Organization in Northern California and Hawaii. Lawrence G. Goldberg and Warren Greenberg. 1979, 10 pp. Availability: Medical Care v17 nl0 p1019-1028 Oct 79.
Blue Cross and Blue Shield plans have responded to health maintenance organization (HMO) competitive pressure in northern California and Hawaii by establishing their own
1-50
HMO's and by altering their traditional procedures. HMO's are found in most sections of the country, although market penetration varies widely. Over one-half of the more than six million HMO enrollees are concentrated in California. In northern California, the Kaiser-Permanente Medical Care Program is by far the largest HMO, and northern California is the only region in the country where the market share of an HMO is nearly as large as that of Blue Cross. According to Blue Cross of Northern California, it began to respond to the presence of Kaiser in the mid-1960's. Not only was the Kaiser market share significant from the standpoint of Blue Cross, but Kaiser also tended to enroll the younger, healthier people who had no attachments to local physicians. The HMO has had a direct competitive effect, and Blue Cross has responded by improving its utilization review procedures, increasing benefits, and by starting rival HMO's. The State of Hawaii is another example of the beneficial effects of direct competition. The Hawaii Medical Service Association (HMSA) is a voluntary nonprofit service organization associated with Blue Shield and has provided comprehensive prepaid medical care to the people of Hawaii since 1938. Hawaii is the only State that does not have a Blue Cross plan. Kaiser began operating in Hawaii in 1958, and HMSA and Kaiser are now clearly the two dominant competitive forces in Hawaii. Commercial insurers play a very small role. Kaiser has stimulated HMSA to establish its own HMO, contain costs, increase the attractiveness of its product, and to compete in price. Although both California and Hawaii have Blue Cross and Blue Shield situations which are substantially different from other States, the HMO competitive presence induced Blue Cross to reduce hospital utilization, offer richer benefit packages, and increase cost control efforts. Statistical results show that the greater the HMO market share, the greater the Blue Cross and Blue Shield response. Eighteen references are provided. (Author abstract modified)
Descriptor(s): Competition/interaction among third-party payors, Prepaid plans, Service benefit plans.
107. Complex Puzzle of Rising Health Care Costs. Can the Private Sector Fit it Together.
Council on Wage and Price Stability, Washington, DC 20506 1976, 195 pp. Availability: President, Council on Wage and Price Stability, Washington, DC 20506.
This 1976 report by the Council on Wage and Price Stability, Executive Office of the President, summarizes the results of six hearings held throughout the country on potential solutions to the growing cost crisis in the health care industry. The series of
Health Care Programs
hearings was begun in June in New York City, N.Y., and followed by hearings in Chicago, Ill., San Francisco, Calif., Philadelphia, Pa., Houston, Tex. and Miami, Fla. Witnesses included providers, consumers, employers, insurers, regulators, and academics. Individual chapters discuss the extent of the problem of rising health care costs; manifestations of the problem in excess capacity and redundancy
of expensive equipment
and services;
the impact of payment mechanisms on rising health care costs; the impact of other Government programs such as regulations, staffing, and facility requirements; and other sources of increased costs, such as improper lifestyles that cause poor health, The report also describes programs to control rising health costs, including consumer, provider, and Government efforts to reduce health care cost inflation. Finally, five innovative cost-control programs are described. The Motorola Corporation began investigating comparatively high hospital costs in Phoenix, Ariz., and after meetings with officials and examinations of records of the local hospitals, the company made recommendations representing a considerable savings. Other efforts include the development of the Kaiser Plan Health Maintenance Organizations, the efforts of Texas and New Jersey hospital association to improve efficiency, efforts of a Seattle, Wash., doctor to clarify advantages of an end-stage kidney disease treatment option, and General Motors Corporation participation in controlling health benefit costs. Three appendices give a list of witnesses who participated at the hearings, cover letters and introductory statements which contain some policy conclusions, and summaries of the findings of previous council studies on the problem of rising health care costs and labor-management innovations in cost control. Two indexes contain names and addresses of sponsors and an alphabetical list of employers and unions cited. A summary
AvMlabib'ty: Superintendent of Documents, Government Printing Office, Washington, De 20402. This bibliography on health maintenance organizations (HMO's) is intended for policymakers, administrators, scholars, and potential purchasers. This first volume is part of a twovolume series and includes an index of 90 HMO terms for accessing the 1,800 entries. It contains journal articles, monographs and proceedings, government publications, doctoral dissertations, and newspaper articles. Citations give ordering information, whenever possible, and various publication formats. In addition, letters in response to landmark articles are listed along with the original work. Two appendices list 20 printed indices in the fields of business, economics, medicine, health planning, legislation, sociology, and political science as well as computerized data bases. (Author abstract modified)
Descriptor(s):
Prepaid plans.
109. Comprehensive Medical Care.
Market and Regulatory Strategies
for
Walter McClure. InterStudy, Excelsior, MN 55331 Bureau of Health Planning and Resources Development, Hyattsviile, MD. 1980, 518 pp. Availability: InterStudy, Excelsior, MN 55331.
of hearings held in New York, Chicago, San Fran-
cisco, Philadelphia, Labor-Management Costs.
Houston and Miami. A Compendium of Innovations in Reducing Hea/th Care
Descriptor(s): Health care cost trends/projections, Cost containment efforts, Economics of third-party payors, Impact of thirdparty coverage, Private health care plans, Present legislation/ regulations, Voluntary initiatives,
108. Comprehensive Bibliography on Health Maintenance Organizations, 1974-1978. Volume I. Nina M. Lane and Anna T. Stocker. Group Health Association of America, Inc., Washington, DC 20036 Department of Health, Education, and Welfare, Washington, DC. Office of Health Maintenance Organizations. Jan 1980, 163 pp.
Three alternative comprehensive strategies to achieve major health-car¢ policy goals are developed and evaluated. By presenting the basic strategic options in a comparative fi)rmat, the report is intended to assist health policymakers, providers, and managers in the public and private sectors to undertake a more rational and systematic approach to health-care issues. The first strategy presented is largely market-oriented, the second largely regulatory, and the third combines market influences and strong regulation. The presentation of each strategy consis_Is of basic concepts, a description of important operational details, an analysis of feasibility and expected impact on goals, and a plan of implementation. The report deals only with acute medical care, and the strategies may be considered comprehensive only within this limitation. Issues of non medical health promotion, longterm care, medical education, and biomedical research are not addressed. Major conclusions are that (1) an effective market strategy can be broadened to include most existing delivery and financing arrangements with rather minimal modification; (2) incentives are as crucial in a regulated system as in a market system; and (3) it may be possible to use a strategy oriented
1-51
toward market forces as well as strong regulation, but this approach is more risky than it appears. Appended are a technical note on adjusting areawide use and expenditure rates for health risk and cost-of-living factors, a discussion of broadening the definition and removing regulatory barriers to a competitive health system, and a consideration of incentive taxes that promote local responsibility for health-care costs. References are provided. (Author abstract modified)
Descriptor(s): Economic/commercial influences, Funding/financing of health care programs, Outcome/evaluation of health administration, Policy/changes re health care.
110. Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Volume VIH, Overview.
Robert H. Brook, John E. Ware, Allyson Davies-Avery, Anita L. Stewart and Cathy A. Donald. Rand Corp., Santa Monica, CA 90406 RAND/R- 1987/8-HEW Department of Health, Education, and Welfare, Washington, DC. Oct 1979, 131 pp. Availability: Rand Corp., Santa Monica, CA 90406.
The final volume in a series of eight focusing on the Rand Health Insurance Study (HIS), this monograph describes the study purpose, design, data collection methods, selection of health status measures, and conclusions. The HIS is a social experiment in which representative samples of different communities are assigned, using a nonbiased selection process, to several different health insurance plans, including a prepaid group practice. The experiment is designed to assess the effects of variation in cost of health services to the patient and of provision of services in either the fee-for-service system or a prepaid group practice on the use of services, quality of care, patient satisfaction, and health status. It is anticipated that study results will be useful to policymakers in determining future health policies, particularly those relating to national health insurance. The HIS sample included approximately 8,000 people in 2,750 families which are enrolled in six sites across the country. Sites were chosen to represent the four census regions and an urban-rural mix. Families are enrolled in 1 of the 16 HIS plans for either 3 or 5 years. Low-income families are oversampled, and eligibility for participation is broad. During the study, data are collected on demographic and socioeconomic variables; use of medical, dental, and mental health services; types of providers seen for care; health status; patient satisfaction; and a variety of other attitudinal
1-52
variables. Data sources include a baseline interview, an enrollment medical history questionnaire, health reports, a health questionnaire, an exit medical history questionnaire, and a multiphasic screening examination. Specific constructs were chosen for evaluation within the four major health status dimensions of physical, mental, and social health as well as general health perceptions. Evaluations of the adequacy of HIS measures of physical and mental health status of adults tested in Dayton, Ohio, indicate that they meet the criteria outlined for their usefulness to HIS analysis. Footnotes, appendices, 16 tables, and 66 references are included.
Descriptor(s): Trends in health status, Health care costs, Impact of third-party coverage, Private health care plans, Participants in health care programs, Health care/services, Plan design/program provisions (under health plans), Funding/financing of health care programs, Evaluations/outcome of health care programs, Health information/data systems.
111. Conditions for Change in the Health Care System.
Robert Blendon, Merlin K. DuVal, William McC. Hiscock, Anthony Robbins and Doris E. Roberts. Health Resources Administration, Hyattsville, MD 20782 DHEW/PUB/HRA-78/642 Sep 1977, 132 pp. Availabib'ty: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-022-00587-5.
This is the third in a series of monographs bringing together staff papers and resource materials relating to the National Guidelines for Health Planning, called for by Section 1501 of the National Health Planning and Resources Development Act of 1974 (Public Law 93-641). Suggestions for change within the health care system are presented, and some of the obstacles which presently stand in the way of such change are identified. One paper proposes a national health policy based on individual responsibility for personal health which must be supported by the social responsibility to create and maintain conditions under which individuals are most able and motivated to optimize their health potential. Recommendations of a seminar on national health guidelines issued under the National Health Planning and Resources Development Act state that three national needs should be addressed: (1) the need to get more complete, direct information on the effectiveness of medical technology; (2) the need for a more rational policy for setting priorities; and (3) the need for a data base which will eventually allow planners to make their decisions from end-result information and criteria.
Health
Care Programs
Other subjects addressed are disaggregative strategies aimed at increasing the ability of persons to manage their own health; a framework for evaluating policy alternatives in health planning using measurements of effectiveness, psychosocial effectiveness, and efficiency; and an alternative approach to health care plan-
is just beginning to be collected, and the sample is small. Health expenditures, national health insurance, and regulatory programs need rigorous, relevant research. Twenty-eight references are provided.
ning that uses the semi-autonomous systems of environmental health care, personal health care, and medical care. In addition, an international perspective on issues in health planning, reaching needy children with health care, questions on health care for the aged, and the goal of preventing early death are the focus of separate papers in the monograph. Tables, footnotes, and chapter references are included.
From NBER Conference Patient Behavior.
Papers on the National Health
Guidelines.
Descriptor(s): Trends in health status, Health information/data systems, Health care costs, Present legislation/regulations, Voluntary initiatives, Policy initiatives, Preventive services.
on the Economics
of Physician
and
Descriptor(s): Health care costs, Economics of third-party payors, Policy/changes re health care, Physicians.
113. Conference on Health Promotion and Disease P_revention, February 16-18, 1978. Volume I. Themes and Policy Suggestions. Institute of Medicine Div. of Health Promotion and Disease Prevention, Washington, DC 20418 IOM-78/002 Department of Health, Education, and Welfare, Washington,
112. Conference
and Unresolved Problems.
Victor R. Fuehs and Joseph P. Newhouse. Robert Wood Johnson Foundation, Princeton, NJ. Henry J. Kaiser Family Foundation, Palo Alto, CA. Department of Health, Education, and Welfare, Washington, DC. 1978, 14 pp. Availability: Jnl. of Human Resources v8 p5-18 Supplement 1978. A sustained, systematic study of health and medical care by professional economists is a relatively recent phenomenon fueled by the rapid growth in health care expenditures. The conference held at the National Bureau of Eoonomie Research at Stanford, California, on January 27-28, 1978, brought public policymakers and academic researchers together to study the contributions and limitations of economies in this area. Nearly all the papers dealt with health care costs. Several focused on the possible role of physicians in determining demand for their services and in influencing hospital costs. Others gave considerable attention to insurance and consumer behavior. Two papers emphasized the effect of government policies on supply and demand. One paper measured participation in medicaid based upon fee schedules, reimbursement forms, and delay in payment. Another investigated the effect of advertising on optometry costs. The data necessary for evaluating the demand for medical care within the fee-for-service system is not yet in, but it should be noted that these studies generally involve the individual's use of insurance, Data measuring the usage of insurance at the community level
DC. Jun 1978, 41 pp. A vailability: National Academy of Sciences, Inst. of Medicine, Div. of Health Promotion and Disease Prevention, Washington, DC 20418. This report, the fLrSt of tWO volumes, summarizes the major themes that emerged from the 1978 Conference on Prevention of Disease and Promotion of Health. These themes included universal eligibility for preventive personal health services, the need for a health promotion infrastructure, the need for grassroots involvement, and the need for sites, such as schools and workplaces, for delivery of preventive services. Additional themes included the need for preventive services manpower and the issue of costs, which were expected to be higher in the short-term. Participants strongly recommended full coverage under appropriate Federal programs and through private insurers for theeurrent limited number ofprograms whose safety and effectiveness were proven. Costs could be reduced, within a prevention infrastructure, through reimbursement for health services provided by nonphysieians, regionalization of certain preventive services, and incentives for physician participation, such as Federal payment of salaries for allied health personnel. Additional themes covered at the conference included prevention information and education, data and research requirements, and speeitic preventive services. The report also presents conference suggestions on Federal prevention policies such _ vehicular accident and cigarette smoking prevention and promotion of health behaviors through increased Federal support. Appendices include a conference agenda, a list of speakers and invited discussants, and a table of contents for Volume II.
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Descriptor(s):
Cost containment
efforts, Preventive services.
Descriptor(s): Trends in health status, Preventive services, Policy initiatives.
114. Conference on Health Promotion and Disease PrevenN tion, February 16-18, 1978. Volume II. Conference Summaries.
115. Consequences of Increased Third-Party Payments for Health Care Services.
Institute of Medicine Div. of Health Promotion
Robert A. Zelten.
and Disease
Prevention, Washington, DC 20418 IOM-78/003 Department of Health, Education, and Welfare, Washington, 13(2. Jun 1978, 84 pp. Availability: National Academy of Sciences, Inst. of Medicine, Div. of Health Promotion and Disease Prevention, Washington, DC 20418.
This report, the second of two volumes, summarizes the preliminary reports of three work groups from the Department of Health, Education, and Welfare (DHEW). The reports, which dealt with personal health care services, the relationship of environmental factors to public health, and the importance of behavioral factors in health were given at the 1978 Conference on Health Promotion and Disease Prevention. The health services presentations discussed reasons for incorporating prevention into the health services; criteria for selecting particular prevention services; the aims of preventive health services packages; the wider application of some current preventive services, such as prenatal care; and barriers to greater emphasis on preventive programs. Participants suggested steps to expand preventive programs, such as offering third-party reimbursement for appropriate preventive services and amending medicare to cover preventive services. Presentations and discussions on the environment covered the control of hazardous agents; environmental control efforts, such as reducing air pollution;and the workplace as a site for occupational health and prevention programs. Participants discussed prevention strategies that included environmental preventive measures. These included fluoridation, health education, and Federal incentives for employers to participate in occupational health programs. Presentations and discussions on behavior and lifestyle examined some of the behavioral risk factors associated with such major illnesses as cardiovascular disease, cancers, and lung diseases. In addition, monetary incentives to encourage community participation in prevention programs were discussed, including premium discounts for persons who practice health-promoting behaviors and preventive service-generated revenues for hospitals faced with bed closures. Footnotes and tabular data are included. Three appendices contain the conference agenda, a list of speakers and invited discussants, and a table of contents for volume I on themes and policy suggestions,
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1979, 16 pp. Availability: Annals of the American Academy of Political and Social Science v443 p25-40 May 79.
This article focuses on some of the adverse consequences of health insurance programs and indicates that the future of private health insurance depends upon how these problems are addressed. Without the widespread existence of third-party payment programs, national expenditures for health care would not be as high as $162.6 billion in fiscal year 1977. The prevalence of third-party payment programs lessens physician fiscal accountability to keep costs down. In addition, because of patient collection problems and the relative certainty of third-party payments, it could be argued that insurance has introduced a bias in favor of nonprimary care specialties. Third-party payor tend to cover the services provided by physicians in these specialties more extensively. Primary care physicians who guide patients through the complicated health care system have lost control of the health care dollar, Further, overspecialization results in more expensive services through high specialist fees, more hospitalization, more ancillary services, and a tendency to treat syruptoms within the narrow context of a single specialty. Moreover, in third-party payment programs with substantial physician control (such as Blue Shield), it is the specialty physicians who often have the strongest voice in policy matters. Insurance programs have also had an impact on the price of services. The mechanics of some widely used reimbursement methods provide a strong incentive for providers to increase their fee levels. Documentation shows that physician fee increases have outpaced the increase in the consumer price index generally. In addition, health care providers are insulated further from the pressures of consumers and premium payers by the group basis purchasing of most health insurance. Third-party payment programs have also created inequities across payment programs, across hospitals, and across patients within a hospital. Suggested solutions inelude reorienting financial incentives through health maintenance organizations and increased competition, and through experimental reimbursement methods. Tables and footnotes are provided.
Descriptor(s): Health care cost trends/projections, Cost containment efforts, Physicians, Impact of third-party coverage.
Health Care Programs
116. Cor,siderations in the Design of Mental Health Benefits Under National Health Insurance. David Mechanic. 1978, 7 pp. Availability: American Jnl. of Public Health v68 n5 13482-488 May 78. The design of mental health benefits under national health insurance (NHI) is discussed in terms of policy issues. The present insurance structure for mental health coverage that has evolved has been a pragmatic response to pressures for greater coverage from insured groups and has not been initiated with the intent to develop the most rational pattern of psychiatric insurance or to improve the mental health care delivery system as a whole, The response of the private sector has been largely incremental, working around the existing pattern of care. Current insurance programs for psychiatric benefits effectively limit total expenditures for psychiatric services, but they also reinforce traditional, ineffective, and inefficient patterns of mental health care; inhibit innovation and use of less expensive mental health personnel; and reinforce a medical as compared with a social or educational approach to patients' psychological problems. Moreover, the structure of benefits favors the affluent as compared with the disadvantaged and provides little assistance for the community integration of the chronic mental patient. Because the pattern of mental health benefits under NHI will establish the future form
This work is designed to supplement an earlier study on legislative responses to the medical malpractice crisis which was prepared for the American Hospital Association in 1977. These update materials focus primarily on reform legislation and judicial decisions made since early 1977. Decisions of the U.S. Supreme Court and other Federal courts within the past year interpreting the equal protection and due process clauses of the 5th and 14th amendments to the Constitution are considered. Recent State court decisions ruling on the constitutionality of malpractice reform legislation are then examined. Finally, the constitutional implications of the recently adopted Texas law providing for a cause of action against an attorney and a party who bring a malpractice action in reckless disregard of the action's lack of merit are analyzed. Overall, the state of constitutional flux in which medical malpractice legislation found itself in 1977 continues to exist. State court decisions continue to be handed down at a rapid rate, and the Supreme Court',,; decision to review the District Court's opinion in the "Carolina Environmental Study Group" ease may well have a significant effect on the future of medical malpractice reform legislation. To the extent that trends may be discerned, it appears that they are moving away from the heightened judicial scrutiny of the last several years toward a recognition that the controversial and delicate issues involved are better suited to legislative rather than judicial resolution. Source material and 140 footnotes are provided. (Author abstract modified)
of mental health services in the community, types of personnel available, and the relationships between the general medical and mental health sectors, it is important that reinforcment of present patterns be avoided. It is suggested that NHI include a
Supplement to the report "Legislative Response to the Me_'cal Maipractice CrY's: Cons_'tutionai Implications, "' w_tten by the author.
mental health resource development fund intended for building a stronger network of community mental health care and that the pattern of insurance benefits under NHI be consistent with developing psychiatric services on a capitation basis. Thirty-nine references are included. (Author abstra_ modified)
Descriptor(s): Economic/commercial lation/regnlations.
Desc_ptor(s): Third-party payors, Mental health services, Exclusions from coverage, National health insurance (NHI), Prov-
118. Consumer Acceptance of HMOs.
iders of health care services, Methods of payment determination, Limitations on coverage.
Claudia B. Galiher and Marjorie A. Costa. 1975, 7 pp. Availability: Public Health Reports v90 n2 p106-112 Mar/ Apr 75.
117. Constitutionality of Medical Malpractice lafion. A Supplemental Report.
Issues focusing on consumer acceptance of the health maintenance organization (I-IMO) concept are explored in tlus article. The experience of new HMO's in enrolling consumers has been more difficult than many health planners and Government proponents had envisioned. It is therefore important to examine the way people learn about HMO's. Most HMO's develop a marketing plan for their geographic areas based on the data about firms employing large numbers of workers, si_e of union
Reform Legis-
Martin H. Redish. American Hospital Association, Chicago, IL. 1978, 32 pp. Availability: American Hospital Association, Chicago, IL 60611.
influences, Pr_ent legis-
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membership, number of Federal and other public employees, medicaid and medicare eligibles, and employees in small groups The majority of HMO's have concentrated on employed groups who could be reached on the job; the work force is generally contacted by mail, telephone calls, and through advertising ir_ local newspapers. Elements involved directly in the consumer-, acceptance strategy focus on the individual's awareness of the HMO's existence, belief in the need for the HMO, the decision to try the plan, experience with the HMO's services, and satisfaction or dissatisfaction with the service. Aspects of the HMO which appeal to the potential enrollee include 24-hour se.rvice, convenient location, more benefits, and a physician who is the total health care manager, backed up by a range of specialists, Cost appem's to be a major factor in choosing the HMO. Initial enrollment activities must identify not only the potential market for the HMO but also the level of consumer awareness regarding health care generatly. Both management and labor representatives should be interviewed to determine existing attitudes about the HMO concept. Those who interview employers should ask them what they consider to be the benefits of an HMO. Generally, employers cite an economically competitive benefit package, more comprehensive benefits, one-source health service, and the: option of another form of health care delivery as being advantages of the HMO. The individual's decision to enroll in the: HMO is usually a group-influenced one. Eighteen references are included.
Descriptor(s): grams,
Prepaid plans, Participation
in health care pro-
community residents about health care problems. Hospital board members were found to have substantially different social characteristics than consumers, and these differing social values influence choices in medical care administration. The hospital board members reject government intervention as a method of reducing the rate of price increases in health care. On the other hand, consumers were much less supportive of the voluntary free market nature of the American health care delivery system. They indicate a preference for a presidential candidate who will support national health insurance and favor more consumer participation in health planning. Since the values of the persons making decisions in health care policy were found to be signiflcant, then it can be anticipated that the decisions made by local health care planners will be dominated by conservative interests, possibly limiting decisionmaking to relatively safe issues instead of including the more controversial issues relevant to consumers. Consumers were found to be concerned about an adequate supply of services but unaware of alternatives enabling more consumer-oriented delivery systems. Four tables displaying statistical analyses of survey data are included, along with twenty-three footnotes. An earlier version of this paper was presented at the 72nd AnnuM Meeting of the American Sociolo_cM Association, Chicago, IL, September 1977. Descriptor(s): Present legislation/regulations, tion of health administration, Demographic tion.
Outcome/evaluafeatures of popula-
119. Consumer Attitudes Toward Health Policy and Knowledge About Health Legislation.
120. Consumer Expenditure Patterns. Volume I. Food, Household Supplies, Personal and Health Care Products.
Elainne Riska and James A. Taylor. National Inst. of Health, Bethesda, MD. General Research Support Branch_ Michigan State Univ., East Lansing, MI. Coll. of Social Science. 1978, 12 pp. Availability" Jnl. of Health Politics, Policy and Law v3 nl
Fabian Linden and Helen Axel. Conference Board, Inc., New York, NY 10022 Columbia Broadcasting System, New York, NY. 1978, 95 pp. Availabilitw Conference Board, Inc., New York, NY 10022.
p I 12-123 Spring 1978. Local health policymakers and medical sociologists have ignored consumer attitudes toward key issues affecting health policy decisions. Much has been said about concern for the quality and cost of medical care, but no one has adequately researched consumer views on these problems and appropriate reforms or their level of knowledge about recent health legislation. Toward this end, surveys were taken of local hospital board members and
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This is the first part of a two-volume Conference Board study on how the American family spends its money, and it contains data on expenditures for nonprescription health care products. These include drugs, such as vitamins, aspirin, and cold and allergy medicines, as well as supplies, such as bandages, heating pads, canes, and eyeglasses. Data are based on a Bureau of Labor Statistics survey conducted over a 2-year period ending in mid1974. They were collected from a representative sample of some 20,000 households, and include demographic characteristics (age, sex, race, education, income, etc.) and expenditure infor-
Health Care Programs
mation. The survey consisted of two parts: a diary survey of detailed expeditures recorded during a 2-week period and an interview survey made every 3 months over a 15-month period, The dollar expenditures collected during the survey are presented in a "share-of-market" format updated to 1977. The expenditure categories of this volume are four: consumer expenditures for food at home; food away from home, alcohol and tobacco; personal care products and services, nonprescription drugs and supplies; and household supplies. The bulk of the volume is comprised of tabular data. Appended is a comprehensive list of items and average annual household expenditures.
patient an additional amount. This payment method is easier for the carriers to administer, but the consumer does not obtain the benefits of a fee review. Thus, through these methods and others, the collective political and economic power of consumers to influence the structure of the dental health care delivery system will have a substantial effect on the quality of dental care. A total of 23 references are included.
Descriptor(s): Dental services, Impact of third-party coverage, Participation in health care programs.
B&,ed on a survey conducted by the United States Department of Labor. Conference Board Report No. 745. Descriptor(s): Demographic features of population, Health care costs, Pharmaceutical services.
122. Consumer Participation and Community Organ_ation Practice. Implications of National Health Legislation.
Lawrence K. Koseki and John M. Hayakawa. 1978, 11 pp. Availability: Medical Care v17 n3 p244-254 Mar 79. 121. Consumer Influence on the Quality of Dental Care. Howard L. Bailit. 1980, 10 pp. Availability: Family and Community Nov 80.
Health v3 n3 p61-70
Consumers can influence the quality of dental care in four basic ways: selection of the dentist and evaluation of the quality of care received, registration of complaints with professional organizations or State regulatory bodies established to handle problem cases, the seeking of redress through malpractice suits, and notification of insurance carriers about dentists who provide unsatisfactory care. In all States the dental profession has established formal systems of responding to patient complaints, consisting of peer review committees of local dental societies and State dental associations. Complaints about quality can also be directed to the State board of dental examiners, the regulatory agency responsible for monitoring the performance of dentists, In contrast to peer review committees, State boards have legal power and can apply sanctions, including simple reprimands, fines, required reeducation, and suspension or revocation of licenses. Patients sometimes complain to their insurance carriers about the quality of dental care they receive. Because insurance carriers are large organizations with access to expert legal and dental advice, and because they control the funds to pay for dental services, they have considerable leverage with individual dentists. In addition to responding to complaints from consumers, most insurers operate formal cost and quality assurance programs. In some dental contracts, the insurance carrier pays a set fee for each service and the dentist is free to charge the
This paper reviews the extent to which 10 Federal health laws incorporate consumer participation in health programming, identifies problems in implementing consumer participation, and advises consumer advocates. Analysis of the 10 laws, which include the 1964 Economic Opportunity Act and the 1966 Model Cities Program, according to 10 criteria indicates the following consumer participation patterns: (1) lack of clarity of purposes and outcomes for participation; (2) alternation of consumer roles between policymaking and advising, (3) delegation of authority and program responsibilities to public agencies and the private sector, (4) inconstant acknowledgement of the consumer role, (5) lack of description of how consumers would be involved, and (6) inconsistency in proportion of consumer representation vis-a-vis other special interest groups. "lTnus, the laws do not attest to a consistent, clear national policy about consumer participation. General areas of consumer participation conflict discussed include philosophy and strategies of participation, the interest of the medical profession; and authority, legitimacy, and the consumer role. Two recent health laws, the 1974 National Health Planning and Resources Development Act and Title III of the 1975 Community Mental Health Centers Amendment, offer improved opportunities for consumer participation. However, because the laws continue to delegate the responsibility for implementing consumer involvement programs to providers, established institutions, and State agencies, consumer advocates are urged to increase their knowledge of the laws and to assist consumers in realizing their right of selldetermination through building of consumer coalitions and provision of consumer education. Tables and 24 references are included.
1-57
Descriptor(s): Present legislation/regulations, Participation in health care programs.
Policy initiatives,
123. Consumer Responsibility in a Prepaid Group Health Plan.
E. Frank Harrelson
and Kirk M. Donovan.
1975, 10 pp. A vailability: American 1086 Oct 75.
The experiences
Jrd. of Pubic Health v65 n l0 p1077-
of a consumer group in attempting to achieve
meaningful participation in a prepaid group health plan are described. The Columbia Medical Plan of Columbia, Md., a prepaid health system affiliated with the Johns Hopkins Medical Institutions, has included a Consumer Council in its structure since shortly after it began operations in 1969. Based upon the authors' experience in serving on the council and observing its operations through October 1973, it is concluded that consumer participation in advising management of a prepaid group health plan can be a positive benefit, provided the consumer's role and relationship to management is clearly defined and accepted by all concerned parties. This identification of roles should be established prior to the creation of a working relationship between the consumer representatives and management. The existence of a consumer advisory group will sooner or later result in demands for consumer representation at the policy level; therefore, the development of policymaking boards should include some provision for appointing members from the consumer groups and the community at large, as well as from providers, insurors, managemerit, and benefactors. In addition to dedicating personal time and effort to represent his/her constituency, the consumer representative should become educated in the organization and contractual arrangements of the group health plan and the management relationships that affect the operation of the plan. Prior experience in the health professions or in a health-related occupation is desirable for a consumer representative. The resolution
124. Consumer Satisfaction. Administrators.
A Model for Health Services
Nancy Wint Mitry and Howard L. Smith. 1979, 8 pp. Availability.. Health Care Management Review v4 n3 p7-14 Summer 1979.
Consumer satisfaction with the provision of health care services as a priority for the health care system is discussed in this article. Concern for consumer satisfaction has typically been overwhelmed by concentration on the effectiveness of medical care. However, recent trends in consumer health education and more comprehensive evaluation of health care services suggest that health care administrators and other professionals must adopt a more progressive attitude toward consumer service. Administrators should recognize that the economic and behavioral quality dimensions compromising consumer satisfaction are conceptually independent in nature and may be empirically independent as well. In making a decision to purchase health care goods or services, consumers evaluate two basic forms of information; i.e., the cost of the service and the benefit accruing from utilization. The consumer generally desires medical services to be readily available and often expresses interest in the freedom to make decisions about health care. Just as the consumer's satisfaction with the economic dimension of the system is based on subjective criteria, so is the consumer's assessment of the quality dimension. Such factors as personalized attention, degree of autonomy, and communication between consumer and health professional are important to the total evaluation. It is suggested that health care administrators assign the economic and behavioral quality dimensions of consumer satisfaction a higher priority among decision criteria and apply the consumer satisfaction model to health services administration. Twenty-three references are provided in the article.
Descriptor(s): Demand/utilization ofheaith care programs, ticipation in health care programs.
of the Consumer Council to establish an ad hoc roles committee is appended, and references are included,
125. Consumer Satisfaction zation.
Article was presented to the Social Work Section, AmeHc, an Public Health Association, at the lOlst Annual Meeting, San Francisco, CA, November 1973.
Clyde R. Pope. 1978, 13 pp. Availability: Jrd. of Health and Social Behavior v19 n3 p291303 Sep 78.
Descriptor(s): Prepaid plans, Participants in health care programs, Evaluations/outcome of health care programs.
This paper examines consumer satisfaction in the Portland, Oreg., Kalser-Permanente Medical Care Program, a health
1-58
in a Health Maintenance
Par-
Health
Organi-
Care Programs
maintenance organization (HMO). Expressions of satisfaction or dissatisfaction may reflect peoples' expectations more than the actual character of services received. The potential for dissatisfaction is less if the consumer's expectations are low in the beginning. More than likely, a person may be generally satisfied with some things, but still have a number of specific complaints, The evidence from prior studies of HMO's shows that the great majority of enrollees are satisfied with their medical care. If complaints are made, the majority have to do with cost, accessibility, and the impersonality of provider service, not with the quality of care. In this study of the Portland Kaiser plan, the two most frequently cited advantages were cost and access to care, especlaUy readily available emergency care. Satisfaction is most strongly related to older, rather than younger, subscribers in families in excellent health who have doctors within the program that they see regularly. The two most frequent complaints were about appointment lag and operating procedures of the system, Dissatisfaction does not appear to be a prominent reason for terminating membership. The most frequent reason for terminating membership was leaving the job that provided the coverage or moving out of the service area. Only about 8 percent terminated specifically because of dissatisfaction with the program. Termination for reasons of dissatisfaction is associated with families who are less healthy, who have lived in the service area a somewhat longer time, and who do not have a regular
The article argues that today's job-centered health insurance hinders economic competition in health services and that a change to a consumer-oriented system would achieve the neces. sary competitive level, as well as universal continous coverage and administrative simplification. Reasons for the present unjustiffed increases in health costs include (1) rewards to &_ctors for providing more costly services, (2) reimbursement of hospitals for their costs, and (3) lack of incentives to consumers to seek out less costly care systems. Alternative care system.,; such as prepaid group practices, individual practice associations, health maintenance plans, health care alliances, and variable cost insurance are already in successful operation in the United States. A system ofuniversal health insurance and fair market coxnpetition among health plans would follow these guidelines: (1) yearly choice for consumers to enroll in the most advantageous health plan in their area; (2) equal financial assistance regardless of the health plan chosen; (3) a uniform set of rules governing all qualified plans with regard to nondiscriminatory pricing, comprehensive benefits, and catastrophic illness insurance; and (4) the offering of two standard health plans to the entire community by each company rather than a different, specially negotiated plan for each employee group. The article urges labor uttions and management tojoin forces to create a fair competition system in the health services industry. Sixteen references are given.
doctor within the program. Other termination for reasons due to dissatisfaction were being a female subscriber, being somewhat better educated, and being of a higher perceived social class. The major complaint was the difficulty in gaining access to care, particularly nonacute, nonemergency care. Other reasons cited for dissatisfaction included the nonreporting of negative results of lab tests to the patient, recordkeeping problems, and the dif-
Descriptor(s): Cost containment efforts, Policy initiatives, Com-
ficulty in settling claims outside the program. These findings are consistent with previously reported studies of other samples of the Portland Kaiser HMO in other time periods. Tables and 26 references are provided. (Author abstract modified)
127. Consumer-Cltoice Health Plan. A National.Health-Insurance Proposal Based on Regulated Competition in the Pri-
petition/interaction among third-party health insurance plans, Prepaid plans.
payors,
Commercial
rate Sector. Alain C. Enthoven.
Descriptor(s): grams.
Prepaid plans, Participants
126. Consumer-Centered
in health care pro-
vs. Job-Centered Health Insurance.
Alain C. Enthoven. Henry J. Kaiser Family Foundation, Palo Alto, CA. 1979, 12 pp. Availability: Harvard Business Review v57 nl p141-152 Jan/ Feb 79.
1977, 12 pp. Availability: New England Jnl. of Medicine v298 n13 p709720 Mar 78.
The Consumer-Choice Health Plan (CCHP) is presented as an alternative to the present fragmented system of health c_e dominated by the cost-increasing incentives of fee for service and proposed direct economic regulation. The CCHP aims at a health care economy composed predominantly of competing organized systems. In such systems, physicians would a¢c,ept responsibility for providing comprehensive health care services to defined populations for a prospective per capita payment or some other form of payment that rewards economy in the use of health care resources. CCHP is designed to ensure that all citizens have a choice among competing alternatives for health care,
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based on quality of benefits and total cost. The system would be based on proven principles of competition, multiple choice, private underwriting and management of health plans, periodic government-supervised open enrollment, and equal premiums for all similar enrollees selecting the same plan and benefits. Proposed changes that would aid the establishment of such a system are reformed tax laws, medicare and medicaid to subsidize individual premium payments by an amount based on financial and predicted medical need, as well as subsidies usable only for premiums in qualified health insurance or delivery plans operating under rules that would include periodic open enrollment, community rating by actuarial category, premium rating by market area, and a limit on each person's out-of-pocket costs, Efficient systems should be allowed to pass the full savings on
lose their jobs, and many others lose their medicaid eligibility when they get even a poorly paid job. Cycling in and out of medicaid eligibility produces hardship and work disincentives for the poor and nonproductive admires"trative burdens for States, counties, and providers. As incomes fluctuate, contributions, not eligibility, should vary. Further, there is a lack of competition and choice in employee health care plans. Analysis of previous proposals for national health insurance shows none to be capable of solving most of these problems. Direct economic regulation by the Government will not improve the situation. Cost controls through incentives and regulated competition in the private sector are most likely to be effective. References (26 items) are provided. (Author abstract modified)
to consumers. Incremental changes should be made in the present system, based on consumer and physician choice. Eleven references are provided.
First of two parts.
Second of two parts,
Descriptor(s): Supply/availability of services, National economic conditions, Economics of third-party payors, Competition/ interaction among third-party payors, Policy initiatives, National health insurance (NHI).
Descriptor(s): Supply/availability of services, Competition/interaction among third-party payors, Funding/financing of health care programs, Policy initiatives, Source of premium payment. 129. Containing Costs in Third Party Drug Programs. Selected Bibliography and Abstracts.
128. Consumer-Choi©e Health Plan. Inflation and Inequity in Health Care Today. Alternatives for Cost Control and an Analysis of Proposals for National Health Insurance.
David A. Knapp and Francis B. Palumbo. Roche Lab., Nutley, NJ. 1978, 246 pp. AvMlabib'ty: Drug Intelligence Publications, IL 62341.
Inc., Hamilton,
Alain C. Enthoven. Henry J. Kaiser Family Foundation, Palo Alto, CA. 1977, 9 pp. Availability: New England of Medicine v298 n12 p650-658 Mar 78.
The causes of inflation and inequity in health care today are identified and discussed, and proposals for national health insurance (NHI) are assessed. The financing system for medical costs in the United States suffers from severe inflation and inequity, The tax-supported system of fee for service for doctors, third party intermediaries, and cost reimbursement for hospitals produces inflation by rewarding cost-increasing behavior and failing to provide incentives for economy. The system is inequitable because the Government pays more on behalf of those who choose more costly systems of care and because tax benefits subsidize the health insurance of the well-to-do while failing to help many low-income people. In addition, employment health insurance does not guarantee continuity of coverage and is regressive in its financing. People lose their coverage when they
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This annotated bibliography contains 259 citations with abstracts on cost containment in drug insurance programs. The works were selected from books, articles, government reports, and conferences published between 1970 and August 1977. The abstracts are arranged by subject, beginning with overviews of cost containment which cover experiences in other countries and inpatient settings. Specific drug cost control approaches are then considered, including controls on patients, product cost, dispeusing cost, and prescriber behavior. The abstracts describe the contents of the original article and are not intended to be critical reviews. The number of references cited in the original article appears at the end of the abstract, along with key words indicating its relevance to other subject areas. A list contains complete citations and references to abstracts are included. Author and subject indexes are provided.
Descriptor(s): Pharmaceutical services, Third-party Cost containment efforts, Private health care plans.
payors,
Health Care Programs
130. Containing Health Benefit Costs. The Serf-Insurance Option.
Richard H. Egdahl and Diana Chapman Walsh. Boston Univ. Health Policy Inst., Boston, MA 02215 1979, 181 pp. Av&ilability: Springer-Verlag, New York, NY 10010. The material in this volume derives from a conference held to examine the advantages and disadvantages of self-insurance for employee health benefits. Background papers are included, the content of discussion sessions is summarized, and emerging themes are defined in the introductory section. Because selffunding and self-administration imply a fundamental change in the traditional insurance relationship, the conference highlighted both positive and negative responses to this trend. The major issues included industry-insurer relationships, financing and administrative alternatives, administrative costs reduction, and use of claims data to contain health care costs. The question of data for effective management of an employee health benefit received special emphasis. Purchaser perspectives were clarified by representatives off our corporations currently practicing self-insurance and self-administration strategies in their efforts to achieve such control. Contrasting viewpoint_ to this trend were submitted by third-party representatives of private, Government, and union-administered insurance organizations. Concluding papers outlined possible industry and insurer interventions to control health benefit costs and delineated some legal problems that may be encountered by corporations attempting to restructure eraployee health benefit plans. Individual chapters contain tabular material and bibliographic notes. The appendix lists conference participants quoted in the book.
Based on a conference sponsored by the Center for Industry and Health Care of Boston Univ., held in Boston, M_A, June 9 and 1(9, 1978. Springer Se_'es on Industry and Health Care, No. 6.
Descriptor(s): Cost containment efforts, Voluntary initiatives, Private health care plans, Premium determination/underwriting.
After a brief review of the principal explanations for the recent explosion in hospital costs, this monograph examines the major strategies that have been employed in the effort to reduce expenditures on hospital care, analyzes the literature describing their implementation, and compares their relative effectiveness. The methods of cost containment discussed are cost sharing, health maintenance organizations (HMO's), certificates of need, utilization review, and incentive reimbursement. None of the methods analyzed is undeniably superior under all circumstances. Current efforts to contain hospital costs must be multifaceted and innovative. Far more research and evaluation of currently proposed cost containment mechanisms must be undertaken. The firmest conclusion to emerge from this review is that HMO's consistently achieve low per capita hospital costs. Furthermore, of the methods reviewed, it is the only one for which the data are sufficient to support an active policy commitment. "I_e question of direct governmental regulation looms large in the background. Certificate of need legislation is clearly not an effective solution. Current data do not justify significant reliance on either cost sharing or the schemes of incentive reimbursement, with the exception of prospective reimbursement. Moreover, there is a critical need to better understand the interaction between ambulatory and hospital services. Data indicate that providing more ambulatory services usually results in increased utilization of hospital services, but the details of this relationship are not adequately understood. The methods currently available to control hospital costs are inadequate. The more successful require further study in order to better understand the reasons for success, and the least successful need critical evaluation as to whether to alter or discontinue them. The diversity of the American health care system yields perhaps the best hope for eventual solution to one of the greater health care challenges to our ingenuity. One hundred twenty-nine references are provided. Descriptor(s): Cost containment efforts, Hospital servi(_es, Outcome/evaluation of health admim'stration.
132. Contrasts in HMO and Fee-for-Service
Performance.
Clifton R. Gaus, Barbara S. Cooper and Constance C;. Hirschman. 1976, 12 pp. Availabih'ty: Social Security Bulletin v39 n5 p3-14 May 76. 131. Containment of Hospital Costs. A Strategic Assessment.
Mark R. Chassin. Robert Wood Johnson Foundation, Princeton, NJ. 1978, 55 pp. AvMlabih'ty: Medical Care v16 nl0 Supplement Oct 78.
This study compares various aspects of health maintenance organization (HMO) performance in 10 plans with that of the fee.for-service system of the medicaid population. Additionally, it examines utilization differences between several types of HMO's, grouped according to organization and provider pay-
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ment. Data were obtained from approximately 24,000 individuais through personal interviews structured by a questionnaire which elicited both precoded and open-ended responses. The four areas of behavior that were studied included enrollment selectivity, use of services, accessibility of care, and satisfaction with services. The only significant difference between the two systems was in hospital use. HMO's had significantly lower hospital utilization than the fee-for-service groups; foundation HMO's, however, did not. This difference seems to indicate that capitation payment to an HMO alone is not significant enough to produce major changes in use, and that the organized multispeclalty group practice arrangement with largely salaried physicians may be more significant. For the other variables of previous health status, ambulatory car_ use, accessibility, and satisfaction, the two groups were remarkably similar. Nine tables and nine footnotes are included. (Author abstract modified)
setting body differently. Generally, the commission may operate within the State department of health but, more commonly, it is a separate entity composed of members appointed by the Governor and administered by an executive director, who serves at the will of the commission. Proponents of rate regulation are convinced it promises to be a solution to rapidly rising hospital costs. Opponents of regnlation argue that mandatory hospital rate setting will reduce the quality of care provided. There is not enough evidence to support either position. Both sides encourage further evaluation studies and the development of improved rate setting methods. A table provides a comparison of State-mandated programs, their administrative bodies, the number of hospitals coyered, and the type of rates currently regulated, along with the estimated percentage of hospital revenues affected through regulation. The synopsis of a panel discussion on hospital rate setting is also provided.
Article is adapted from a paper presented Deeembex 30, 1975, at the American Economic Association meetings in Dallas, Texas.
Descriptor(s): Cost containment efforts, Methods of payment determination, Present legislation/regulations, Inpatient facilities.
Descriptor(s): Prepaid plans, Medicaid, Demand/utilization of health care programs, Comparisons of health care programs, Participants
in health care programs, Private health care plans.
133. Control of Hospital Costs by Rate-Setting. Richard H. Egdahl, Stephen M. Weiner, Lawrence and Steven Sieverts.
A. Hill
Coopers and Lybrand Health Care Services Div., Boston, MA 10020 Boston Univ. Center for Industry and Health Care, Boston, MA 02215 1978, 41 pp. A vailability: Coopers and Lybrand, New York, NY 10020. An overview of mandatory hospital rate-setting programs under State commissions is provided. Operational as well as philosophical program differences are discussed, and prospective reimbursement, the new philosophy in cost containment, is briefly outlined. In recent years, Colorado, connecticut, Maryland, Massachusetts, New Jersey, New York, and Washington have established mandatory hospital cost containment programs operated by a State agency or an independent commission. A more recent philosophy of hospital cost containment is called prospeetive reimbursement. For this method of paying hospitals, amounts or rates of payment are established in advance for the coming year, and hospitals are paid these amounts or rates regardless of the costs incurred. Each State has organized its rate-
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134. Controlling Health Care Costs. A National Leadership Conference.
National Journal, Washington, DC 20036 1978, 81 pp. Availability: Government Research Corporation, DC 20036.
Washington,
This publication contains an edited transcript of the National l.,cadership Conference on Controlling Health Care Costs, which was opened with a keynote address by Sen. Edward M. Kennedy. The opening remarks called for a restructuring of the health care system for national health security and was followed by a panel discussion on the perspectives of State and Federal government, health care economics, and medical technology on the future of American health care. The Carter Administration's hospital plan was then analyzed by a speaker representing the viewpoint of hospital workers concerning the cost containment problem. A panel of physicians discussed alternative health delivery systems from their experience with innovative ways of delivering health care. A subsequent panel dealt with the effect of entitlement practices on health care costs and analyzed how policymakers determine who will get what services. Topics of other working groups included advance rate setting for hospitals as a means of cost containment, the implications of a surplus of physicians, the role of biomedical research in the cost versus quality crunch, and the potential of planning as an effective cost containment tool. Connecticut experiences with State-level regulation of hospital
Health
Care Program_
costs was reported, and the Vice President defended the Administration's recommended Hospital Cost Containment Act. In addition, the concluding general session heard labor and management agree on the need for health cost containment and administrators of ongoing health cost control programs discuss practical measures. In the closing remarks, the ranking minority member of the Senate Human Resources Committee outlined an
introduce utilization review as another way of imposing coverage limitations. In general, it is argued that private-sector efforts are likely to be more effective than government-sponsored controls, as well as more appropriate in a pluralistic society. (Author abstract modified)
June 27-28,
Adapted from testimony delivered before the Council on Wage and Price Stability, Houston (TX), October 21, 1976. Also reprinted with permission from the Journal of Health Poh'tics_ Policy and Law vl n4 Winter 1977. AEI Occasional papeas Se_'es, Reprint No. 68.
Descriptor(s): Supply/availabillty of services, Health care costs, Cost containment efforts, Policy/changes re health care.
Descriptor(s): Cost containment efforts, Exclusions from coverage, Health insurance industry, Voluntary initiatives, Deductible/coinsurance, Evaluations/outcome of health care programs.
135. Controlling Health Care Costs. Strengthening vate Sector's Hand.
136. Controlling Hospital Costs. The Revealing Case of Indiana.
agenda for immediate action against medical cost increases. I1lustrations are provided, An edited transcript of the conference proceedingt 1978, Washington, DC
the Pri-
Clark C. Havighurst. National Center for Health Services Research, Hyattsville, MD.
Patrick O'Donoghue. Department of Health, Education, DC.
Jun 1977, 28 pp. Avallability: American Enterprise Inst. for Public Policy Research, Washington, De 20036.
1978, 146 pp. Availability: Policy Center, Inc., Denver, CO 80203.
This article examines the limitations on private-sector cost-control efforts and suggests actions which would permit and encourage private decisionmakers to be more effective. The Council on Wage and Price Stability has recently discovered that many highly promising approaches to cost control (e.g., obtaining second opinions or direct control of hospital admissions) are not being pursued by private health care insurers. The article argues that, given appropriate protection against organized professional resistance, private industry could use exclusions from coverage as one possibility to control cost. For example, a highly-deductible major risk insurance would only begin coverage when financial catastrophe threatens. Another possibility is to focus on specific exclusions which are discretionary or easily budgetable (e.g., dental care, cosmetic surgery, or routine childbirth). As a means of offering reasonable but less expensive protection in the difficult area of catastrophic disease, a plan might find consumers willing to accept exclusion from a number of very expensive measures whose value is less than clear (e.g., coronary bypass surgery, exotic treatments for terminal cancer, and some organ transplants). Plans could also limit themselves to paying not the incurred costs, but a fixed indemnity based on estimated minimum or average cost, leaving the patient free to spend more for additional increments of perceived quality. Insurers could also
and Welfare, Washington,
Results and conclusions of a 1968 to 1973 study of the Indiana Prospective Rate-Setting Program are presented. The program was intended to control hospital costs by increasing the efficiency of hospital care. The study was designed to test the hypothesis that prospective rate setting could reduce hospital cost inflation without adversely affecting the effectiveness of hospital care and without incurring inordinate expenses. The study had seven specific objectives: (1) to determine if, and to what extent, the Indiana program reduced hospital cost inflation; (2) to determine the pathways of the program's cost influence; (3) to determine whether the Indiana program had important side effects which enhanced or reduced its net benefit; (4) to determine how the program influenced hospital management to achieve its cost and other effects; (5) to determine the size of the program's operating expenses; (6) to determine the net benefit of the Indiana program; and (7) to assess the program's replicability in other settings. Study results showed that the Indiana program fulfills its expectations for prospective rate setting which were embodied in the general hypothesis. The program had a strong negative impact on hospital costs. Its operating costs were trifling compared to its hospital cost savings. It did not reduce the quality of hospital services or otherwise diminish the effectivehess of hospital care, and it had no other harmful side effects. In 1973, the program's hospital cost savings exceeded $60 rail-
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lion. During the entire study span, cost savings approximated $200 million. Thus, this study clearly demonstrated that a major prospective rate-setting program could achieve results generally expected of such programs. Because of its effectiveness inside Indiana and its replicability outside Indiana, the program is likely to serve as a model for the development of prospective rate-setting programs. Tables, footnotes, and approximately 25 references are provided. Descriptor(s): Cost containment efforts, Inpatient facilities, Outcome/evaluation of health administration, Methods of payment determination.
137. Controlling Hospital Costs. The Revealing Case of Indiana. Sununary. Patrick O'Donoghue. Department of Health, Education, and Welfare, Washington, DC. 1978, 17 pp. Availability: Policy Center, Inc., Denver, CO 80203. This is an adjunct to the report entitled "Controlling 'Controlling Hospital Costs: The Revealing Case of Indiana," a study of the Indiana Rate-Setting Program. The purpose of the program is to control hospital costs by increasing the efficiency of hospital care. The study was designed to test the hypothesis that prospective rate setting can reduce hospital cost inflation without adversely affecting the effectiveness of hospital care and without incurring inordinate expenses. The study determines the effects of the Indiana program by comparing Indiana and control hospitals selected from Michigan, Illinois, Minnesota, and Iowa. A computerized matching procedure was used to select the specific control hospitals. Most study results are based on regression analysis, but some findings are derived from two sets of site visits. Results showed that the Indiana program substantially reduces total hospital cost, that the program's dominant effect is on the hospital's use of labor resources, that influence of hospital quality is insignificant, and that the program influences the actions of hospital administrative staff in general and the administrator in particular. Other results indicate that the net operating expenses of the Indiana system are $76,000 or about $700 per hospital. The program's net benefit in Indiana is strongly positive; the program supports the hypothesis postulated. The report lists characteristics which constitute the minimum set essential to the program's effectiveness and states that the system is substantially replicable. Generic conclusions address the centrality of the labor sector, efficiency and effectiviness gains, professional versus financial incentives, justifiability versus allowability, and conflict with conventional wisdom. Tables are included,
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Descriptor(s): Cost containment efforts, Inpatient facilities, Outcome/evaluation of health administration, Methods of pay ment determination.
138. Controlling Medicaid Utilization
Patterns.
John Holahan and Bruce Stuart. Urban Inst., Washington, DC 20037 UI-986/15 National Center for Health Services Research, Hyattsville, MD. Ford Foundation, New York, NY. Jun 1977, 127 pp. Availability.. Urban Inst., Washington, DC 20037.
This paper is the second of a four-part series on alternative strategies for controlling the costs of State medicaid programs. The series is a systematic examination of State options which are permitted by Federal regulations and which would improve the efficiency of the programs. Cost containment issues and options regarding medicaid eligibility, benefits, provider reimbursement, and utilization controls are set forth. Possible changes in Federal regulations and financing mechanisms which might improve State management of medicaid are then addressed. This paper, focusing on cost sharing and utilization controls, first examines arguments for and against cost sharing as a cost control device. Presently, States are permitted the use of cost sharing, the payment by the recipient of some portion of the bill for a service at time of use, as a cost control device. However, use must be limited to nominal copayments on optional services for cash assistance recipients and on all services for the medically needy. It is suggested that cost sharing, if imposed mostly on routine services, can be a fairly equitable approach to reducing program costs. Evidence on the efficiency aspect of cost sharing is less clear. Nevertheless, cost sharing may offer a powerful technique for policing the system and helping to limit abuses, such as unnecessary diagnostic services and referrals. A comprehensive examination of utilization control strategies which are available to the States is then presented. Utilization control is defined as any regulatory mechanism which materially affects the behavior of providers or patients in terms of the quantity, quality, or type of medical service utilized. The need for utilization control is based on the assumption that there is serious misutilization in current systems of medical care delivery and that regulatory rather than market reform is the appropriate public response. Requirements for effective utilization control are delineated as appropriate targeting, efficient administration, ease of enforcement. Predelivery controls include prior review mechanisms and prior authorization. Posttreatment review consists of institution-
Health Care Programs
al utilization review, professional standards review organization profile analysis, and surveillance and utilization review systems. Reference notes total 164. (Author abstract modified)
Descriptor(s): Cost containment efforts, Medicaid, Medical/surgical services, Hospital services, Deductible/coinsurance, Present legislation/regulations, Policy initiatives, Demand/utilization of health care programs.
Budget Issue Paper for Fiscal Year 1980.
Descriptor(s): Cost containment efforts, Inpatient facilities, Present legislation/regulations, Voluntary initiatives, Policy initiatives.
140. Controlling the Cost of Dental Care.
139. Controlling Rising Hospital Costs.
Paul B. Ginsburg and Lawrence A. Wilson. Congressional Budget Office, Washington, DC 20515 Sep 1979, 110 pp. A vaJlabih'ty: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 052-070-05116-7.
This paper, prepared at the request of the Subcommittee on Health and the Environment, Committee on Interstate and Foreign Commerce, analyzes proposals to hold down hospital costs either through regulating hospital revenues or by promoting competition in the hospital industry. Three options are described: voluntary approaches, the regulation of hospital revenues, and the promotion of competition. The report states that voluntary effort, despite its apparent success to date, is probably not a long-term solution to rising hospital costs. On the other hand, all three versions of the Hospital Cost Containment Act are viewed as resulting in significant savings for purchasers of hospital care, lowering general inflation, minimizing government intervention and red tape, and keeping the present quality of care. The Act's disadvantages include virtual elimination of real growth in hospitals not exempted and treatment inequities, The Talmadge-Dole Bill is viewed as increasing, rather than reducing, Federal outlays and as providing incentives to hospitals to increase routine services without increasing red tape. Mandatory State-level cost containment programs, which would be encouraged by the Hospital Cost Containment Act and the Talmadge-Dole Bill, appear to have been effective in reducing the rate of growth of hospital expenditures. Finally, the report states that bills that seek to improve competition among hospitals by giving patients greater incentives to seek lower cost medical care could be used in addition to the regulation of revenues, Footnotes are provided for each chapter. Eleven tables and three appendices containing technical notes on the voluntary effort study, details and methodology of the inflation impact of the Hospital Cost Containment Act of 1979, and technical notes on the effectiveness of State level regulation are included. (Author abstract modified)
Howard L. Bailit, Melvin N. Raskin, Susan Reisine and Douglas Chiriboga. Public Health Service, Washington, DC. 1979, 5 pp. Availability: American Jnl. of Public Health v69 n7 13699-703 Jul 79.
Methods of controlling dental care expenditures are taking on greater importance with the rapid increase in prepaid dental plans. Because almost all people have some form of treatable dental disease, dental insurance is not the same as hospitalization or life insurance for unpredictable events occurring, at a known rate in the population. Dental insurance is actually a prepaid budget plan with premiums calculated on the basis of actuarial predictions of utilization of dental services by the insured group. The use of regulatory systems to monitor provider performance are necessary to prevent gross overutilization, but it is unlikely to result in net savings of more than 5 percent of total gross premiums. Theoretically, prepaid group dental practice may reduce expenditures by changing the mix of services patients receive. The modest estimated savings and the small number of groups presently in operation limit the importance of this alternative for the next 5 to 10 years. If substantial reductions in dental expenditures are to be obtained, it will be necessary to limit dental insurance plans to cover only those services which have demonstrated cost effectiveness in improving health for the majority of people. The concept that richer benefit plans may have small marginal effects upon improved oral health may not be easy for the public to accept, but until they do expenses for dental care will be difficult to control. In conclusion, the issue of which services to include in dental plans is becoming the central focus in attempts to control dental costs. The challenge is to convince the general public that more comprehensive dental plans with fewer financial constraints will not necessarily lead to better oral health. Nineteen references are provided. (Author abstract modified)
Summary version of this pap_ was presented at the 106th Annual Meeting of the Americam Pubh'c Health Association, Los Angeles, CA, October 15-19, 1978.
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Descriptor(s): Impact of third-party coverage, Dental services, Cost containment efforts, Limitations on coverage,
142. Controlling the Costs of Retirement eal Care Plans.
Income and Medi-
Philip M. Alden, American Management Associations, New York, NY 10020 1980, 78 pp. Availability: American Management Associations, New York, NY 10020.
141. Controlling the Cost of Health Care.
National Center for Health Services Research, HyattsviUe, MD 20782 DHEW/PUB/HRA-77/3182 May 1977, 22 pp. Availability.. National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782.
Research findings of a study of the rising costs of U.S. health services are summarized. In particular, this report describes what is known about the consequences and effectiveness of vailous strategies intended to reduce or minimize increases in service costs. Topics treated are supply incentives and disincentives (hospital investment controls, hospital investment incentives, and the supply of ambulatory services), incentives and disincentives affecting provider behavior (changes in treatment patterns, the effects of insurance, changes in physician productivity and workload, physician reimbursement, hospital reimbursement, and hospital cost controls), and incentives and disincentives for consumer behavior (insurance and the demand for health setvices and the financing of public health care programs). Findings indicate that the dynamics of private and public incentives and disincentives in the health sector inevitably lead to the conclusion that inflation will continue and that health care will claim
Ways that employers can control the costs of retirment income and medical care plans are discussed. The cost of an employee benefit plan is equal to the dollars of benefits actually paid plus the costs of plan administration, minus amounts (if any) contributed by employees and any investment income on assets accumulated to pay benefits in the future. There are four actions a company can take to control plan costs: (1) reduce benefit payments, (2) reduce administrative costs, (3) increase employee contributions, and (4) increase the plan's investment income. Actions in these four areas of cost control are discussed in detail for retirement income plans and medical care plans. The ideal medical plan is simple in design, offers broad protection, provides limited coverage for budgetable expenses, substitutes lowcost treatment for high cost, avoids duplication of benefits, and gives employees a stake in controlling costs. Arriving at such a plan requires a number of simultaneous efforts by the employer, including designing the plan properly, selecting the proper financing mechanism, becoming involved in plan administration, and educating the plan users. Cost control in medical benefit design should provide for deductibles which adjust automatically to inflation, do not cause employees to seek the most costly treatment, and serve to allocate plan benefits to the big expenses. The proper management of coinsurance (the reimbursement ratio that comes into play after the deductible) can also help
an increasing share of the country's resources. A national health insurance plan, even with deductibles and coinsurance, will still have an inflationary impact on the health services system, particularly in the area of ambulatory care. Inflation will be fueled not only by a sharp increase in demand for physician services, but by a supplier's response in which physicians tend to trade off increased revenue for greater leisure time, and institutions invest in costly equipment and facilities. Thus, there is no proven network of policies that can contain health care costs while providing an equitable and efficacious health care delivery system, References are provided,
control employer cost. Reasonable requirements for employee contributions to the medical plan can also help control employer costs. Suggestions are also offered for controlling costs within the following plan provisions: ambulatory surgical care, preadmission testing, diagnostic x-ray and lab exams, extended care and home health care, routine physical exams, second opinions, and alcohol or drug abuse care. Other areas of cost control discussed are cash incentives, financing alternatives, expense reduction, cash flow improvement, medical plan administration, and education and communication. A glossary, tables, and seven references are provided.
NCHSR
Pohcy Research
Series, Report No. NCHSR
Descriptor(s)" Cost containment efforts, Third-party Private health care plans, Publicly sponsored/mandated plans, Supply/availability of services,
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77-130.
payors, health
AMA
Management
Briefing.
Descriptor(s): Cost containment efforts, Deductible/coinsurance, Limitations on coverage, Plan design/program provisions (under health plans), Source of premium payment, Voluntary initiatives, Private health care plans, Health care/services.
Health Care Programs
143. Controlling the Use and Cost of Medical Services. The New Mexico Experimental Medical Care Review Organization. A Four-Yeur Case Study.
Robert H. Brook, Kathlecn N. Williams and John E. Rolph. Rand Corp., Santa Monica, CA 90406 RAND/R-2241-HEW Department of Health, Education, and Welfare, Washington, DC. Office of the Assistant Secretary for Planning and Evaluation. • Nov 1978, 76 pp. Availabih'ty: Rand Corp.,SantaMonica, CA 90406.
Thisstudydescribes theeffects oftheNew Mexico Experimental MedicalCare Review Organization (EMCRO) on thecostand use of ambulatoryand hospital services from September1971 through August 1975.Although theEMCRO was neither designed nor designated as a peer service review organization (PSRO) prototype, it can be considered one, since it comprehensively reviewed both hospital and ambulatory care based upon claims for services billed to medicaid. Hospital utilization review (UR) involved a preadmission certification program for elective admissions, a certification program for emergency admissions, and a recertification program for extended stay admissions. The level of nursing home care was also reviewed. In the ambulatory area, the frequency and level of office visits, frequency and type of laboratory tests, and frequency and appropriateness of injectionswere reviewed. The peerreviewprogram had distinct advantagesover typicalPSRO's becauseof itscomprehensive naturc.EMCRO evaluation involvedexaminationof trendsin the use of major medical care for one cohort (eligibles enrolled in the Aid to Families with Dependent Children and in medicaid forall4 yearsof thestudy). Itwas concludedthatexceptfor injections, useofambulatoryservices pereligible permonth in allage categories increased over time.The UR approachto controlling hospital use had no apparent effect. The only substantial dollar savings to the New Mexico medicaid program were brought about by the administrative efforts of the fiscal intermediary, which required no professional review. Based upon this study, it is concluded that PSRO's may influence the quality of care but will play little part in containing medical care costs. Footnotes, 36 tables, and 28 references are included in the monograph. (Author abstract modified)
Repnnted
from "Medical
Care Supplement"
144. Colmyments and Demand for Medical Care. The Callfornia Medicaid Ex_rienee.
L. Jay Helms, Joseph P. Newhouse and Charles E. Phelps. Rand Corp., Santa Monica, CA 90406 RAND/R-2167-HEW Department of Health, Education, and Welfare, Washington, DC. Feb 1978, 29 pp. Av_lability: Rand Corp., Santa Monica, CA 90406.
Thisstudyemployeda verygeneralZellner-type indirect regressiontechnique toassess theimpactofa copaymentrequirement on theutilization ofout-of-hospital healthcareresourc_by the poor.The datacame from theCalifornia Copayment Experiment. The major shortcomingof the dataisthatthe study's experimental and control groupsexhibited verydifferent propcnsities to use the hospital in the period when neither had to copay. For data analysis, it was assumed that the two groups were equally affected by the incidence of disease and by other variahies not tested in the study, and that the difference between them is captured by controlling for between-group differences, seasonal variation, personal characteristics, major structural change during the study period, and figures on hospital inpatient days. The results indicate that strong price effects may be at work in a welfare population. Requiring a $1 copayment of physician visits appears to decrease the demand for ambulatory c_re by 8 percentand increase thedemand forhospital inpatient services by 17 percent. Althoughthe95 percentconfidence intervals for theestimates ofthetotal resource costoftheprogram arelarge, including negative as well as positive values, point estimates indicate that there was a 3 to 8 percent increase in overall program cost.Thus, out-of-pocket payments forambulatorysetvicesina welfare population couldbeself-defeating asa method of controlling costs. Tabulardata,footnotes to thetext,and a footnoted appendix are supplied. A reference list contains 14 items. (Author abstract modified)
Descriptor(s): Medicaid, Deductible/coinsurance, Diagnostic services, Cost containment efforts, Demand/utilization of health care programs, Medical/surgical services, Hospital services.
v16 n9 Sep 78. 145. Corlmrate Role in Containing Health Care Costs.
Dtm_nptor(s): Cost containment efforts, Medicaid, Health care/ services, Inpatient facilities, Outpatient facilities, Funding/financing of health care programs, Present legislation/regulations, Outcome/evaluation of health administration, Long term care facilities.
Larry M. Fisher. Hansen (A.S.), Inc., Chicago, IL 60605 Mar 1979, 22 pp. Av_lability: Hansen (A.S.), Inc., Chicago, IL 60605.
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This paper describes the magnitude of the problem of increased health care costs, government and private sector efforts to contain costs, and the administration, design, and development of an employer health care plan. The plan is based on the view that those who provide the dollars to finance the health care system are the most effective groups to control health care costs. The discussion on administration covers hospital admission certification, hospital claims review, entity cost allocation, physician information, acceptance of payment, and employee service assistance. Plan design suggestions are presented that either shift the location from the hospital setting to the less costly outpatient setting or pay for services which detect, prevent, or treat diseases at their early stages. They include preadmission testing, presur-
technology and the degree to which it is regulated, and the effect of this equipment on patients and the quality of care delivered. The Government has begun to intervene in these linkages through new laws that aim at containing costs, ensuring quality, and influencing the system's growth. Federal decisionmakers do not want to inhibit the orderly diffusion of life-saving technology; nor do they favor imposing arbitrary restraints on the use of sophisticated diagnostic equipment such as the brain scanner. Government intervention appears needed, however, when the proliferation of a technological device like the scanner is so rapid and the growth is not guided by rational planning. There is a Government concern that stems from an evolving belief at the National Institutes of Health that the biomedical research com-
gical testing and second surgical opinion programs, ambulatory surgery benefits, home health care benefits, alcoholism benefits, and preventive health care such as hypertension screening. Finally, the article suggests that employers create a Community Health Care Consortium in which groups of employers in the
munity must relate more closely to This position, plus the many other engaging the Government, guarantee unsettled. References are provided.
community negotiate and communicate about benefits and needed changes with groups of doctors, groups of hospitals, and alternative systems. Different alternative systems are described briefly including expanded industrial clinics, insurer-physician health plans, health care alliances, health maintenance organizations, individual practice associations, and prepaid group prac-
Descriptor(s): Medical technology impacts, Publicly sponsored/ mandated health plans, Diagnostic services, Therapeutic services, Present legislation/regulations, Policy initiatives.
tices. A chart showing the structure of a consortium
147. Cost Containment and Health Planning. A Bibliography.
is included.
Descriptor(s): Cost containment efforts, Private health care plans, Prepaid plans, Voluntary initiatives, Source of premium payment, Methods of payment determination, Plan design/program provisions (under health plans).
146. Cost and Regulation of Medical Technology. Policy Directions. John K. Eglehart. 1977, 35 pp. Availability: Milbank Memorial Fund Quarterly Society. v55 nl p25-59 Winter 1977.
Future
Health and
The effects of medical technology on spiraling medical costs are examined, and future policy directions for Government regulation in this area are discussed. Because the products of medical technology are becoming more complex, the new machines themselves are not only more expensive, but they require the additional cost of more manpower and space. As medicare and medicaid have evolved into major cost programs, Federal decisionmakers have begun to see more clearly vital links affecting service costs: links between the manner of reimbursement and the amount of technology deemed essential, the development of
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medicine's clinical practice. health regulatory activities that the system will remain (Author abstract modified)
Bureau of Health Planning, Hyattsville, MD 20782 DHHS/PUB/HRA-80-14011 Jul 1980, 367 pp. A vMlability: National Technical Information Service, Springfield, VA 22166, HRP-0301401. This annotated bibliography is intended to assist health planning agencies with literature reviews of cost containment and health planning. The 846 publications listed were selected for their usefulness to those involved with health systems agencies, statewide health coordinating councils, State health planning and development agencies, and centers for health planning. The publications cited are arranged in 12 sections: analyzing cost increases; controlling capital expenditures; identifying and reducing excess facilities and services; enhancing efficiency of facility design and operation; promoting alternatives to inpatient care; linking planning with reimbursement; fostering geographically and service integrated health care delivery; modifying provider behavior, attitudes, and use; modifying consumer behavior and attitudes; promoting cost-effective preventive strategies; assessing and modifying role of environmental/occupational factors; and developing measures of impact of system performance, requirements, and responses. Entries in each section are arranged alphabetically by author, corporate author, or by title if there is no specific author. Following the author's name, each citation includes the title of the publication and the reference source or publisher. (NTIS abstract)
Health Care Programs
Health
Planning Bibliography
Series, No. 14.
Descriptor(s): Cost containment efforts, Outcome/evaluation health administration, Supply/availability of services.
of
er whether the care of an individual patient, as well as the statistical pattern of care, is appropriate, effective, of the right amount, and of high quality. A graph and 38 references are given. Presented
148. Cost Containment and Quality Assurance Requirements for Third Party Coverage for Ambulatory Psychiatric Care. Alex Richman. Nov 1977, 25 pp. Availability: Mount Sinai School of Medicine of the City University of New York and Beth Israel Medical Center, New York, NY 10003.
This paper outlines some of the problems which must be solved before cost containment and quality assurance can be considered adequate and effective for ambulatory care of mental disorders. While the Professional Standards Review Organization (PSRO) system is generally appropriate for physical disorders in acute, short-term hospitals, and the system can be applied to mental disorders, application of PSRO procedures to ambulatory care of mental disorders does create certain problems. Ambulatory treatment is more variable, even for physical disorders, than is in patient care, and no agreed-upon PSRO approaches to ambulatory treatment of physical disorders exist Furthermore, a variety of activities, required for accreditation, reimbursement, and administrative purposes, have been inappropriately referred to as "utilization review" or "quality assurance," generally far removed from PSRO procedures. Furthermore, graphic analysis of the distribution of mental health services in two prepaid medical insurance plans showed that 3 to 4 percent of the patients used 30 to 40 percent of the services. Mechanisms are needed which can consider the overall utilization and quality of care and at the same time focus on those situations where there is a major resource absorption by a disproportionately small number of patients. Some of the factors to be considered in developing cost containment and quality assurance procedures for ambulatory care of mental disorders are; that diagnosis of a mental disorder does not by itself justify treatment, that mental disorders must be distinguished from psychological reactions and other emotional responses, and that objectives and goals of treatment must be specified. In addition, there are wide variations existing in types of treatment and providers. Other factors to be considered include the clinical setting, the appropriate norms for reviewing the continuation of treatment, the importance of professionally predetermined screening criteria, and the requirement that the predetermined criteria must be based on items that should be in the clinical record. The paper concludes that mechanisms are needed which enable professionals to advise the third-party pay-
nt the Joint Session of Mental Health
and MedicM
Care Sccttbns: Third Party Coverage for Mental lllne_: Current Status and a Look to the Future, 105th Annum Meeting of the American Pubh'c HeMth Association, October 30-November 3, 1977, Washington, DC Descriptor(s): Demand/utilization of health care programs, Cost/benefit analyses, Mental health services, Policy initiatives.
149. Cost Containment by a Third Party Payer. Negotiations of Surgical Fees.
Ann Susan Kamons, Fred Goldman, and Agnes Rupp. 1980, 10 pp. AvMlability: Employee 1980.
Eugene G. McCarthy
Benefits Jnl. v5 nl p2-9,23,24 Winter
This paper presents the results of a cost containment program which was directed at surgical services and designed to reduce the financial liability of subscribers to a third-party administered health plan. The program retroactively negotiates the prices of surgical services which exceed the allowed fee. The study subject is the Building Service Union Welfare Plan, Local 32B, of New York City. The union instituted a self-insured plan for medical and surgical expenses in October 1975. The plan cx)vers 100 percent of an acceptable charge for surgical fees less than $1,000. For fees exceeding $1,000, the excess is included under a major medical policy. During the period from October 1975 to October 1976, the plan reimbursed members for an average of $318 per surgical procedure. Also during this period, 440 cases representing 10 percent of all surgical cases were subjected to the negotiation process. A control group of 440 nonnegotiated cases was selected from the remaining 4,012 cases for comparison. In approximately 73 percent of the eases, physicians' charges for all surgical procedures were higher than the amount reinabursable by the plan. The actual negotiation of a surgeon's fee was conducted by a fund officer by telephone with the surgeon, entailing no written commitment. The difference between the fo." that the surgeon had requested and the union allowance, as well as any deductible and coinsurance, was presented in conversation as the patient's responsibility. The surgeon was told the amount that the plan would cover and was asked whether this was acceptable as full payment. Results for the 1-year period indicate that of the
1-69
440 negotiated cases, 308 or 70 percent, were successfully negotiated, and the fee was reduced. Most of these cases resulted in an acceptance of the plan allowance as full payment. Four tables and 16 footnotes are included in the article,
to control than physicians and patients. Furthermore, for institutional managers, effective cost control may well mean the difference between survival and failure. Institutions now need not only to be actively engaged in cost control programs, but also to pubhcize efforts to those groups applying cost containment pres-
Descriptor(s): Cost containment efforts, Third-party payors, Medical/surgical services, Methods of payment determination,
sures -- government, third party payers, labor unions, corporations, and private citizen groups. The charge of excessive profits is based on the archaic system of historical cost measurement and unrealistic conceptions of the profit hospitals actually achieve. The use of simplistic measures like adjusted patient days ignores the increasing intensity of service provided per adjusted patient day. Only administrative costs have skyrocketed, and regulation is a major reason for this increase. Historically, occupancy rates have been declining by reductions in average length of stay and substitution of outpatient care, but the industry's success on this score has been criticized instead of praised. The only documented waste in the hospital industry is in utilization of resources, but incentives under the existing system clearly favor excessive utilization. The practice of defensive medicine by
150. Cost Containment Medical Schools.
Education Efforts in United States
James I. Hudson and Judith B. Braslow. 1979, 6 pp. Availabih'ty: Jnl. of Medical Education v54 nl 1 p835-840 Nov 79. This article describes the results of a survey conducted by the Association of American Medical Colleges in 1978 to discover the extent of cost containment education programs. A 100 percent response rate was received from the 119 U.S. medical schools surveyed. Analysis of the data showed that 41 institutions (34 percent) had programs underway or specifically planned to teach health care cost containment to undergraduate medical students, residents, or both. The majority of these programs were introduced during the past 2 years and averaged $22,680 per year in costs. Respondents indicated that further activities might be enhanced by developing a primer for faculty and students on elements of cost containment education and the organization of a series of regional workshops related to this subject. Two references, two figures, and three tables are includ-
physicians may be a far more serious problem. The effectiveness of the developing professional review organization system cannot be determined at this time, but the financial consequences for hospitals and other health care facilities could be catastrophic. Generally speaking, managers can contain costs by improving efficiency (reducing physical quantity of resources used), by reducing prices paid for resources (making group purchases), and by making program changes (reducing volume or applying management engineering techniques). Reducing volume will raise the average unit cost, but management engineering techniques to control labor costs and to institute performance reward systems which increase productivity are effective tools. Nine references and 10 tables are provided.
ed. (Author
Descriptor(s): Cost containment efforts, Facilities providing health care, Outcome/evaluation of health administration.
Descriptor(s): initiatives.
abstract modified) Cost containment
efforts, Physicians,
Voluntary
152. Cost Containment Mechanisms. 151. Cost Containment in the Health Care Industry. Jeffrey A. Prussin and Jack C. Wood. William O. Cleverley. 1977, 17 pp. Availability: Topics in Health Care Financing v3 n3 pl-17 Spring 1977.
1975, 18 pp. Availability: Topics in Health Care Financing v2 nl p47-64 Fall 1975. This article on cost containment mechanisms discusses incentive
Most of the causes for inflation in the health care industry have been identified as structural and are thus beyond the control of the individual institutional manager. In the absence of structural reform, pressures for cost control will continue to exist, and institutional providers will be singled out because they are easier
1-70
reimbursement formulas, regulation, utilization control, and a combination plan for optimizing appropriate utilization. Both retrospective and prospective incentive formulas include an apparent potential to limit hospital costs; however, neither of these formulas contain counterbalances to assure the quality of hospi-
Health Care Programs
tal services. Incentive reimbursement formulas for physicians, while presently uncommon, could encourage the use of allied health professionals and therefore reduce health care costs. Ratesetting activities, which focus on insurance premiums, hospitals, and physicians, can have a substantial effect on health costs and private third party payment systems. The article assesses the cost containment effectiveness of various forms of regulation including subscriber premium regulation, direct State regulation, or review of hospital rates, direct regulation of physicians' fees, and health planning legislation. The article also examines the problem area of excessive ufflization of health care services and discusses such mechanisms for utilization control as patient cost sharing, experience rating, preadmission certification, the use of professional standards review organizations (PSRO's), and the attempt by the Aetna Life and Casualty Company to control the costs of health insurance by controlling the costs of claims for physicians' fees. A combination plan for optimizing appropriate utilization is suggested that includes noninsurable deductible
unified program without the need for new legislation. This approach would be far superior to that of focusing solely on cost containment, an approach which could severely disturb the quality and equity of health care across the Nation. Congress and the academicians agree that the major cost problem is the hospital - too much emphasis on hospitalization, too much use of and reliance on expensive technologic equipment, too much specialized medical care from physician specialists and technical specialists, hospital mismanagement, and little hospital resistance to demands for salary increases, additional equipment, or supplies. Eighteen references are provided.
and coinsurance requirements, limitation of inpatient bed availability, development of inpatient utilization review procedures, and development of quality assurance and medical audit procedures. Ten tables and 11 references are given.
Descriptor(s): Cost containment efforts, Policy initiatives, Comparisons regarding foreign health policies, Methods of payment determination.
Descriptor(s):
Cost containment
Presented before a joint meeting of the S_tion on Medicine and the Georgia Society of Internal Medicine, Southern Medical Association, 72nd Annual November 11-14, 1978.
Scienti_c
Assembly,
Atlanta,
GA,
efforts, Private health care
plans, Deductible/coinsurance, Reimbursement, Methods of payment determination, Present legislation/regulations, Outcome/evaluation of quality assurance.
154. Cost Containment Through Employee gram.
Incentives Pro-
Pat N. Groner. 1977, 144 pp. Availability: Aspen Systems Corp., Rockville, MD 20850. 153. Cost Containment.
Medical System Rehabilitation
or
Reform.
This book chronicles the productivity incentives and cost containment policies used in the hospital for over a decade. Part One
George A. Silver. 1979, 6 pp. Availability: Southern Medical Jnl. v72 n4 p467-472 Apt 79.
Medical practice must be radically changed to control health care costs without causing more inflation and more inequities than already exist in the health care system. Serious reform can be accomplished only by ending fee-for-service treatment and putting physicians on a salary, providing catchment areas for hospitals, establishing accountability at the community level, negotiation for salaries and working conditions, and setting national standards for service. However, turning a country of more than 200 million around is no easy task, and should not be
describes early cost control incentives in the Baptist Hospital of Pensacola, Fla., including the sick leave program, the shortened work week, and the development of an incentives system in the laundry department. It discusses factors that contributed to major changes in hospitals, such as the development of new technolo&y, hospital unions, Government reimbursement of health care and the consumerism movements, and it explains Baptist Hospital's development of a productivity formula and its application to such areas as radiology, the operating suite, the coffee shop, and nursing. Mother chapter discusses the development of an Arkansas seminar to help administrators or assistants, business office heads, directors of nursing, and other department heads apply the hospital's cost control principles. In addition, the Internal Revenue Service's review and eventual
attempted with untried academic solutions. In Canada, Saskatchewan tried out a universal health scheme first, and it took more than 10 years to become a national program. Here, a national child health program might be tried furst in a few States with existing programs, then funds could be redirected into a
clearance of the hospital's productivity incentive program is detailed. Section Two discusses the development and design of the hospital's cost incentives program under the Medicus Systems Corporation and describes the basic objectives. Details of the Manpower Utilization Program, the Supply Utilization Pro-
1-71
gram, and the Quality Assurance Program are given. The section outlines the importance of the utilization programs, employee awareness of the plan, and administrative responsibility in making the program effective, and it makes some final recommendations for applying the hospital's program. A total of 52 tables, figures, and exhibits are given. Four appendices contain reports of four independent studies, before-and-after indicators, Baptist Hospital financial indicators, and hospital administrative services productivity indicators,
mary physicians' claims and review physicians' accounts, as well as provide data on the quality of service. Preliminary assessmerits show that hospitalization use rates for UHC are lower when compared to other plans in the same area. Replication of the UHC model in other geographical areas requires the interest and involvement of four separate parties with differing vested interests -- an insurance company, physicians, employers, and employees. A definitive evaluation of UHC's cost-cutting capability is forthcoming in June 1981. Three references are given.
Descriptor(s): Cost containment efforts, Inpatient facilities, Outcome/evaluation of health administration,
Descriptor(s): Physicians, Voluntary initiatives, Claims administration, Methods of payment determination, Plan design/program provisions (under health plans), Cost containment efforts, Comparisons of health care programs, Prepaid plans, Health information/data systems.
155. Cost C_ntainment Through Risk-Sharing by Primary Care Physicians. A History of the Development of United Healthcare. 156. Cost Control Challenge for Hospitals. Stephen H. Moore, Diane P. Martin, William C. Richardson and Donald C. Riedel. Health Care Financing Administration, Washington, DC. 1980, 13 pp. AvMlabilit):" Health Care Financing Review vl n4 pl-13 Spring 1980.
Robert A. Vraciu and John R. Griffith. 1979, 8 pp. AvMlability_ Health Care Management Review v4 n2 p63-70 Spring 1979. Cost containment
This article provides a brief description and history of the IJnited Healthcare (UHC)prepaid primary care network plan organized by the SAFECO Insurance Company. This is a preliminary background paper for a large-scale study comparing the UHC with Blue Cross and Group Health Cooperative of Puget Sound_ The data presented here were gathered through discussions with UHC employees and from reports obtained from them. UHC is designed as an independent practice association organized to encourage primary physicians in private practice to become coordinators and financial managers for their patients' medical care. Each patient chooses one internist, family or general praeti.tioner, or pediatrician and must be referred by that physician for all specialized care. The primary care physician authorizes pay.merit from his own account for hospital or referral care provided to patients and shares any deficit or surplus remaining at the end of the year. Thus, the primary care physician is put in charge and is "at risk" for the costs of medical care to his patients. The plan has been operating in Northern California, Washington, and Utah and has 40,000 members and 750 participating physicians, The special features characterizing this plan are UHC's alliance with primary care physicians, the relationship with specialists as "doctor's doctors", the program's cost cutting appeal to employers, and an information system which is the backbone of the relationship among the employees, physicians, and the UHC plan. The computer information system serves to pay the pri-
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strategies and proposals focusing on hospital
services are discussed in the context of the national economy. American health care is emerging from an era in which it held a highly favored position in the economy. Guidelines for the 1980's will be clearly more restrictive, and future management decisions in hospitals will be made under some cost containment program. The existence of a hospital-specific target level, referred to as maximum allowable increase (MAI), and its recoguition by the hospital industry represent a significant change from the usual operational policy of most States. The national cost containment proposals currently under consideration reflect this goal of reducing the rate of increase of national expenditures for hospital care. The ultimate form of the national ceiling will have a major impact on management autonomy, the possible reactions, and the ultimate success of any cost containment program. The four definitional concerns that are associated with specifying that ceiling form include total costs versus total charges, total versus unit costs, the gross national product versus consumer price index (CPI), indices, and general versus hospital-industryspecific CPI. Faced with an MAI in total operating costs, the challenge for many hospital administrators will be to reduce the rate of increase without reducing the quality of care. Four general categories of cost containment strategies are available to administrators, including short-term amenities' reductions and purchase delays, input price reductions, improved production efficiency, and improved market efficiency (volume reduction).
Health
Care Programs
Estimates of the potential savings associated with these four strategies are tenuous. While individual hospitals will react differenfly to a binding MAI, it is anticipated that in general, hospitals will tend to view the MAI as a target, will tend to implement strategies for cost containment in the order discussed,
demand for nursing homes, and pressure to convert the emptying acute beds of hospitals to long-term or nursing home uses if necessary. Three tables, 1 figure, and 34 notes and refl_rences are given.
and will frequently fail to initiate the latter two strategies. Less efficient hospitals are in a better position to delay reductions in volume in order to comply with a specific MAI. Potential exists for reducing the use rate of hospital services without adversely affecting the quality of care. The responsibility for achieving these lower rates ties jointly with the physician, the hospital representative, and the community. One figure and 17 references
13_scriptor(s): Cost/benefit
are provided.
158. Cost of Benefits for Alcoholism Insurance Program.
Descriptor(s): cy/changes
analyses, Cost containment
efforts,
Inpatient facilities, Present legislation/regulations, Hospital setvices, Supply/availability of services, Long term care facilities.
in a National Health
Cost containment efforts, Inpatient facilities, Polire health care.
157. Cost Effective Acute Care Facilities
Gordon R. Trapnell. Trapnell (Gordon R.) Consulting VA 22044
Planning in Miehi-
gan. John R. Griffith and Robert A. Chernow. 1977, 11 pp. AvailabiIity: Inquiry vl4 n3 p229-239 Sep 77.
This article examines arguments for reducing the use of inpatient hospital care in Michigan, discusses the Bureau of Hospital Administration's recommended occupancy guidelines, and predicts the likely impact on hospitals, doctors, and patients. In 1976, an Advisory Committee proposed that the number of patient days of acute general hospital care in the State be reduced by 13 percent over time to 1,137 per thousand population and that the lower number be used as a guide for the proposed future construction of hospital beds between 1976 and 1981. The proposal was based on arguments that hospitalization rates well below the Michigan average are satisfactory elsewhere and the prediction that improved systems for scheduling and routing patients should cause the demand for beds to drop. The article predicts that if the proposal were fully implemented, together with utilization review, an admissions scheduling and control system, preadmission testing, and outpatient surgery, there would be a slight decrease in the number of inpatients treated annually. In addition, there would be a much larger drop in the average daily census and the average length of stay. Further, the patients would benefit from shorter stays, lower insurance premiums, and more smoothly organized hospitalizations. The proposal would also slow hospital construction and lower costs but would disrupt the normal pattern of hospitals and doctors. Other iraplications include substantial pressure to discharge long-term patients earlier, leading to more rapid referral and increased
Actuaries, Falls Church,
Group Health Association of America, Inc., Washington, DC. National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD. Mar 1979, 54 pp. Availabih'ty: TrapneU (Gordon R.) Consulting Actuaries, Fails Church, VA 22044.
Data are interpreted as a basis for comparing the cost of several approaches to the coverage of services for the treatment and rehabilitation of alcoholism under a national health insurance program. The proposed sets of provisions defining the benefits payable differ in (1) the scope of providers included, (2) the types of services eligible for reimbursement, and (3) the number of services paid for by the program. Any national health insurance program must provide alcoholism services at least comparable to the "minimum" benefit package; an attempt to provide fewer services is likely to discourage program integrity and waste program resources without significantly reducing program outlays. The inclusion of specialized alcoholism providers is clearly cost effective, and in the context of a universal national health insurance program would not require a substantial increase in Federal outlays. A separate benefit package for alcoholism (which could be tied into overall limits for all services for mental and nervous conditions) would provide the flexibility needed to tailor coverage to the peculiar characteristics of the specialized alcoholism providers and permit more effective benefits with a given level of funds. A unit substitution rule would provide more extensive treatment from a given level of funds, and a managed system of providers would be highly desirable to achieve greater effectiveness in treatment and minimize expenditures. Inadequate information is available for determining the extent to which alcoholism services should be limited. Whether limits should be set to allow for one effort at rehabilitation for a year or more
1-73
depends on the cost effectiveness of the treatment for recidivists and the priority assessed to further attempts to rehabilitate them. Tabular data, 11 references, and footnotes are provided, Descriptor(s): Cost/benefit analyses, Mental health services, Funding/financing of health care programs, National health insurance (NHI), Plan design/program provisions (under health plans).
159. Cost of Catastrophic
Descriptor(s): Health care cost trends/projections, Private health care plans, Publicly sponsored/mandated health plans, Participation in health care programs, Plan design/program provisions (under health plans), Exclusions from coverage, Funding/financing of health care programs, Policy initiatives, Long term care facilities, Trends in health status.
Illness.
Howard Birnbaum and Michael Schwartz. Abt Associates, Inc., Cambridge, MA 02138 National Center for Health Services Research, MD. 1979, 110 pp. Availability: D.C. Heath and Company, 02173.
Hyattsville,
Lexington,
160. Cost of Disease and Illness in the United States in the Year 2000.
MA
This book provides a baseline profile of the incidence, cost, and financing of catastrophic illness in the United States. Background is provided on five illnesses that potentially involve catastrophic levels of expense: heart disease, cancer, stroke, kidney disease, and accidents. In addition, the magnitude and distribution of catastrophic illness is described, based on estimates of the number of individuals of different demographic characteristics who spend over $5,000 per year on medical care. The book also considers the extent of individual protection against catastrophic costs by analyzing the degree of public and private insurance coverage for these costs. Information on the types of medical services accounting for catastrophic costs is given. The book concludes that the national policy toward catastrophic illness relates squarely to our public policy toward the aged, the disabled, and the institutionalized. The rate of catastrophic illness expense for these three groups is three times that of the remaining population. The book suggests that policymakers continue public support of medical care payments for low-income persons and private support of middle-income persons but improve major medical coverage in the private sector. Proposals should include the institutionalized in catastrophic illness legislation. In addition, improvements in medicare and medicaid programs should be examined, particularly the spend-down provision of medicaid. Further research is suggested to assess the effect of insurance on catastrophic expenditures, to evaluate hospital responses to a catastrophic insurance program, to analyze the benefits of treatment for catastrophic illness, and to calculate the total cost of public support for the catastrophic population. Footnotes, 5 figures, and 17 tables are included. An appendix contains the developing of the profile of catastrophic illness, an index, and a bibliography of 171 citations. (Author abstract modified)
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Abt Associates Series in Social Policy Analysis. This book summatized in "Catastrophic Illness Expense: Implications for National Health Policy in the United States."
Selma J. Mushldn. Georgetown Univ. Public Services Lab., Washington, DC 20007 Public Health Service, Washington, DC. Div. of Program Analysis. 1978, 96 pp. Availability: Public Health Reports v93 n5 I>493-588 Sep/Oct 78.
This special supplement projects the direct and indirect costs of illness in the United States for the year 2000 and compares the results with estimates for 1900, 1930, 1963, and 1975. An introductory discussion summarizes trends in total economic costs of illness, direct outlays for health care, the relations of indirect illness costs to direct expenditures, and costs of premature death and sickness. The report reviews the major factors affecting long-term economic growth and outlines the model of the U.S. economy used to make the forecast. Economic components of the cost of illness are also described, such as wage rates, productivity, future earnings, price movements, and labor force participation. Both aggregate and disaggregate models are used to project the direct cost of illness by type of health care service. The report analyzes the impact of morbidity and mortality on the health status of the population in the year 2000. Earnings and productive years of work lost by premature death are considered, as are costs of disabilities which can reduce productivity. The projections show more illness in the population as it ages; this should be reflected in increased work loss in the economy. However, this loss is tempered by economic conditions which have reduced work force participation rates of older men. The real cost of illness will continue to rise unless breakthroughs are made in disease prevention and control. Tables, graphs, and 67 references are provided.
Health Care Programs
Descriptor(s): Health care cost trends/projections, health status, National economic conditions.
Trends in
161. Cost of National Health Insurance, The Province of Quebec.
Joseph C. Morreale. National Center for Health Services Research and Development, Rockville, MD. 1977, 11 pp. Availabih'ty: Inquiry v14 n4 p330-340 Dec 77.
The Genesee Region Home Health Care Association in New York received Blue Cross reimbursement to provide 24-hour payment for skilled nursing and ancillary home health care support, on a demonstration basis, for dying patients. The purpose of the demonstration was to test the hypothesis that an intensive array of fully reimbursed home health services will reduce the dying patient's utilization of hospital days of care. "['hehome hospice program, operated as part of a home health agency, enjoys certain advantages due to its integration into a re_ognized and established component of the local health care defivery systern. Referral patterns, assessment admission procedures, and health service resources already in place have been reorganized to serve terminally ill patients at home. Persons eligible for service are those diagnosed by physicians as terminal, with a life expectancy of roughly 2 months. The patient's family must ac-
This study of the implementation of national health insurance (NHI) in Quebec, Canada, suggest important considerations about the effect of the adoption of NHI on a given population, After the introduction of medicare, an initial sharp increase occurred in health care expenditures caused mainly by increased expenditures on physician services. This increase showed that more resources - as measure by per capita expenditures, percent of gross national product (GNP), percent of personal income, and percent of the provincial budget - were devoted to health care. However, this sudden increase was not maintained. After
cept the plan of hospice care and agree to provide a reasonable amount of support in its management. The physician is responsible for the plan of care and must be available for support and direction. Patient condition shapes the plan of care and dictates what services are offered to meet the individual's special requirements as the condition worsens. Stage I services are for patients whose condition is terminal but where life expectancy may be measured in months. Stage II services are for patients who are imminently terminal but whose famih'es are unable to manage even routine care. Of 55 patients in the demonstration study, the
the initial year of the program (1971), overall health care expenditures and total government health expenditures returned to their pre-medicare rates of increase. In terms of overall health care expenditures, physician expenditures increased relative to hospital expenditures. In terms of government health spending,
average length of service was 27 days, including Stage I and Stage II phases of care, at an average per diem cost of $75.28. Home hospice service effectiveness should be measured in terms of cost savings and in relation to patient and family satisfaction.
expenditures on medical care increased relative to expenditures on hospital care, preventive services, and other health services. These results indicate that when all health care services are
Descriptor(s): Service benefit plans, Facilities providing health care.
covered by a comprehensive health insurance program_ the bias toward expenditures on hospital services fostered by private health insurance coverage is tempered. However, there is also some evidence showing a reduction in emphasis on preventive services. These fmdings are considered preliminary; further analysis of the distribution effects on the Quebec population will be performed. Tables are included. (Author abstract modified)
Descriptor(s): Demand/utilization of health care programs, Impact of third-party coverage, Comparisons regarding foreign health policies, Health care cost trends/projections.
162. Cost of Terminal Care. Home Hospice vs Hospital. Anthony Amado, Beatrice A. Cronk and Rich Mileo. 1979, 5 pp. Arailability: Nursing Outlook v27 n8 p522-526 Aug 79.
163. Cost Reimbursement pital Industry.
Home
health
and Price Competition
Robert Austin Milch. 1979, 4 pp. Availabi_ty: Health Care Management Spring 1979.
services,
in the Hos-
Review v4 n2 p53-56
The rationale behind increasing governmental regulation of the health care industry and free market mechanisms for reducing hospital costs are explored in this article. Public policy debate continues over the escalation of health care costs, the inoperative nature of medical markets, and the alleged necessity for pervasive structural reform of the health care industry. The debate had its origins in the early 1900's, and has confmued to gain momenturn since the early 1950's. It is suggested that cost is a relative
1-75
concept, and that very few markets are completely incapable of being revived and stimulated. Proposed solutions include increased governmental regulation and implementation of' free market mechanisms. What is really involved in increasing governmental regulation of the health care industry is not so much a market or managerial failure, but a change in fundamental societal attitudes and political beliefs about the role of Government in the organization and delivery of personal health care services. Regulation is thus an effort to advance a conception of the public interest apart from, and often opposed to, the outcomes of the marketplace. Government supervised price competition between and among hospitals might initially appear undesirable. However, it is a policy prescription that holds out some realistic hope of reducing the total costs in the hospital system. To ensure a competitive health insurance industry, governmental bureaucracies that now exist at Federal, State, and local levels should redirect their energies toward assuring the availability of equivalent hospital alternatives, maintenance of high quality care, and minimizing technical monopolies and other market imperfections. Sixteen references are included.
Descriptor(s): Policy initiatives, Inpatient facilities, Competition/interaction among third-party payors.
tion of eligible patients, and some patients have a larger choice of facilities. The costs to society result from a reduction in the number of skilled nursing home beds and an increase in the net cost of providing the same service. Study analysis indicates that the social costs of reduced availability of skilled nursing home beds and increased health care expenditures outweigh the benefits of State tax dollar savings. Nine tables and a 17-item bibliography are included. (Author abstract modified)
Descriptor(s): Cost/benefit analyses, Medicare, Medicaid, Intermediate care facilities, Long term care facilities, Outcome/ evaluation of health administration.
165. Cost-Beaefit Study of a Hypertension Treatment Program at the Work Setting.
Screening
and
Edward L. Hannan and J. Kenneth Graham. New York State Dept. of Health, Albany, NY. Bureau of Disease Control. 1978, 14 pp. Availability: Inquiry v15 n4 p345-358 Dec 78. The purpose of this study is to develop a model that will enable
164. Cost-Benefit tion.
Analysis Mandatory Medicare Participa-
Kenneth L. Hamitton. 1979, 22 pp. A vailability: Inl. of Long-Term Care Administration p7-28 Summer 1979.
v7 n2
The objective of this study was to analyze the costs and benefits accruing to the citizens of Georgia as a result of a Georgia policy decision to require that all skilled nursing facilities participating in medicaid (which is State-Funded and Federally-funded) also participate in medicare (which is Federally funded) Benefits to the State result primarily from the transfer of health service costs from medicaid to medicare. This cost-benefit analysis involved evaluation of the savings which would have accrued to the State in fiscal 1977 if those medicaid skilled nursing facility patients who were dual eligible had received medicare benefits. These benefits were then compared to the costs which would have been incurred by medicare for that patient group. Administrative costs to nursing homes as a result of medicare participation were determined, as these are the costs of compliance. Private vendors of nursing home services have traditionally had the right to selectively participate in providing services with governmental reimbursement. Skilled nursing facilities have a larger popula-
1-76
a specific company or organization to predict the costs and benefits which would result if a hypertension screening and treatment program were introduced in the work setting. The expected costs and benefits will depend upon the age/sex/bloodpressure distribution of the employees, as well as the size of the company and the extent of the existing medical department in the company. The costs of such a program are the incremental costs for the personnel, supplies, facilities, and equipment needed to implement the program. A computer model was developed in order to determine the costs and benefits of such a program for "n" years (where "n" is between 1 and 5) at a specific work setting. Steps required in order for a given company to predict the costs and benefits are delineated. The only hypertension screening and control program implemented at the work setting with reported data relating to program cost, is a study which involved a small self-insured union headed by a leader who was fully aware of the costs and detrimental effects of hypertension. The article suggests that a hypertension program at a work setting should probably be channeled through upper level management or through a union. The model presented in this study can be helpful in estimating the desirability of setting up a hypertension program that is wholly or partially financed by the employer. Tables and 32 references are included. Descriptor(s): Preventive services, Cost/benefit analyses, Voluntary initiatives, Participation in health care programs.
Health Care Programs
166. Cost-Effectiveness Louisiana vs. Texas.
of a Restrictive
Drug Formulary,
Dennis L. Hefner. National Pharmaceutical Council, Inc., Washington, DC. May 1980, 14 pp. Availability: National Pharmaceutical Council, Inc., Washington, DC 20005. The cost-effectiveness of a restrictive drug formulary is examined in a comparison of Louisiana and Texas medicaid costs. The study was designed to determine whether changes in expenditures and diagnoses which occurred in Louisiana following im. plementation of the restrictive drug formulary were unique to that State's program or typified a general trend within medicaid populations. During the period studied, Texas retained an open drug formulary and made no major program changes in any service area.Studydataincluded medicaidbeneficiaries randomly matched to the stratified random sample drawn from the medicaid population in Louisiana. Each of the study groups for the States contained more than 10,000 recipients. Results show that the Texas medicaid program did not have the large use increases found in Louisiana. Further, the "service substitution" effect caused by Louisiana's restrictive formulary is highlighM by examining "constant dollar" increases for nonprescription services, which rose by $30.11 per Louisiana recipient, while the comparative Texas figure was only $3.11 per recipient. Much of the Louisiana increase was ascribed to a doubling in hospital use by the Old Age Assistance and Aid to the Disabled recipients categories. In contrast, Texas recipients under these programs had a decline of 6.14 percent in the use of hospital services during the study period. Two of the three disease groups most affected by the restricted drug products (heart and central nervous systern) exhibited decreases in the Texas medicaid program, in contrast with the significant increase in these disease groups in Louisiana. The findings support the hypothesis that the savings achieved by restricting the availability of certain drugs were outweighedby increases in theuse and costsofotherservices. Tabulardata arcprovided. Descriptor(s): Cost/benefit analyses, Medicaid,Pharmaceutical services, Presentlegislation/regulations, Comparisonsofhealth careprograms.
167. Cost-Effectiveness tion.
The criterion of cost effectiveness was used to assess the relative merits of primary and secondary prevention in rheumatic heart disease. The study was conducted in a southern State which did not have a statewide primary prevention program for this disease. A model was used to assess the cost effectiveness of the currently accepted secondary prevention program and another model was used to assess the cost effectiveness of a program designed for primary prevention. It was found that 520 cases were being actively treated at the time of the survey. A sample of 130 cases was selected for analysis. For each case, researchers recorded all the services that had been provided for treatment of any problems related to rheumatic fever and rheumatic heart disease. The study showed that it cost the State $182,771 to maintain a treatment program that by definition, is effective in preventing rheumatic heart disease. To design a model for primary prevention of rheumatic fever, an extensive review of the literature was completed, and directors of programs in States which had a primaryprevention program were consulted. A significant similarity among the programs reviewed was a focus on prevention of first attacks of rheumatic fever through a school-based program for the detection of strep throat. Use of the school model revealed that a primary prevention program would cost only $110,886 per year. The study concluded that a program of detecting and treating strep throat was significantly more effective and efficient than the present system of treating rheumatic fever and rheumatic heart disease. It is suggested that planners must not only appeal to humanitarian principles to justify programs to policymakers, but they must also prove the efficacy of these programs. Three tables and three footnotes are provided. Descriptor(s): Cost/benefit analyses, Preventive services, Cornparisons of health care programs, Policy initiatives.
168.Cost-FimmeedMental Health Facility.
HerzlR. Spiro,IradjSiassi, Guido Crocetti, Robert Ward and EleanorHanson. NationalInst. of Mental Health,Rockville, MD. 1975,I0 pp. A vailabih'ty: Jnl.of Nervous and Mental Diseasev 160 n4 p231-240Apr 75.
of Primary and Seenndary Preven-
Susan Cox, Jon G. Keith, Gerard L. Otten and Frank B. Raymond. 1980, 5 pp. At'ailabJ]ity: Health and Social Work v5 n2 p56-60 May 80.
This paper describes the clinical features of a cost-finanoM mental health group practice initiated in 1966 by the Johns ttopkins Hospital for members of the United Auto Workers and their families. A cost-financed practice includes a multidisc_plinary team of mental health professionals serving a defined population of enrollees and differs from health maintenance organ:izations
1-77
in that the subscriber group, the carrier, and the mental health professionals negotiate directly about all aspects of mental health services. With the aid of a Federal grant and cooperation from Maryland Blue Cross-Blue Shield, data were collected on characteristics of patients seen in the Labor Union Clinic, use of services, visiting patterns, costs, staffing, and program evolution, The cost-financed system encouraged early treatment and prevention by eliminating deductibles and coinsurance, by undertaking educational programs to inform workers about :mental health benefits, and by creating accessible services. Because patients came for help early, acute crisis intervention could be used and hospitalization rates dropped as a result. A $400 outpatient benefit limitation necessitated the evolution of time-hmited therapy which had the advantage of bringing withdrawal and loss issues usually addressed in the termination phase to the forefront early in treatment. The clinic was able to design chronic care programs within the $400 limit built around nurse-led groups and monthly visits for medication checks. Cooperation between therapists and union personnel enabled all patients to return to theirjobs in the plant. Consumer control ofthe practice was exercised through the union leadership. Staffing arrangements evolved which included not only therapists, but a cornmunity psychiatric nurse, a mental health counselor, a child psychologist, and union counselors who also worked in the plant. A few footnotes and 28 References are provided,
Descn'ptor(s): Mental health services, Cost/benefit analyses, Outpatienl facilities, Participants in health care programs, AIlied health professionals, Evaluations/outcome of health care programs, Private health care plans, Plan design/program provisions (under health plans).
169. Cost-Sharing in Health Insurance. Service Utilization.
well as to investigate the effects of a small copayment on the use of health services in a closed-panel prepaid group practice setting. Analysis involved three separate stages. In the first stage, health service use patterns within distinct types of health insurance plan sponsorship were analyzed. Beneficiary populations were separated into groups whose policies were characterized by high or low cost-sharing requirements. Service use patterns were then compared while socioeconomic and demograpic variables were held constant. Analysis indicated that the cost group in the commercial indemnity plan was apparently affected more by cost-sharing requirements than were the cost groups in the provider-sponsored plans. A small copayment for services in the prepaid group practice plan had no impact on the use of health services. The second stage of the analysis established that the percentage cost-sharing requirements called for in the three feefor-service insurance plans were significantly correlated with several types of health service use. Stage three made an effort to further investigate these findings by analyzing the strength and direction of these associated items. Analysis of covariance and variance as well as regression analysis revealed no clear cut pattern of cost-sharing effects. It is concluded that although cost sharing apparently does have some effect upon use, the effect is relatively weak and difficult to isolate when measured across the membership of an insurance plan. An extensive bibliography, footnotes, and 43 tables are provided in the study. (Author abstract modified)
Submitted in partial fulfillment of the requirements for the degree of Doctor of Public Health to California Univ., 1979. Descriptor(s): Demand/utilization of health care programs, Third-party payors, Deductible/coinsurance, Participants in health care programs, Private health care plans.
Its Effects on :Health 170. Costs, Financing, and Distributional Effects of a Catas-
Neill F. Piland. 1979, 206 pp. Availability: University MI 48106.
trophic Supplement to Medicare. Microfilms International,
Ann Arbor,
This stud_ focuses on three objectives relevant to the impact of health insurance cost sharing on the use of different types and quantities of health services. These objectives were to evaluate the effects of different cost-sharing levels on the use of several types of health services while controlling for the effects of selected economic and sociodemographic variables. Evaluation results would be used to examine the effects of cost sharing on health service us<,"-after the patient has made an initial decision to seek medical care and has made at least one visit to a physician, as
1-78
M. Susan Marquis. Rand Corp., Santa Monica, CA 90406 RAND/R-2431-HEW Department DC.
of Health, Education, and Welfare, Washington,
Aug 1979, 109 pp. Availability: Rand Corp., Santa Monica, CA 90406. This report examines and compares the distributional prototype catastrophic insurance plans to supplement fits of the medicare program. One prototype limits beneficiaries' <:ost sharing to a fixed dollar amount.
effects of the benemedicare The other
Health Care Programs
varies the limit as a function of family income. Measured in 1976 dollars, the fixed dollar catastrophic plan limits the patient's cost sharing for hospital care to $600 per year and limits the patient's liability under the Supplementary Medical Insurance program (SMI) to $250 per year. The income-related prototype limits cost sharing to 5 percent of family income for SMI services and to 10 percent of income for hospital care. Five alternative methods of financing the additional benefits are considered in combination with each type of catastrophic plan: an increase in the medicare deductible, an increase in the coinsurance, premiums, payroll taxes, and personal income and corporate profits taxes, The report concludes that, on the surface, a catastrophic plan financed by an increase in the coinsurance rate for small medical bills would appear to be optimal. However, such a plan should take into account considerations such as health care consumption by the aged and income changes across health-loss states, The report also recommends further reseaxch on spreading risk and on the variation of demand response among population subgroups or the response to other parameters of the insurance policy. Eight figures, 40 tables, footnotes, and about 80 references are included. Seven appendices give estimates of popula-
and draw heavily from decision analysis, statistics, and economic theory in their examination of an area of modern medicine where the costs, risks, and benefits are large. Consideration is given to the effects of surgery on the quality and length of life and to the interests of the individual in comparison to those of society. The book is intended primarily for physicians and surgeons, public health planners, policy analysts, faeulty and students of medical schools, members of legislatures and their staffs, and others interested in the allocation of resources to medical care. The work emphasizes the fact that modern surgery, with such techniques as cardiopulmonary bypass, organ transplantation, and total hip replacement represents medical care at its greatest cornplexity and highest cost. Quantitative tools designed to aid analytical thinking are discussed. Next, the process of surgical innovation, in contrast to any specific innovations, is viewed in some detail. The section focusing on assessment of risks and benefits by decision analysis explores established procedures and scrutinizes a variety of operations. Attention is then directed to new procedures (i.e., to complicated and costly therapi_ which include dramatic extensions of medical care). The work condudes with recommendations for further research and educa-
tion sizes in the subgroups of medicare enrollees, derivations of initial distribution of medical expenditures, reliabilities of the estimates of the effects of SMI and other catastrophic insurance, derivations of initial distribution of hospital expenditures, calcu-
tion. It is suggested that studies of the effectiveness of surgical treatment be carried out for selected conditions, particularly for those where uncertainty leads to professional disagreement. Information on outcomes as well as costs of medical care should
lations of tax rates and subgroup tax burdens, and calculations of changes in the tax subsidies. (Author abstract modified)
be routinely formulated in a manner suitable for presentation to the public. An index, a few footnotes, and extensive tables and references are provided in the work.
Descriptor(s): Medicare, Deductible/coinsurance, Funding/financing of health care programs, Premium determination/underwriting, Limitations on coverage, Plan design/program provisions (under health plans), Source of premium payment, Participants in health care programs, Policy initiatives.
171. Costs, Risks, and Benefits of Surgery.
John P. Bunker, Benjamin A. Barnes and Frederick Mosteller. Harvard School of Public Health, Center for the Analysis of Health Practices, Boston, MA 02115 National Science Foundation, Washington, DC. Edna McConnell Clark Foundation, New York, NY. Robert Wood Johnson Foundation, Princeton, NJ. 1977, 401 pp. A vailability: Oxford Univ. Press, New York, NY 10016.
This volume is a collection of papers which focus on how to appropriately allocate resources to surgical care efforts. Thirtyfour contributors from various fields use cost-benefit analysis
Descriptor(s): Cost/benefit analyses, Medical technology impacts, Medical/surgical services, Evaluations/outcome of health care programs, Outcome/evaluation of quality assurance.
172. Council on Wage and Price Stability Report on Rising Health Care Costs.
Council on Wage and Price Stability, Washington, DC 20506 1980, 5 pp. Availability: Collective Bargaining Negotiations and Contracts vl0 n909 p37-41 Apr 80.
This report, released by the Council on Wage and Price Stability (CWPS) in March 1980, focuses on reasons for the rapidly rising cost of health care. Increases in medical care costs have, with two exceptions, persistently outpaced the general inflation rate during the past 25 years. The increasing costs are attributed by CWPS to distinctive aspects of the medical care market. The incentive and ability of consumers to limit price increases is more restricted than in other markets. In addition, the noncompetitive
1-79
nature of health care providers further limits the ability of market mechanisms to restrain price increases. If consumers were bearing the full cost of their expenditures, they would have a strong incentive to respond to cost increases by avoiding unnecessary treatment. However, even if the patient bore the full zost of care, the ability to minimize expenditures would still be limited. Prices for medical care costs are not posted, and few zonsumers do comparison shopping to ascertain the distribution of available products. Several public and private programs are intended to restrain medical care prices on a voluntary basis. CWPS and the Department of Health, Education, and Welfare share the responsibility for formulating and administering Government voluntary restraint programs. In the private sector, a national coalition has also sought to restrain costs. Principal participants in this effort include the American Hospital Association, the American Medical Association, and Blue Cross/ Blue Shield. Three tables are included,
(PSRO's), health maintenance organizations (HMO's), health Systems Agencies (HSA's), and State-level commissions to control hospital costs, are discussed in detail. To avoid further Government control of what critics label the non-competitve, free-spending health care industry, other groups are exploring alternatives such as commercially sponsored HMO's; national health insurance (NHI) is also under consideration. The study describes malpractice suits and malpractice insurance as factors in rising costs and the struggle between private insurance and NHI as a major health care issue. Appendices, figures, an index, and a glossary are supplied.
Descriptor(s): Demand/utilization Health care cost trends/projections,
of health care programs, Cost containment efforts,
Economic/commercial influences, Physicians, Present legislation/regulations, Voluntary initiatives, Supply/availability of services.
Descriptor(s): Health care costs, Economic/commercial influences, Third-party payors, Voluntary initiatives, Policy initiatives, Cost containment efforts. 174. Current and Future Development of Intermediate Care Facilities for the Mentally Retarded. A Survey of State Officials. 173. Crisis in Health Care.
Jordan Braverman. 1978, 344 pp. Availability: Acropolis
Books, Ltd., Washington,
DC 20009.
Mary A. Allard and Gail E. Toll. George Washington Univ. Intergovernmental Health Policy Project, Washington, DC 20006 President's Committee on Mental Retardation, Washington, DC. Minnesota Univ., Minneapolis, Inst. of Public Affairs.
An overview of the health care problems and solutions affecting individual citizens, physicians, business, and government is presented. The rapid rises in the cost of health care have occured since the Federal Government during the Johnson Administration recognized health as a basic human right and set up mechanisms to support that tenet. Together with rapidly growing public demand for health services, reforms have taxed the health care delivery system to the limits. Uncontrollable increased in health care costs are attributed to such factors as failure to comprehend long-term health effects from certain technological innovations, reliance on industry to find technological solutions to identified problems, duplication of high-cost hospital services resulting in idle capacity, and a lack of efficiency incentives and disincentives under prevailing health insurance reimbursement plans. Also cited as contributing factors are shortages and maldistribution of alternatives to hosptial care, inadequate incentives to use paramedical personnel and shared services, regional health manpower shortages, and poorly coordinated administration of public medical programs. Actions of the Federal Government of deal with health care cost and quality issues, such as establishment of Professional Standards Review Organizations
1-80
MN. Hubert
Health Care Financing Administration, 1979, 66 pp.
H. Humphrey
Washington,
DC.
Availability: George Washington Univ., Intergovernmental Health Policy Project, Washington DC 20006.
A study focusing on the Intermediate Care Facility Program for the Mentally Retarded (ICF/MR) is presented. The ICF/MR was added to the medicaid program as part of the 1971 amendments when it became another optional service that States could offer. The purpose of this study was to collect information regarding the current status of the ICF/MR networks; the scope of planned ICF/MR networks projected for the future; economic, social, political, and administrative factors facilitating or inhibiting these networks; and Federal policy and regulatory changes necessary to facilitate development of such networks. Methodology consisted of the following eight tasks: designing interview schedules to obtain estimates for the fiscal year 1978 through 1979 and projections for 1983 through 1984, contacting State mental retardation program directors and requesting their assistance, arranging and preparing interviews by telephone,
Health Care Programs
conducting interviews, making followup contacts, supplementing interview data with document reviews, reviewing general policy materials, and synthesizing interview results. A total of 42 States responded to the initial request for information, and telephone interviews were conducted in 39 States. Only 17 of the responding States have developed small private ICF/MR's. They reported a total of 256 privately administered facilities as of June 30, 1979. Twelve respondents provided cost estimates for small facilities; these States spent approximately $67.5 million on the facilities. Twenty-four of the 39 responding States reported 237 large private ICF/MR's in operation. Thirty-seven of the respondents reported a total of 221 large public ICF/MR's. Study results indicate that the ICF/MR program continues to pose many difficulties for both Federal and State officials. Most problems stem from use of "rifle XIX funds to develop small, community-based facilities. Recommended changes in Federal policy include clear differentiation between institutional and community requirements for certification as ICF/MR providers, flexibility in community ICF/MR standards, and programmatic and financial incentives. Six tables, an appendix, and a glossary are included in the survey,
Descriptor(s):
Medicaid, Mental health services, Intermediate
care facilities, Present legislation/regulations,
175. Current Developments Program.
in the National Health Planning
SHPDA, and five are fully designated. SHPDA's have been establishing working relationships with those other agencies and programs that help make up large parts of the health care delivery systems, and a greater acceptance on the part of Governors and State governments is becoming evident. Fifty States have established their SHCC's, and this year they will begin reviewing and approving the first round of State health plans. The year ahead should move the health planning program away from the inflation stage and into a fully operating planning system. Three major areas of tension have surfaced in this review of the health planning program: the basic goals of health planning, the functional approaches available to carry out those goals, and the organizational elements responsible for administering the planning effort. These competing demands and goals are deemed to be created by the health care system and the aspirations of the country, not by the health planning program. The health planning program, however, tends to make the issues visible and raise expectations that the issues can be dealt with. There is chance for disappointment in that the planning program has little effect on the reimbursement system. Decisions made under t]_e medicare and medicaid program and by third party payers continue to set the major trends in the health care system, and Congress, by turning its back on cost containment, has placed an intolerable burden on the health planning program. It is expected that in the future, the health planning program will slow the growth of hospital construction and make consumers and providers explore alternatives, disseminate information on prevention and health, and focus attention on community health. To achieve these goals, a period of certainty and relative calm is needed. Thirteen charts are provided.
Henry A. Foley. Health Resources Admires' tration, Hyattsville, MD 20782 DHEW/PUB/HRA-79/14004 1978, 24 pp. Availability: Health Resources Administration, Hyattsville, MD 20782.
Health Resource
Studies.
This booklet reviews the progress which has occurred in health care delivery in the 3 years and six months since the passage of
176. Current Emphasis on Preventive Medicine.
the National Health Planning and Resources Development Act
Ernest W. Saward and Andrew A. Sorensen.
on January 4, 1975. The law creates a network of Health Systems Agencies (HSA's), State Health Planning and Development Agencies (SHPDA's), and Statewide Health Coordinating Councils (SHCC's) responsible for health planning and resources development throughout the country, with emphasis on local health planning. Two of the duties of HSA's, reviewing applications for various Federal health program funds and reviewing institutional health services, mark the first time that a planning body has been given the authority to implement as well as plan programs. HSA's were to be developed in 205 areas, and to date, 147 are fully designated. All States have established their
1978, 6 pp. Availability: Science v200 n4344 p889-894 26 May 78.
Descriptor(s): Cost containment efforts, Present leg4slation/ regulations, Outcome/evaluation of health administration.
This article examines the current emphasis on preventive medicine and recommends several approaches to improv_ _lprevention techniques. Noting that U.S. health care policy is expected to shift from expansion to closed-end funding, the article suggests (1) reducing environmental pollutants and eliminating unsafe working conditions including accidents, (2) moderating self-imposed risks through such techniques as mass-media cam-
1-81
paigns and Federal programs that improve nutritional status, (3) changing consumer expectations to include better information about the limitations and benefits of medical care, (4) establishing more adequate health insurance coverage (the medicare program specifically excludes payments for preventive services to the elderly), and (5) developing a holistic approach to health education. The article concludes that the most effective means
related to their patients' care. In addition, the abandonment of parochial disciplinary stances in favor of reimbursement criteria based on standards of competence would go far toward lending credibility to the mental health care system. Footnotes and 12 references are provided.
of disease prevention and improved health status lie outside the medical care process. On the other hand, the adherence to inappropriate lifestyles by millions of Americans does not absolve our society and the health care professions of social responsibility for the consequences of such life styles. Finally, the freedom
Descriptor(s): Mental health services, National health insurance (NHI), Providers of health care services.
of an individual lifestyle is subject to the constraints of the rights of those who live a different lifestyle, the limits of the environment, and the high health insurance costs of health-detracting behaviors. Seventy-four references are included.
178. Cutting Cost Without CuRing the Quality Slmttuek Lecture.
Descriptor(s):
Preventive
services, Policy initiatives.
177. Current Issues in National Insurance Services. Scott H. Nelson. 1976, 4 pp. Availability: American Jul 76.
Jnl. of Psychiatry
for Mental Health
v133 n7 p761-764
The possible inclusion of mental health services in a national health insurance (NHI) program is assessed, and changes are suggested that would further facilitate the provision of such services in an NHI program. The current economic crisis has again placed the inclusion of mental health benefits under NHI in jeopardy. Progress has been made in establishing effective peer review systems and in demonstrating that costs of mental health services are reasonable. Yet, the lack of agreement on diagnosis and appropriate treatment; the inadequacy of use, cost, and treatment outcome data; and the absence of professional selfregulation remain causes for concern in the effort toward eventual comprehensive coverage for mental disorders. Better and more comprehensive data from insurance and other financing mechanisms need to be collected and disseminated. In many cases, such data can be obtained only by restructuring current information-gathering practices. Research that demonstrates the effectiveness of various modalities and patterns of treatment is also needed. Mental health professionals' increased involvement in maintaining and improving systems of peer review is also required. Whether these efforts will be made depends on the ability of mental health practitioners to assume new roles and responsibilities in regard to the costs of and financing policies
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of Care.
Alain C. Enthoven. Henry J. Kaiser Family Foundation, Palo Alto, CA. 1978, 10 pp. Availability: New England Jnl. of Medicine v298 n22 p12291238 1 Jun 78.
The medical profession should accept the challenge to approach cost control with incentives, not only because physicians are by far the best qualified to make the difficult judgments about need and cost effectiveness, but also because the outcome would be far more satisfactory to doctors and patients. To avoid increasing direct economic regulation, the basic framework of financial incentives within the health care industry must be changed. Incentives and competition could promote economy and equity in a system in which consumers and providers choose from various health care plans which use resources economically. The key issue in health care costs is not physicians' fees but rather how to motivate physicians to use hospital and other resources economically. Several promising models exist. The prepaid group practice holds the cost of premiums and out-of-pocket expenses to levels well below those for fee-for-service, insurancecovered care. The individual practice association, a fee-for-service health maintenance organization, is another alternative, although it has so far not succeeded in controlling costs significantly. A third and much more recent model is the health maintenance program in which choice between a conventional third-party insurance plan with cost sharing is offered along with a prepaid health plan with essentially no cost sharing. There are enough models to suit the tastes of many, with substantial room for individual fee-for-service practice simply because some would choose to accept the higher cost associated with it. Lower cost, it should be noted, does not mean lower quality care. Spending can be reduced substantially with no discernible loss in benefits to the patients. It seems unnatural for the physician to stand back and not do all that is possible for patients whether or not it helps, especially in light of increasing malpractice suits, but the costs of such medical care are simply becoming too large.
Health Care Programs
Economies can be achieved by consolidating facilities, and although regionalization is a well-known idea, its implementation is not widespread. Furthermore, physicians should encourage and participate in the development of cost-effective analysis for medical decisionmaking. Health care spending will inevitably be brought under control, be it voluntarily by physicians or in-
modalities of treatment, both clinically and economically, but has seldom been successful in the private sector because of the differentials in coverage for inpatient and outpatient care. (Author abstract modified)
voluntarily by direct notes are provided,
Descriptor(s): Cost/benefit analyses, Government employee plans, Mental health services, Voluntary initiatives, Outpatient facilities, Facilities providing health care, Reimbursement.
Government
regulation.
Fifty-two
Presented at the annual meeting of the Massachusetts Society, Boston, MA, May 22, 1978.
Descriptor(sg: Cost containment Physicians, Prepaid plans,
efforts, Voluntary
179. Day Hospitalization as a Cost-Effective Inpatient Care. A Pilot Study. William Guillette,
Brian Crowley,
foot-
Metfl'cal
initiatives,
Alternative to
180. Deciphering Deinstitutionalization. cy and Program Analysis.
Complexities
Stephen M. Rose. 1979, 32 pp. Availability: Milbank Memorial Fund Quarterly/Health Society v57 n4 p429-460 Fall 1979.
in Poli-
and
S. Alan Savitz and F. Dee
Goldberg. 1978, 3 pp. Availability: Hospital and Community
Psychiatry v29 n8
p525-527 Aug 78. Two private day hospitals and an insurance company offering group health coverage to Federal employees undertook a pilot study from September 1975 until June 1977 to determine if providing insurance coverage for day hospitalization on the same basis as for inpatient treatment was a feasible means of controlling the cost of psychiatric care. A total of 31 patients, ranging in age from 14 to 69, were included in the study. The majority of the patients had histories of severe psychiatric disorders and fairly extensive prior treatment. The study was not controlled, partly because both centers were committed to the principle that inpatient hospitalization should be avoided and because patients were referred to the centers specifically for day hospitalization, Calculations are based on the premise that if a patient had not been in a day hospital setting, inpatient treatment for the same number of days would have been required. It was estimated that the day treatment saved the insurer more than $255,000. It is recommended that day hospitalization no longer be equated with outpatient care in group health policies but reimbursed on the same basis as inpatient care. However, this recommendation is made with the proviso that to be eligible for such reimbursement, a day hospital should meet stringent criteria ensuring that it provides appropriate, intensive, high quality treatment rather than primarily custodial care or training or recreational activities, and that suitable guidelines are provided. Day hospitalization appears to be among the most promising currently available
This article analyzes deinstitutionalization policy and focu_ses on the sector of community mental health care - its approach to reform, its programs and practice, its accomplishments and difficulties, and criticisms of its operations or results. The article traces the historical development of community mental health care including the founding of State asylums and their growing decline following World War II, the rapid decline in State hospital populations after 1963, and the operation of 507 comraunity mental health centers in 1975. The paper contends that medical determination of the best methods of treatment for the mentally ill has consistently been regulated by the economic needs of the State. Further, although State hospitals have achieved a more than 50-percent reduction in inpatient populations within one decade, the goals of preventing mental illness, hospitali:mtion, and rehospitalization have failed. In assessing the broader issue of deinstitutionalization, the paper suggests that the use of the courts can either support or contest prevailing practices. The paper also critiques what is viewed as the prevailing medical paradigm in mental health which provided a rationale for State hospitals for the mentally ill and the later reduction of inpatient populations. The policy of deinstitutionalization is viewed as demonstrating the power of reigning and socially stabilizing paradigms; organizational rearrangements are made in the name of humane social change while, simultaneously, traditional orientations and practices are maintained in new settings. Thirty-seven references are given.
Descriptor(s): Mental health services, Policy/changes care, Long term care facilities.
re health
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181. I)einstitutionalization
and Mental Health Serviec_.
Ellen L. Bassuk and Samuel Gerson. 1977, 8 pp. Availability: Scientific American v238 n2 p46-53 Feb _8. This article reviews the issues raised by the deinstitutionalization of chronic mental patients and considers how such a well-intentioned reform could have created so many problems. The historical treatment of the mentally ill is reviewed, and legislation leading to the development of an extensive support system tbr the mentally ill, based on community mental health centers, is described. The article notes that the dual promise implied by the community mental health concept -- treatment and rehabilitation of the severely mentally ill within the community and the promotion of mental health generally -- has not been fulfilled, Many patients are shunted into nursing homes or drift to substandard inner-city housing that is overcrowded, unsafe, dirty, and isolated. Part of the problem is related to funding and the burden that is placed on third party reimbursement. Insurance coverage of the mentally disabled has always been incomplete, biased in favor of inpatient care, and markedly inferior to coverage for physical illness. The combined effect of Federal insurance
Summaries of addresses and workshops are presented from a conference on manpower, availability and accessibility of care, alternative delivery systems, costs, and financial resources in rural health care delivery. Conference addresses and workshops noted that rural communities need access to a system of health care more than to single physician practices. The system should be based in a group practice which can serve one or several communities 24 hours a day, 7 days a week, and whose efforts are augmented by those of other skilled health professionals. Physicians in the group practice would confer with specialists practicing at the community hospital. The most difficult cases would be referred to a major medical center. A new concept of rural hospitals was also discussed at the conference emphasizing the grouping of independent hospitals which will provide cornplementary inpatient, outpatient, and preventive services. The use of allied health professionals in rural areas was also emphasized: emergency medical technicians are bringing service to remote areas, nurse practitioners are providing primary care in small communities, physician's assistants are making it possible for doctors in underserved areas to see more patients, and home health workers are caring for bedridden patients at home. Conference participants urged the Government to (1) remove Government-imposed obstacles to more efficient health care and (2) use reimbursement as a tool to help shape a more rational and
plans of medicaid and medicare has been to limit development and use of community-based alternatives. Other problems inelude shortages of money and personnel, shortages of funds allocated to basic research in mental illness, bureaucratic fragmentation, and court decisions which, although they advance the cause of human rights, may be immediately damaging to
efficient health care system. The conference further concluded that a system of health care can operate effectively only with informed local input, some measure of local autonomy, and public enhghtenment. Approximately 100 references are provided'
some patients. The article briefly describes the development of the Community Support Program by the National Institute of Mental Health (NIMH) which asserts the willingness of the Federal Government to accept more responsibility for the mentally ill and suggests that decent places of habitation should be provided for those who suffer from severe forms of emotional disability. Charts and drawings are provided,
Summaries of speeches and workshop discussions at an invitational conference held in Washington, DC, June 7-8, 1976.
Descriptor(s): Mental health services, Present legislation/regulations, Policy initiatives, Limitations on coverage.
182. Delivery
Descdptor(s): Health care costs, Facilities providing health care, Health care/services, Inpatient facilities, Providers of health care services, Supply/availability of services, Policy initiatives.
183. Delivery of Health Care in Urban Underserved
Areas.
Salvinija G. Kernaghan. American Hospital Association, Chicago, IL 60611 AHA-I165
of Health Care in America.
McDonalds Corp., Oakbridge, IL. American Hospital Association, AHA-2920
Chicago, IL 60611
McDonalds Corp., Oakbridge_ IL. 1977, 87 pp. Availability: 60611.
1-84
American Hospital Association,
1979, 109 pp. Availability: American Hospital Association,
Chicago, IL
60611. Chicago, IL
Speeches and recordings of workshop discussions made during the 1978 conference conducted by the American Hospital As-
Health Care Programs
sociation and the Hospital Research and Educational Trust are presented in this book. The conference brought together representative urban providers and technical experts and congressional and Federal agency staff members who promulgate legislation and fund programs that affect urban efforts. For 2 days participants worked together to discover common concerns and to air differences. Sessions were held on urban resources, accessibility and acceptability of health care services, and manpower. Emphasis was on the problem common to workshop participants -- the poverty-stricken cities in which they are trying •to maintain essential human service health care delivery, Participants' remarks indicated that acceptability of health care services cannot be achieved without a significant degree of consumer control over service delivery. Despite support for the concept of consumer control, many doubts were raised concerning implementation. Questions focused on how consumers could actually help improve delivery of health care through participation in the planning process and whether consumer participation is synonymous with the public good. Conference participants agreed that the possibility of losing the current resource of foreign medical graduates looms large. However, they also agreed that the inner-city health care community will have to deal with several other manpower problems before it can provide comprehensive, continuing care to the urban population. It was coneluded that the current organization of health care delivery is illogical. Specifically, the piecemeal approach of past Federal funding encourages fragmentation of services. When short-term programs are initiated, they must be maintained until local financing can undertake their continued support. Existing grant demonstration or experimental programs should be used to selectively channel funds to improve basic services as well as to encourage new delivery programs. A few references and a selected bibliography of 89-items are included in the book.
Report 1978.
of a conference held in Washington,
Descriptor(s): Funding/financing cy initiatives, Supply/availability care services, Participation
184. Delivery
DC, Feb. 13-14,
Descriptor(s): Prepaid plans, Home health services, Outpatient facilities, Long term care facilities.
of health care programs, Poliof services, Providers of health
in health care programs.
v54 n7 p91-92,94
185. Demand Elasticities for Health Care With Special Emphasis on Out-of-Pocket Price.
Pamela J. Farley. National Center for Health Services Research, MD.
Prospers in Diversity.
Beaufort B. Longest. 1980, 3 pp. Availability: Hospitals
nance organizations (HMO's), long-term, and ambulatory care -- into the existing health care delivery system. Although ihospice care is undoubtedly meeting the needs of some terminally ill patients, there is still uncertainty as to how many patients are better served by hospices than by home care, what tlhe best locations for hospice services will be, and what effect the hospice movement will have on the entire health care delivery system. For the other modes of health care delivery reviewed here, the focus of the literature was on performance evaluation and on technical or operational aspects. One article reviewed 20 studies comparing the costs of home care with those of hospitalization and of care in skilled nursing and intermediate care facilities. The article concluded that, from the standpoint of third party payers, home health care was less expensive than extended care but the costs of nursing home services were roughly equivalent to the costs of home care for patients who needed comparable levels of care. In addition, the cost of an increased use of home health services would not be offset by decreases in the use of inpatient services, thus increasing the total cost of health care. However, it is argued that the use of home health services may encourage improved use of institutional services. Two other artieles emphasize that not only providers, but also organi2ations, government surveying agencies, and educational institutions, ineluding medical and nursing schools must move from the conceptual to the planning stage if continuity of care is to become a reality. Additional articles review the development of _alongterm care system, the growth of hospital-related ambulatory care, ambulatory surgery, the discharge of chronically :ill psychiatrie patients from public mental hospitals, and the development of HMO's as reasonable alternatives to traditional health care delivery. A final study outlines the central elements of a competitive health care system. A photograph and 11 references are provided.
1 Apr 80.
This review of the 1979 literature examines the integration of alternative health care modes -- hospice, home, health mainte-
Aug 1978, 40 pp. Availability: National Div. of Intramural
Hyattsvi]Lle,
Center for Health Services Resem'ch, Research, Hyattsville, MD 20782.
The question of whether and to what extent the pattern of health services use is determined by economic forces as well as medical
1-85
considerations is examined in this review of research on the demand for health care. Particular attention is given to the responsiveness of the demand for service to changes in its own money price; the effects of income, the opportunity costs of time spent in traveling to and waiting for services, and the prices of other sources of care are also considered. Own money price elasticities is the focus of the report, because coinsurance is often included in national health insurance proposals as a feature intended to promote efficiency and discourage inappropriate use. Further, if research is able to document any of the economic factors which might theoretically affect health care use, it is most likely to be the price that the consumer pays (1) natural experiments where changes in health insurance coverage have resulted in changes to the net price faced by consumers and (2) regression analysis of both State and household data. The quasi-experimental approach usually involves the comparison of use patterns among groups with different insurance plans or analysis of a single group with insurance coverage that changed over time. The accumulated evidence suggests that the own money price elasticity of hospital use lies between minus 0.1 and minus 0.7, and the own money price elasticity of demand for physician services is between minus 0.1 and minus 0.3. More refined and meaningful estimates of money price and other demand elasticities will require a higher level of disaggregation and better measures of time costs. If the effects of coinsurance vary by age, sex, income, diagnosis, or other patient characteristics, then estimates of price elasticities by population subgroup may provide information important to the design of an equitable and costeffective national health insurance plan. Tabular data and 19 references are provided,
Descriptor(s): Demand/utilization of health care programs, Economic/commercial influences, Deductible/coinsurance, Health care/services.
186. Demand for General Practitioner and Internist Services.
David S. Guzick. 1978, 18 pp. Availability: Health Services Research ter 1978.
v13 n4 p351-368 Win-
This is a study of functions of demand for services of general practitioners and internists that uses a demand equation estimated from 1970 Center for Health Administration Studies and the National Opinion Research Center survey data. The sample consisted of 3,565 families containing 11,619 individuals who were interviewed in their homes in 1971. Respondents' observations were grouped according to cross-classified independent varia-
1-80
bles, and regression analyses were performed using group means as data. According to this study, the demand for the services of general practitioners and internists, the physicians who provide the bulk of primary care, is significantly different. As ability to pay increases either by income or insurance, there is an apparent substitution of visits to internists for those to general practitioners. Efforts to improve ability to pay by increasing insurance coverage, therefore, may actually confound current attempts to increase the utilization of primary care physicians. It remains to be seen whether consumers will show the same demand response to better insurance coverage for family practitioners that they did for general practitioners in this sample. Differences in demand were also found with respect to disability days, age, sex, race, and residence. Inelastic demand curves indicate that physicians may be expected to behave as monopolists rather than competitors. Such a structure implies excess capacity, and the same total quantity of service could be provided more cheaply if it were divided up among a smaller number of physicians, each providing a greater quantity of service. Previous empirical studies of demand for physician services have used data aggregated across specialties. The differing structure of demand for general practitioners and internists suggest that it is indeed appropriate to view physician services as being organized into specialty markets rather than a single market for physician services. Twentyfour references are provided. (Author abstract modified)
Descriptor(s): Supply/availability of services, Physicians, mand/utilization of health care programs, Medical/surgical vices, Impact of third-party coverage.
Deser-
187. Demand for Medical Care in a Rural Setting. Racial Comparisons.
Laurence A. Miners, Sandra B. Greene, Eva J. Salber and Richard M. Scheffler. National Center for Health Services Research, Hyattsville, MD. Robert Wood Johnson Foundation, Princeton, NJ. 1978, 15 pp. AvailabiIity: Health Services Research v13 n3 p261-275 Fall 1978.
Household data from a southern rural community were employed to examine racial differences in the use of medical care services. Both monetary and nonmonetary determinants of demand were considered. The data were gathered as part of a community survey conducted between 1973 and 1975. The survey consisted of 5 visits to each household; the total number of households visited was 704. Of primary concern were social
Health Care Programs
differences in the use of services. Data were stratified by race not only to account for differences in demand between black and white households but also because programs designed to improve the health status of the community may be most effective when aimed at subsets of the population. The primary purpose of the survey was to investigate the effect of variables such as health status, monetary and nonmonetary health care costs, income, and household size on the household's demand for ambulatory medical care. Regression analysis results indicated that office waiting time for black households and travel time to the provider for both black and white households had a greater impact on demand than price. Racial differences exist in the effects of health insurance coverage and. household income on household medical visit expenditures, and both need and household size were found to be consequential determinants of demand. Six tables and 20 references are included. (Author abstract modified)
demand for such insurance would be positive, but it is still likely to be small. These predictions are corroborated by the experience under medicare; only about 1 in every 10 persons eligible for Medicare has chosen to supplement the $60 per person deductible in Part B (which pays for physician services), although somewhat more than half have purchased policies that supplement medicare coverage for hospital services only. If NHI is written with a moderate deductible that applies to unreimbursed expenses (as the present medical deduction on the personal income tax does), persons can eliminate that deductible only by foregoing any benefits from NHI; thus, there will be no demmld for supplementary insurance. None of the current health insurance bills propose this treatment. Footnotes, tabular data and approximately 23 references are provided. (Author abstract modified)
DescNptor(s): Deductible/coinsurance, ante (NHI), Private health care plans.
National
health
insur-
Descriptor(s): Demographic features of population, Demand/ utilization of health care programs, Economic/commercial influences. 189. Dental and Vision Care Benefits in Health Insurance Plans.
188. Demand for Supplementary Health Insurance, or Do Deductibles
Matter.
Donald R. Bell. Bureau of Labor Statistics, Washington, DC 20212 1980, 5 pp. Availabih'ty: Monthly Labor Review v103 n6 p22-26 Jml 80.
Emmett B. Keeler, Daniel T. Morrow and Joseph P. Newhouse. Rand Corp., Santa Monica, CA 90406 RAND/R-1958-HEW Department of Health, Education, and Welfare, DC. Jul 1976, 30 pp. A vMlability: Rand Corp., Santa Monica,
Washington,
CA 90406.
The probability of demand for supplementary insurance, should a national health insurance (NHI) plan include deductibles, is estimated. An economic model of the decision to purchase supplementary insurance is used, based upon the assumption that the consumer is risk averse and is therefore willing to pay a certain loading fee (excess over actuarial value) for a supplementary insurance policy. In calculating the loading fee the eonsumer would be willing to pay, the following analytical assumptions are made: (1) group insurance is involved, (2) all members of the group must belong to the supplementary insurance plan, and (3) supplementary insurance has no effect on demand for medical services. Findings indicate that if there are no special tax benefits for supplementary insurance, consumers will almost certainly not purchase such coverage for nonhospital services; however, if tax subsidies for supplementary insurance are continued, the
This article analyzes the principal features of 85 dental care and 46 vision care plans which comprise two of the fastest-growing areas of employee health insurance in recent years. All of the 85 plans provided diagnostic, preventive, restorative, and prosthodontic services. Fifty-six plans also covered orthodontic services which frequently cost more than other dental services. The most common reimbursement arrangement in the dental plans studied was the nonscheduled cash allowance which paid a proportion of the reasonable and customary charge for a procedure:. This procedure applied to all services except orthodontic in 65 of the 85 plans; 17 plans used a scheduled cash allowance and 3 provided full payment. A few plans encouraged preventive care by gradually eliminating the copayment requirement for annual dental checkups. Costs were controlled by limiting the frequency of service, setting a maximum benefit amount, setting deductibles, and establishing pretreatment reviews in which the insurer reviews the proposed treatment and cost before agreeing to cover the cost. Of the 46 vision care plans, 45 provided at least partial coverage for eyeglasses. Three-fifl3as of the plans paid benefits according to a schedule of allowances which included specific amounts for one examination and either one pair of glasses or contact lenses. Cost controls, other than those provided by scheduled cash allowances and eoinsurance features of nonscheduled
1-87
allowances, consisted of limits on the frequency of benefits, maximum benefits, and deductibles. Employers paid the full cost of dental insurance for employees and their dependents in 74 of the 85 plans; all but one of the 46 vision care plans were fully financed by the employer. Three tables and five footnotes are given.
Descriptor(s): Dental services, Vision/hearing services, Cost containment efforts, Plan design/program provisions (under health plans), Limitations on coverage, Source of premium payment, Private health care plans.
190. Dental Care and the Health Maintenance Concept.
Organization
Max H. Schoen. 1975, 21 pp. Availability: Health and Society v53 n2 p173-193 Spring 1975.
This article contends that the consequences of the commo_ dental diseases can be prevented by regular health maintenance in an organized system accepting responsibility for a population, The principal dental diseases, caries and periodontal disease, affect almost the entire population and result in considerable: pain and discomfort with eventual tooth loss, if untreated. Despite the existence of some 100,000 practicing dentists in the United States, the majority of the population lose all of their natural teeth if they live out their normal life spans. The solopractice fee-for-service system, even with third-party payment_ may reduce the difficulties somewhat but cannot solve the prob-, lem. Prepaid dental group practice, either independently or as part of a general health care system, has the potential of vh'tually eliminating edentulism (loss of teeth) in populations tbr which it has responsibilities. Problems of implementation include the cost of dental maintenance over a lifetime, the integration of dentistry into existing health maintenance organizations (HMO's), the relationships of dentists to physicians, and the additional inflationary costs of dental fees. The article conclud_ that unless a national health insurance plan becomes law and includes comprehensive dental care, there is little chance of reaching lower income groups who need the HMO concept the most. A total of 33 references are given. (Author abstract modified)
Descriptor(s):
1-88
Prepaid plans, Dental services.
191. Dental Care Demand. Point Estimates and Implications for National Health Insurance.
Willard G. Manning and Charles E. Phelps. Rand Corp., Santa Monica, CA 90406 RAND/R-2157-HEW Department of Health, Education, and Welfare,
Washington,
DC. Mar 1978, 57 pp. A vailability: Rand Corp., Santa Monica, CA 90406.
Using a 1970 national cross-sectional survey of individuals, this report concludes that the demand for dental care is much more sensitive to price than is the demand for other forms of medical care. The survey' was augmented by region-specific information on the number of dentists per 100,000 persons, the price of dental services, and the fluoridation of water. With full coverage (no out-of-pocket c_mt), the predicted number of visits was over twice as high for adults and over three times as high for children as their demands were with no dental insurance coverage. In addition, the report found that the probabilities that extractions and dentures would be obtained were less income-responsive. However, cleanings, examinations, and orthodontia were more income-responsive than dental demand in the aggregate. Further, as the price for dental service fell, income became a more important determinant of dental demand. The report also concluded that full or partial dental coverage under national health insurance (NHI) would considerably increase the demand for dental care, even if coverage was limited to children and ifcopayments and deductibles were imposed. The report recommends that any dental coverage should be phased in slowly for children so that the supply of dental services could adjust to increases in demand. This strategy was adopted when Sweden inaugurated a national dental insurance plan in 1974. Footnotes, 21 tables, and 30 references are provided. Four appendices contain related study materials. (Author abstract modified)
Descriptor(s): Demand/utilization of health care programs, Dental services, National health insurance (NHI), Supply/availability of services, Impact of third-party coverage.
192. Dental Care for Everyone.
James M. Dunning. 1976, 234 pp. A vailability: Harvard 02138.
University
Problems and Proposals.
Press, Cambridge
MA
Health Care Programs
This book discusses dental care delivery systems and financing. Because payment methods profoundly affect the availability of care to large population groups, the book delineates the major forms of third party payment, including prepayment, postpay-
This report reviews problems connected with providing dental services to the handicapped, assesses federal programs to alleviate these problems, and recommends ways to increase handicapped persons' access to dental services. There are about 33
merit, and other mechanisms for payment (i.e., fee-for-service, capitation, and a combination of the two). In addition, variations in payment plans according to sponsor -- consumer groups, the dental profession, commerical carriers, and the Federal Govern-
million handicapped oral health status of cisely defined, this needs and receives
ment -- are outlined. Despite the growth of the notion that health care is a human fight, large portions of the lower income classes cannot afford dental care. Although medicaid had greatly iraproved the quality of dental care to some low-income groups, the inadequacy of financial mechanisms to aid poor families is moving the Nation toward national health insurance (N-HI). While solo practices have tended to dominate clinical dental treatment, early efforts toward subsidized group dental care have usually been made in clinics. A number of approaches have been tried in an effort to provide clinical services and to subsidize payment for comprehensive dental care to selected groups, but no clearly superior method has emerged. However, immense increases in the amount of dental care will be needed to assure equitable treatment. Consequently, a number of approaches to dental care are outlined to ease the problem: reduction of dental disease through prevention, recruitment of dentists, attention of consumer demands, and establishment of service priorities. The book also examines group practices, health centers, and health maintenance organizations; work simplification through use of dental auxiliaries; third-party payment for dental care; evaluation of care quality; and cost-benefit analysis. Dental system efficiency can be improved through development of clinics, organization of the work force, and inclusion of practical dental care in NHI. Tables, graphs, a subject index, appendices, extensive references, and a glossary are supplied,
population. Many handicapped people face barriers to dental care posed by the cost of dental services, transportation difficulties, poor building and office design, and difficulties in identifyhag and securing a source of dental care. Congress has authorized several different programs administered by the Department of Health and Human Services and the Department of Education to help improve and expand dental services for handicapped persons. Chief among these are the medicaid, Head Start, and Maternal and Child Health and Crippled Children's Services programs; the Developmental Disabilities and Vocational Rehabilitation programs; the Early and Periodic Screening, Diagnosis and Treatment program; and the National Health Service Corps and Community Health Centers programs. Not all of these specifically focus on handicapped people, but they do provide dental services for handicapped as well as nonhandicapped individuals. In addition, several programs that train graduate dental students, practicing dentists, and dental auxiliaries to work with handicapped persons are being supported. Although the full impact of these programs on the dental care needs of the handicapped cannot be determined due to insufficient data, areas appearing to need strengthening or improvement have been identified, and recommendations have been made. These include improved coordination of oral health activities for the handicapped, support for a program ofdental student training in the care of handicapped people in each dental school in the United States, and support for the remodeling of private dental offices and the upgrading of institutional dental facilities
Descriptor(s): Demand/utilization of health care programs, Dental services, Supply/availability of services, Funding/financing of health care programs, Impact of third-party coverage, Policy/changes re health care, Cost/benefit analyses, Prepaid plans, Private health care plans, Publicly sponsored/mandated health plans,
193. Dental Care for Handicapped
People. Special Report.
Department of Health and Human Services Office of the Assistant Secretary for Health, Rockville, MD 20852 DHHS/PUB/PHS-81/50154 Sep 1980, 24 pp. Availability: Department of Health and Human Services, Ofrice of the Assistant Secretary for Health, Rockville, MD 20852.
people in the United States. Although the the handicapped population cannot be pregroup has proportionately greater dental fewer dental services than the "'normal"
to make them more accessible to handicapped persons. Other recommendations focus on changes in the medicaid law to provide for greater financial incentives for dentists who treat medic.aid-eligible patients and the provision of dental services for needy, handicapped adults as a mandated, rather than an optional service. Footnotes and 19 references are supplied. (Author abstract modified) Descriptor(s): Dental services, Supply/availability of services, Medicaid, Publicly sponsored/mandated health plans, Policy initiatives.
194. Dental Insurance. Opinion Research Corp., Princeton, NJ 08540 Jul 1979, 4 pp.
1-89
Availability: Bureau of Economic and Behavioral Research, American Dental Association, Chicago, IL 60611.
of medical bills in any given year, or to establish a separate plan. On the whole, most companies use the separate plan approach (74 percent of the plans), but the major medical plan is used for
Results are reported from a personal interview survey regarding the dental habits and dental opinions of the general public. The survey was based on a probability sample of 1,949 men and women 18 years of age and older living in private households in the continental United States Interviewing for the survey was completed during the period January 7 through January 28, 1978. All interviews were conducted in respondents' homes. The most advanced probability sampling techniques were used in the selection of households to interview and in the random selection
this purpose by about 35 percent of those plans that are not negotiated with unions. Another basic decision, whether to cover "reasonable and customary" fees of dentists or limit reimbursement to a schedule of maximum charges, has been made in favor of the reasonable and customary strategy by 71 percent of the
of a designated respondent within the household. One callback was performed in all cases where the originally designated respondent was not available at the time of the initial call to the housing unit. Only one interview was conducted per household, The representativeness of the sample was such that the results may be projected to the total U.S. population of adults 18 years of age and older. Data and information are provided on oral health habits, patterns of dental visits, methods of receiving dental care, personal dental experience, auxiliary dental personnel, dental expenditures, dental fees, dental insurance, national health insurance, dentures, and dental awareness. A description of the survey methodology and a sample of the survey are: appended. Tabular and graphic data, a bihliography, and an hldex are provided.
age $10.67 (median), but vary widely. Premiums have not been increased since the plan's inception in 48 percent of the plans. Despite the apparent potential for cost saving to the company when the employee contributes, the typical plan is entirely company paid. Tables, charts, and footnotes are provided. (Author abstract modified)
From "Dental Habits and Opinions of the Public. Results of a 1978 Survey, "p48-5L 1979. Descriptor(s): Demand/utilization of health care programs, Dental services, Demographic features of population,
plans. More than half the plans exclude o_hodontia To control costs, dental insurance applies techniques
expenses. developed
for medical insurance: deductibles, coinsurance, and benefit ceilings. Monthly premiums for an employee with dependents aver-
Conference Board Report
No. 680.
Descriptor(s): Private health care plans, Dental services, Plan design/program provisions (under health plans), Source of premium payment, Comparisons of health care programs.
196. Dental Prepayment Plans. American Dental Association, Bureau of Economic Research and Statistics, Chicago, IL 60613 Nov 1977, 21 pp. Availability: American Dental Association, Bureau of Economic Research and Statistics, Chicago IL 60613.
195. Dental Insurance Plans.
Mitchell Meyer. Conference Board, Inc., New York, NY 10022 1976, 25 pp. A vailability: Conference Board, Inc., New York, NY 10022. Dental insurance benefit plans are the fastest growing new fringe development. This coverage will receive increased interest from both major companies and unions in the next few years. ]'his Conference Board survey of 170 plans from 137 companies, about half of all the major plans in existence, identifies a number of planning choices that must be made in setting up a dental insurance plan. One early decision is whether to add dental care as a covered expense under the company's regular medical plan, thereby making dental benefits partly dependent on the amount
t-")0
A 1976 Survey of Dentists, regarding selected issues in dentistry, is discussed. Ten percent of the population of dentists listed in the American Dental Association's registry data tape, which includes both members and nonmembers of the association were systematically selected. The sample consisted of 9,393 general practitioners and 955 specialists representing the age and geographic distribution of the dental profession. Survey findings provide data regarding dental prepayment plan participation. Almost 50 percent of the respondents reported that over 30 percent of their patients are covered by privately sponsored third-party payment plans, while only 5 percent reported that over 30 percent of their patients are sponsored by Federal programs. Most dentists, regardless of practice type or year of graduation from dental school, accept direct payment from carriers on a routine basis. In addition, the majority reported that their auxiliaries spend between 1 and 9 hours per week complet-
Health Care Ptogram_,
ing insurance forms; the dentists themselves spend between 1 and 4 hours. Results also indicate that most dentists submit x-rays to carriers; these are usually originals. There are some indications that as the year of graduation becomes more recent, likelihood of automatically submitting x-rays decreases. Sixteen tables are provided. (Author summary modified)
Office of the Assistant Secretary for Planning and Evaluation (HHS) Cost Estimating Group, Washington, DC 20201 Feb 1981, 272 pp. AvMlabih'ty: Department of Health and Human Services, Ofrice of the Assistant Secretary for Planning and Evaluation, Washington, DC 20201.
Desczffptor(s): Third-party payors, Dental services, Participation in health care programs, Physicians, Private health care plans.
197. Department of Health, Education, and Welfare, Office of the Inspector General. Annual Report, January 1, 1979 to December 31, 1979. Office of the Inspector General (HEW), Washington, DC 20201 Mar 1980, 81 pp. Availability: Deptartment of Health, Education, and Welfare, Office of the Inspector General, Washington, DC 20201. This annual report from the Office of the Inspector General (OIG) of the Department of Health, Education, and Welfare (DHEW) reports on programs to improve efficiency and effectiveness and to reduce fraud and error. For example, the Audit Agency identified situations where nursing home residents were not being given proper protection against certain hazardous conditions and where State agencies had improperly granted waivers of serious deficiencies. In addition, under the Office of Investigations, State medicaid fraud control units have continued to increase and now total 29 as of 1980. OIG has also initiated a number of cross-cutting or multidisciplinary programs such as Project Integrity I, a national project conducted by OIG and the Health Care Financing Administration (HCFA) that uses cornputers to detect fraud or error in payments to pharmacists or physicians under medicaid. Five OIG recommendations cover procurement, grantee and contractor performance, audit resolution, computer security, and the importance of speedy congressional legislation to assist States in funding State medicaid fraud control units. Tabular data are provided, Made pursuant
to Section 204(a) of Public Law 94-505.
Descriptor(s): Cost containment efforts, evaluation of health administration,
Medicaid,
Outcome/
198. Description of the Health Financing Model. A Tool for Cost Estimation. Robert
C. Bonhag.
This study summarizes the most important features of the Health Financing Model, describes the sources of data used, explains the operation of the different modules or components, and shows how the components are integrated to produce cost estimates. The Health Financing Model evolved out: of a need to estimate the costs of and the population affected by various proposed changes in national health care policy. The Population Module details the demographic, social, and economic characteristics of the Nation's population in a specific future year, including health insurance coverage and medical care use. The State Module details State economic and budgetary characteristics as well as programmatic information. National expenditures for the specific health services to be covered by a plan are estimatedforabaseyeax. The source ofpayment for theseexpenditures is identified and referred to as the Health F:.xpenditures Matrix. The Present Law Profile Module combines this information with demographic and health use data compiled by the Population Module to produce the Present Law Profile of the health care system. This profile contains the baseline data regarding the use and financing of health care in the United States should current laws and policies continue. The effects of a proposed health policy are shown relative to the projection of health care spending under present law. This is accomplished by creating a Future Law Profile showing how the selwices in the Present Law Profile will be financed after the policy change has been fully implemented. Much of this is done through the Future Law Profile Module (FLPM), which produces estimates of how health care trmancing will change under a propos£xi program. The FLPM simulates the principal effects of a proposal on the health care system in terms of the use of services and change in financing of services, including any alteration in insurance coverage. The last step is to integrate all the estimates generated in the modeling process and reformat the results of this modeling into tables which display the information in a manner most useful to policymakers. Appended are discussions of the State health insurance pools of Connecticut and Minnesota and a preliminary design of a medic.aid eligibility submodule. Tabular data, figures, and footnotes are provided.
Descriptor(s): Health information/data systems, Health care cost trends/projections, Participation in health care programs, Policy/changes re health care.
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199. Design for a Corporate Health Care Monitoring System.
Mary M. Hunter and John C. Rosala. InterStudy, Excelsior, MN 55331 Health Care Financing Administration,
Baltimore, MD
Sep 1980, 34 pp. A vailability: Health Care Financing Administration, Grants Branch, Baltimore, MD 21207.
Project
The rationale for a Corporate Health Care Monitoring System is outlined; the design of a generic system is described; and a methodology for adaptation of such a system to a specific company is suggested. The distinguishing feature of the Corporate Health Care Monitoring System described is its two-tier approach: a summary level of geographic-based reporting which focuses on 11 key indicators of cost and use to identify problem areas and a detail level of reporting which can deirme and address problems identified by the summary report. The summary report component of the monitoring system makes 11 utilization and costs indicators available to location/division managers on a quarterly basis for their unit's covered population: The utilization measures include number of hospital inpatient days, number of hospital admissions, average length of hospital stay, number of surgical procedures, and number of outpatient provider encounters; cost measures include premium payments, reported charges, claims paid, hospital inpatient costs (room/board and ancillary), and surgical expenses and out-of-hospital costs. The detail reporting capability makes available both diagnosis-specific and provider-specific identifications of health care services for age/sex groupings of employees, dependents, and retirees. The company must identify or reliably estimate its covered population to allow construction of per capita comparison measures. The modification of this generic system to create a company's own monitoring system requires top management approval and the commitment of adequate resources for design, testing, installation and evaluation. Forms and procedures for the CHCMS are appended. (Author
abstract modified)
Descriptor(s).. Demand/utilization of health care programs_ Cost containment efforts, Voluntary initiatives, Participants in health care programs, Private health care plans, Claims adminis-tration, Health information/data systems.
200. Design of Failure. Health Policy and the Structure of Federalism. Bruce C. Vladeck. Duke Univ. Dept. of Health Administration, Durham, NC 27706 1979, 14 pp. Availabilitv: Jnl. of Health Politics, Policy and Law v4 n3
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p522-535 Fall 1979.
This paper explores the impact of the Federal structure of American government on health policy through the examination of three case studies of unsatisfactory policy: medicaid cutbacks, provider licensure, and health planning under Public Law 93641. State cutbacks, which occur when medicaid costs overrun earlier estimates, often take the form of withdrawing coverage for optional services or of restricting access to those services by imposing prior authorization, utilization review, or similar bureaucratic procedures. Such budgetary cuts fail to lower orerail costs effectively, substitute effectiveness in coping with bureaucracies for need as the criterion for receipt of service, and further discourage professional participation and service to the poor. The division of Federal and State responsibilities in the licensure of providers creates a situation in which the Federal Government pays providers meeting certain standards of competence or quality and then plays no role in setting or enforcing those standards. Finally, the two-tiered system of health planning, established by Public Law 93-641, may actually accelerate duplication and overbuilding as well as create additional fragmentation and irresponsibility. In considering the establishment of national health insurance (NHI), a sound and sensible system of Federal sharing of responsibilities should be developed. States could be used as basic administrative units, as carriers or intermediaries for either all or some parts of NHI, and as direct service providers with local governments. Sixteen notes are given. (Author abstract modified)
Descriptor(s): Medicaid, Participants in health care programs, Eligibility requirements, Economic/commercial influences, Present legislation/regnlations.
201. Determinants of Pediatric Care Utilization.
Ann D. Colle and Michael Grossman. National Bureau of Economic Research, Inc., Cambridge, MA 02138 Robert Wood Johnson Foundation, Princeton, NJ. 1978, 39 pp. Availability: Jnl. of Human Resources v8 p115-153 Supplement 1978. This paper uses multivariate techniques to identify the main sources of variation in the decision to obtain pediatric care, the number of pediatric visits to physicians, and the composition of visits among various types of physicians. Four measures of pediatric care for children between the ages of 1 and 5 are used: physician contact within the past year, preventive physical ex-
Health Care Programs
amination within the past year, number of office visits to private practice physicians, and average quality of these visits. These four measures are studied in fight of six variables: family income, price of visits, mother's schooling, time, availability of physiclans, and family and child characteristics such as age, sex, and number of siblings. Family income had positive effects upon all four measures of use. Mother's schooling and number of children in the family were extremely important determinants of use. However, it was not clear that these differences are legitimate concerns of public policy. Unless the observed outcome that black families have more children and spend less on medical care per child is a result of imperfect information or racial discrimination, these differences do not call for public policy intervention. Clearly, further research directed toward explaining the sources of these differences is needed. Fifty footnotes are provided. Tables displaying variable definitions, physician costs, family income and elasticities, mother's schooling, time, availability of physicians, family characteristics, and the differences between black and white use are provided. (Author abstract modified)
Descriptor(s): Demographic features of population, utilization of health care programs, Medical/surgical
Demand/ services.
from among generic equivalents can actually yield substantial savings to consumers and not increase risk to physicians, pharmacists, and consumers, attempts to legislate generic pr_Lctices will be less effective than anticipated. Fears about governmental efforts to encourage genetic competition may influence pre,cription drug manufacturers with regard to future product development and managerial planning. Approximately 50 references, 3 figures, and 3 tables are provided.
Descriptor(s): Pharmaceutical services, Physicians, health professionals, Cost containment efforts.
.Allied
203. Determining Health Needs.
Robin E. MacStravic. 1978, 268 pp. A vailabih'ty: Health Administration 48109.
Press, Ann Arbor, MI
This book presents a model for defining health needs and evaluates alternative methods for determining what those needs are. It maintains that determination of needs forms the basis for 202. Determinants Generic Drugs.
of Physician
and Pharmacist
Support of
William O. Bearden and J. Barry Mason. 1980, 10 pp. Availability: Jnl. of Consumer Research v7 n2 p121-130 Sep 80.
A recursive model depicting a theoretical chain between hypothesized determinants of support for generic drug practices was examined using a maximum likelihood estimation procedure and was applied to samples of 412 physicians and 118 pharmacists. Study methodology involved preliminary interviews with physicians and pharmacists to assess the salient information underlying drug-related decisions and the issues surrounding generic practices. Based on these initial responses, a questionnaire was developed and administered to study subjects. Data were collected from physicians and pharmacists residing in a State in which legislation designed to encourage generic prescribing was being discussed in the legislature and through the media. A total of 31 parameters were estimated using the maximum likelihood procedure for both samples. Results suggest that confidence in regulation, potential savings, and impact on drug research represent plausible determinants of physician and pharmacist support of generic drugs. Until professionals become convinced that their efforts to lessen drug expenses by prescribing and dispensing
health planning and that the success of systematic planning in developing and controlling health services is influenced by what are perceived to be the health needs of the community and the Nation. Subjects addressed include basic concepts regarding identification of health needs, the service constituency, determination of need for health services use, current use of ]_ealth services, future use of services, and resource requirements. Also discussed are the organization and location of resources, errors and uncertainty in measurement, acute inpatient facilities, longterm care facilities, outpatient facilities, and emergency medical services. Throughout the work, the increased understanding and improved use of analytical methods in making health need determinations is emphasized. It is suggested that the determination of health needs can ultimately be reduced to resource allocation; i.e., analytical as well as capital and operating resources for health services. The purpose of each allocation decision should be to move toward a health services system which speods an amount on health services resources appropriate to the conttibution made and which provides resources sufficient to deliver the appropriate health services at identified peribrmance levels of efficiency, quality, cost, accessibility, acceptability, accountability, and appropriateness. It is essential for planners and administrators to cooperate with each other. Problems must be identified, utilization review and professional standards review organization (PSRO) programs must be used effectively, and certificate of need programs must control wasteful duplication of facilities. Thus, the health services planning system seeks to
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determine the future of health services delivery by ant:cipating inevitable future conditions and intervening when necessary to move society toward appropriate health and social goals. Some chapters include tables and reference notes; a selected bibliography of about 35 references is included
lags, economic fluctuations, and natural disasters will affect the variation in claims experience and hence the likelihood that crisis or prohibitive levels will be reached. Sudden changes in the cost and utilization of medical care can also create claims variations. With a benefit plan that contains deductibles, these cost trends can be leveraged, creating much greater fluctuation. Tabular data and a chart are provided.
Descriptor(s): Demand/utilization of health care programs, Trends in health status, Participation in health care programs, Health care/services, Facilities providing health care, Funding/ financing of health care programs, Providers of health care setvices, Policy/changes vices,
204. Determining
re health care, Supply/availability
Present and Future iieaitb
of ser-
Descriptor(s): Cost containment efforts, Economic/commercial influences, Claims administration, Source of premium payment, Health care cost trends/projections, Premium determination/ underwriting.
_3_ia Cosl_s. 205. Development
William A. Halvorson
and Stephen
1980, 3 pp. Availability:
Benefit Plan P,_eview '34 hi2
p20,24,116
Employee
D. Brink.
Jun 80.
This article reviews methods used to determine present and future health claims costs. These determinations are necessary in making a decision to self-fund a health plan The true costs of the health plan can be determined only by matching claims allocated by incurred month against the number of employees and families exposed to health claims. By dividing the claims incurred by the number of employees and number of dependent units (or families), one can derive the average monthly claims costs for any time period, l_hese monthly claims costs cm_ then be compared with the premiums paid for the period to determine the loss ratio (the percentage of premium that is allocated to health care payments). Comparing an employer's costs with an actuary's expected claims costs for a group having comparable demog: aphic and geographic distributions also is important. Future claims should be projected by using both local and national trends in costs and utilization. I'he most difflcvlt task here is to anticipate the probable effects of changes in benefit plan design on utilization. Under a self-funded plan the employer assumes the risk of claims fluctuation which takes on a critical significance in determining whether benefit womises can be kept. Claims variation reduces as the size of the plan increases, thus increasing the predictibility of future claims. For example, a plan that covers 100 to 250 lives might expect claims experience te vary substantially from year to year and in some years reach 200 percent or more of predicted claims. As the size approaches 1,000 lives, the chance of claims exceeding 200 percent is mini-, mal but a 22 percent probability remains that claims will exceed 120 percent of predicted levels. Besides random fluctuations in claims, nonrandom factors, such as reporting and processing
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of Health Insurmace.
Jeffrey A. Prussin and Jack C. Wood. 1975, 12 pp. Availability: Topics in Health Care Financing Fall 1975.
v2 nl pl-12
This article on the development of health insurance reviews the insurance concept of risk sharing, the development of private third party payment systems, the history of Blue Cross and Blue Shield plans, the development of health maintenance organizations (HMO's), and the use of medicare supplements by the elderly. The article notes that the number of individuals covered by hospital expense insurance has increased from 12 million in 1940 to 182 million in 1973; the number of individuals covered for surgical expense insurance has increased from 5 million in 1940 to 169 million in 1973. Further, an increasing number of persons have coverage for dental expenses, ambulatory care, mental health, alcoholism, and drug abuse. As a result, the total number of dollars paid for health insurance premiums, as well as the ratio of health insurance premiums to disposable income, has increased from .3 billion in 1940, or .4 percent of disposable personal income, to $28.8 billion or 3.2 percent in 1973. Total health insurance benefit payments were $1.3 billion in 1950 and $22.9 billion in 1973. Of the 182 million persons covered by some form of hospital expense protection in 1973, 109 million were covered by commercial insurance companies. The article also discusses trends in Blue Cross and Blue Shield insurance such as the broadening of their benefits packages in an attempt to avert enactment of an adverse national health insurance (NHI) plan; problems in the development of health maintenance organizations (HMO's); and the use of private insurance coverage by the elderly as a supplement to medicare. Seven references and 9 tables are included.
Health Care Programs
Descriptor(s): Private health care plans, Publicly sponsored/ mandated health plans, Health care/services, Participants in health care programs, Health care costs, Health insurance industry.
207. Differences by Age Groups in Health Care Spending. Charles R. Fisher. 1980, 26 pp. A vailability: Health Care Financing Review v l n4 p65-90 Spring 1980. This annual article examines differences in health care spending
206. Diagnosis and the Dole. The Function of Illness in American Distributive Pofitics.
Deborah A. Stone. Duke Univ. Dept. of Health Administration, Durham, NC 27706 1979, 15 pp. Availability: Jnl. of Health Politics, Policy and Law v4 n3 p507-521 Fall 1979.
This paper is intended to demonstrate the extent of social benefits distributed on the basis of illness, to explain why medical certification is increasingly used as a distributive mechanism, and to explore the meaning of this phenomenon for distributive politics in the United States. The extensive volume of social resources and privileges include (1) direct monetary transfer programs such as pension plans and State-operated Worker's Compensation programs, (2) the provision of food and shelter at societal expense, (3) illness-tested privileges such as prescriptions for certain addictive drugs, and (4) medically-based exemptions from civic duties and obligations. The article argues that the concept of illness has certain properties that make it a convenient administrative device for managing a need-based redistributive system in a society whose primary distributive system is based on work. These properties include cultural acceptance of illness as a legitimate excuse for not working, objective standards for identifying illness, and restrictiveness. Paradoxically, the traditional rationales for using illness as one of the keystones of categorical welfare policy are eroding, yet welfare programs based on illness certification are growing rapidly. To explain this anomaly, the article suggests that medical certification as a distributive mechanism serves certain latent political functions, such as allowing welfare programs to be responsive to political unrest, siphoning off opposition to controversial policies by the granting of medical exemptions to intense opponents, and reducing political conflict by using physicians as arbiters. Tabular data and 24 notes are included. (Author abstract modified)
Descriptor(s): Demand/utilization of health care programs, Workers compensation, Eligibility requirements, Policy/ changes re health care.
for three broad age groups -- the young (under age 19), the intermediate group (ages 19 to 64), and the aged (65 and over). Reports for earlier years were published in the Social Security Bulletin. Data are presented for calendar year 1978 and for several earlier periods. Of the $168 billion total spent for personal health care in 1978, 12 percent was spent for the young, 59 percent for those of intermediate age, and 29 percent for the aged. The average medical care bill for the aged reached $2,026 per person, compared with $764 for the intermediate group and $286 for the young. About half of all public spending tbr personal health care was for the aged. Medicare payments covered 44 percent of the personal health care expenses for the aged, and medicaid reimbursed an additional 13 percent. Private financing, primarily private health insurance and direct payments, is the major channel of payment for younger age groups, and provides about 70 percent of their health care costs. In addition to citing the above data, the article discusses some of the reasons contributing to the diversity in health care spending by different age groups. Age-related utilization statistics are shown by type, volume, and intensity of service, and they are examined for patterns of hospital care, physicians' services, drugs, and nursing home care. Also considered are demographic changes and variations in health status. Policy-relevant variables, such as payment source and reimbursement policy, are examined to the extent that they affect utilization. Channels of payment for health care, mainly private health insurance, public financing, and direct payments, are explored. The role of the major public programs, medicare and medicaid, in funding health care are described. Trends in channels of payment in the hospital sector demonstrate how private and public funding interact. Finally, the amount and sources of out-of-pocket expenses for health care, particularly for the elderly, are described. Tabular data, footnotes, and 17 references are provided. Descriptor(s): Demographic features of population, Health care cost trends/projections, Private health care plans, Source of premium payment, Publicly sponsored/mandated health plans, Participation in health care programs.
208. Digest of Hospital Cost Containment Projects, Edition. American
Hospital Association,
Third
Chicago, IL 60611
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AHA-1020 1980, 121 pp. A vailability: American 60611.
Hospital Association,
care facility, home health care, surgical and medical (excluding major medical), maternity benefits, major medical, benefits for retirees and dependents, financing (employee or retiree contribution), and eligibility. In addition, a section on out-of-hospital benefits has been included to report information on diagnostic
Chicago, IL
This third edition of the Digest of Hospital Cost Containment Projects is a compilation of cost containment programs and projects implemented in hospitals nationwide to diminish the rise in health care expenditures. The Digest is divided into 21 categories of cost containment activities. Each activity is listed by bed size and in alphabetical order by State. To aid hospitals in obtaining more information about a particular project, the guide lists the name of the person who originally supplied the information at the end of each example. The examples were selected from letters submitted to the American Hospital Association in response to a request for information on cost containment programs and activities implemented during the past year. The "Cost Containment Selected Bibliography," which in the past was a companion document, has been incorporated in
x-ray and laboratory services, mental health care, dental care, vision care, and prescription drugs. An introductory section ineludes definitions and qualifications to clarify the material presented.
this edition of the digest and contains approximately 200 citations. Periodical references are divided into categories similar to the activities and date from January 1, 1978. A summary of American Hospital Association cost containment resources and
Moshman Associates, Inc., Washington, DC 20034 Department of Health and Human Services, Hyattsville, MD. Office of Health Research, Statistics, and Technology. Aug 1980, 59 pp. Availability: Moshman Associates, Inc., Washington, DC 20034.
instructions for acquiring the materials are also provided. thor abstract modified) Descriptor(s): Cost containment efforts, Providers of health care services, Voluntary services,
(Au-
Inpatient facilities, initiatives, Hospital
209. Digest of Selected Health and Insurance Plans. Volume I. Health Benefits. 1977-79 Edition.
Donald R. Bell and Cynthia Thompson. Bureau of Labor Statistics, Washington, DC 20212 Dec 1978, 372 pp. A vailability: Superintendent of Documents, Government Printing Office, Washington, 029-001-02261-1.
DC 20402, order number
This volume summarizes the principal health benefits of selected health and insurance plans in effect as of June 1, 1977, for office and nonoffice employees in private industry. The plans include both negotiated and nonnegotiated plans. Benefits paid for entirely by the employee are included only if they are available on a group-rate basis. Coverage available through conversion to individual policies is not included. Summaries of health benefits are provided for 139 companies and are categorized under the following topics: hospital benefits, convalescent care in extended
1-90
Desclqptor(s): Private health care plans, Health care/services, Plan design/program provisions (under health plans).
210. Directions for the '80s. Final Report of the Panel Evaluate the Cooperative Health Statistics System.
The Panel to Evaluate the Cooperative
Health Statistics
to
System
found that the Cooperative Health Statistics System (CHSS) as implemented by the National Center for Health Statistics has moved between the objective of supporting collection of national data by coordinating data initially collected on a State level and that of developing strong statistical capacities in each State. In its study, the panel found the following: (1) a lack of cooperation among the Federal agencies involved contributed to a view that CHSS activities were extraneous to programmatic systems and inadequate to provide the national data needed for program and policy decisionmaking; (2) the expectations that the CHSS would produce national data were unrealistic in the absence of established record systems at the State level; (3) data set elements were developed on the basis of their common existence at all levels and not on their ultimate use at the national level; (4) usefulness of the data was impaired because the prescribed standards of data quality and timeliness were not enforced; and (5) the effectiveness of the CHSS has been hampered by the program's emphasis on data collection rather than on data dissemination and use. The lack of a clear statement of the concept, purpose, and priorities of CHSS has been a major handicap in the system's development. The panel therefore recommends that the CHSS, which is a nationwide system, be clearly distinguished from the Cooperative Health Statistics Program (CHSP), which is a Federal program. Accordingly, CHSS should be perceived as a nationwide cooperative network of public and private agencies
Health Care Programs
linked together to meet their respective needs in health statistics and having a central coordinating agency in each State and at the national level. CHSP coordinates the flow of national data into and out of the system and provides CHSS Agencies.
Saad Z. Nagi and Judith Marsh. Social Security Administration, Washington, systems,
Outcome/
From Social Problem to Federal Program.
Irving Howards, Henry P. Brehm and Saad Z. Nagi. 1980, 171 pp. A vailability: Praeger Publishers, New York, NY 10017.
This book discusses the Government's response to the problem of disability, focusing on the Social Security Disability Insurance Program (SSDI). The analysis was based on the 1970 Census data and SSDI program data on application and award of benefits and State Disability Determination Services characteristics. A review of the developmental history of the legislation authorizing SSDI considers factors which influence the definition of social problems and social policy. The analytical model used to assess the interaction among problems, policy, and program is described. Disability is defmed, followed by statistics on demographic characteristics of disabled individuals and the impact of disability on their lives. An examination of disability insurance legislation suggests that conflicting views about the need for Government intervention to solve social problems have resulted in a disjointed approach to disability programs. Information on the relationship between rates of people defining themselves as disabled and applying for disability benefits and the socioeconomic characteristics of the States in which they live is presented. This analysis suggests that disability benefits have been approved on the basis of labor market conditions and need factots, rather than purely mental or physical impairments. The determination of disability by States and award rates were examined, with particular attention to the impact of administrative personnel. The study demonstrates a significant relationship between the socioeconomic characteristics of the State and rates of application for benefits; (i.e., the more depressed the economy and the labor market, the higher the application rate). Implications of these findings for Federal policies and programs are detailed. About 100 References, footnotes, and an index are provided. The appendices contain detailed statistical data used in the analysis. Descriptor(s): cy initiatives, health status,
of Health Ser-
Federal support for State
Descriptor(s): Health information/data evaluation of health administration.
211. Disability.
212. Disability, Health Status, and Utilization vices.
Publicly sponsored/mandated health plans, PoliDemographic features of population, Trends in
DC.
Rehabilitation Services Administration, Washington, DC. 1980, 20 pp. Availability: International Jnl. of Health Services vl0 n4 p657-676 1980.
This report presents findings on the relations of disability, ihealth status, and coverage by health insurance and other payment plans to the utilization of health services and to the prevalence of unmet needs for health care. A number of socioeconomic factors were introduced as control variables in the analysis. Data for the report were derived from a survey of a probability sample of persons 18 years of age and over in the United States, exctuding institutionalized populations. The 1972 survey data were collected through personal interviews. During the year prior to the interviews, about 75 percent of all respondents received services from one of the major health care delivery systems, primarily from physicians in private practice. Data indical:e that utilization of all types of health services was associated with the prevalence and severity of health problems and disabilities. A strong association was indicated between limitations in emotional performance and physicians; this trend tends to support the proposition that many people who seek the advice of a physician about a physical complaint are actually suffering from an emotional problem. Of the total sample, 11 percent reported receiving less care than they needed or receiving no care despite feeling or having been told that they needed such care. These residual needs were more evident among the vocationally disabled and the emotionally impaired. Fear kept many respondents with emotional problems from seeking care. However, in most cases, the cost of medical services appears to be the primary reason for failure to obtain care. A substantial portion of respondents had no insurance or other payment plans for the costs of health care services. Present arrangements still exclude large groups of people with low income, poor health, or vocational disabilities. The extension of medicare to disabled beneficiaries under Social Security would alleviate the problem somewhat. In view of the fact that only 10 percent of respondents reported using outpatient clinics, evaluation of the availability and accessibility of such facilities should be considered. Four tables and 15 references are included. (Author abstract modified)
Descriptor(s): Demand/utilization of health care programs, Private health care plans, Publicly sponsored/mandated ihealth plans, Health care/services, Non-participants in health care programs, Participants in health care programs, Demographic leatures of population.
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213. Disability
Insurance. Program
Issues and Research.
one of the many other chronic diseases of later life. It can be demonstrated that the 61 percent rise in loss ratios on noncancel-
Mordechai E. Lando and Aaron Krute. 1976, 15 pp. Availability: Social Security Bulletin v39 n l0 p3-17 Oct 76.
This article outlines the dimensions of work disability in the United States and summarizes the characteristics of the 15.6 million adults aged 20 to 64 in the civilian noninstitutionalized .population in 1972 who have some limitation in the amount or kind of work they can do. Such a study is necessitated by the unexpected growth of the disability insurance program, with benefit payments in 1975 more than 4.5 times higher than they were in 1966. The number of persons receiving benefits rose from 1.9 million to 4.4 million in the same period. Attention has thus been focused on the administration and operation of the program. Analyses reveal that the program growth has manifested itself by increases in the number and rate of disability applications, a rise in the number of persons requesting reconsideration and hearings, and a decline in the number and proportion of benefits being terminated as a result of recovery, return to work, or rehabilitation. Among the major causes underlying this program growth are changes in economic conditions; awareness of and attitudes toward the program; changes in program pro,Asions, including the broader definitions of disability and higher benefit levels; changes in program administration, particularly the application of the criteria for determining the existence of disability; and changes in the incidence of disability. Tabular material is provided. (Author abstract modified)
Descriptor(s): National economic conditions, sation, Trends in health status.
214. Disability
Workers compen-
Descriptor(s): Trends in health status, Impact of third-party coverage, Publicly sponsored/mandated health plans, Policy initiatives, Comparisons regarding foreign health policies, Private health care plans.
Insurance. Trends Since World War II.
John H. Miller. 1980, 7 pp. Availability: Benefits International 80.
215. Disability Policies and Government Programs. v9 n l0 p2,3,5,6,8-10
Apr
Insurance and government experience statistics reveal that even though there have been dramatic advances in medical science and practice in the 35 years since World War II, significantly reducing mortality rates and lengthening life expectancies, evidence of any reduction in the frequency or severity of disability is lacking. To some extent this may result from the fact that often a life spared from early death by tuberculosis, diphtheria, or other infectious disease, or extended by insulin or heart surgery, gains many years of life only to succumb to cancer, arthritis, or
1-98
lable disability policies from 1968 to 1976 was almost entirely the result of longer claim durations rather than increasing claim frequencies. The possible reasons for this trend are investigated by looking at private disability insurance data, social security disability benefits, and similar types of coverage in Canada, Great Britain, and the Netherlands. It is suggested that primacy should be placed not on dealing with disability, but on avoiding it in the first place. The further conquest of disability must largely depend upon a resurgence of the concept of personal responsibility. Furthermore, those individuals who have suffered an injury or a serious illness should not be labeled permanently disabled, but categorized according to degree of potential recovcry, as are those who are convalescing from a curable condition and those who may require rehabilitation treatment and training before again being able to pursue a gainful occupation. Disability insurance has been and is a system which implies the entitlement of a disabled person to statutory or contractual benefits. Legal entitlement to compensation should be replaced with a new concept in which all parties involved would be motivated to seek the same goal, that is, the earliest possible termination of the physical or mental disability, or, when that appears not to be possible, the vigorous conduct of a rehabilitation strategy, if there is any significant probability of success. The removal of disincentives to the resumption of work and their replacement by incentives toward rehabilitation should overcome most of the faults in the present system. Nevertheless, an effective administration and surveillance of claims will still be essential to an efficient and equitable program.
Edward D. Berkowitz. Rutgers Univ. Bureau of Economic Research, New Brunswick, NJ 08903 Department of Housing and Urban Development, Washington, DC. Office of the Assistant Secretary for Planning and Evaluation. 1979, 185 pp. Availability: Praeger Publishers,
New York, NY 10017.
A collection of essays describes the state-of-the-art in disability policy and develops suggestions for changes in public programs.
Health Care Programs
Formulating disability policy has proved difficult over the years because of the complexities of determining eligibility and of administering such programs as permanent disability insurance and workers' compensation. However, an effective disability policy is of great importance because it would facilitate integration of the and Government's income support services as public assistance social security, so that benefits wouldsuch be allocated in a cost effective manner. The collection has a multidiseiplinary focus. The economists proceed from the assumptions that soeiety's resources andofthat rising costs of entire disability system as wellareas limited the lack incentives to reduce costs of individual
programs
require analysis. These principles
are illus-
trated in a study of the costs associated with disability-related income maintenance programs and in a study of a costly Dutch program to provide employment for the severely handicapped. An historical analysis of U.S. disability policy, including origins of disability insurance, workers' compensation, vocational rehabilitation, and Supplemental Security Income (SSI) demonstrates that old programs die hard and that public policy often runs counter to the intentions of the policymakers because incentives are not built into the system. A sociological study on the attitudes of various individuals toward disabilities concludes that more exact measurements of disability are needed. In an epidemiological study, childhood disability is shown to be illdefined and the service system for childhood disability underdeveloped. Finally, two interdisciplinary studiesthe examine specific issues. One questions the need to modify difinition of disability contained in disability insurance and SSI programs if necessary adjustments such as eliminating lump-sum settlements are not made. All authors agree that programs must avoid duplication of benefits and must come to terms with disability measurement, and that incentives for program efficiency must be developed without jeopardizing access of certain groups to benefits. Tables and extensive references are supplied. (Author abstract modified) Praeger Special Scientific
Stu_'es.
field, VA 22161, HRP-0029964.
This paper focuses on differential pricing and discountinp.; in the hospital field. Differentisl pricing is the practice of accepting different rates of payment from different classes of customers or for different types of services, and discounting is any deduction from nominal value. Differential payments occur because hospitals enter into contractual reimbursement arrangements that result in lower charges from certain payers (Blue Cross, medicare, and medicaid) while other persons pay full charges (patients and commercial indemnity insurers). Certain factors to assess, in determining payment differentials have been suggested by the Blue Cross Association, including community service activities of purchasers, health care education and support of health ageneies, business practices of purchasers, hospital assistance, and programs to reduce hospital utilization and costs. Propc,sals of Blue Cross for assessing payment differentials are reclassified into four groups: working capital requirements, quantity considerations, risk, and decisions made by insurers for the advancement or enhancement of the company (hospital). Cost containment measures in the hospital field include prospective rate determination, tighter Blue Cross review, State regulation of third-party payers, limits on charge increases, allowable and reimbursable cost limits, restricted cost-finding methods, lower costs or charges applied to smaller production units, restricted but extended measures of reasonableness, and prudent buyer concepts. Discounts applicable to the purchase of hospital services encompass cash discounts, allowances, and rebates. Discounts in the commerce sector and public utility pricing are discussed, and additional information on these topics is appended. A reference list of 25 items is supplied. (NTIS abstract) Descriptor(s): Service benefit plans, Medicare, Medicaid, Methods of payment determination, Commercial health insurance plans, Competition/interaction among third-party payors, Hospital services, Impact of third-party coverage.
Descliptor(s): Cost/benefit analyses, Demand/utilization of health care programs, Policy initiatives, Comparisons of health care programs, Eligibility requirements, Trends in health status,
Workers compensation,
217. Disenroliment From a Prepaid Group Practice. An Actuari_ and Demographic Description. Loyd J. Wollstadt, Sam Shapiro and Thomas W. Bice.
216. Discounting and Differential Pricing Practices in the Health Care Field.
National Center for Health Services Research, Hyattsville, MD. National Inst. of Health, Rockville, MD.
Fredric L. Sattler. Social Security Administration Die. of Health Insurance Studies, Washington, DC 20203 Dec 1976, 54 pp. A vailability.. National Technical Information Service, Spring-
1978, 9 pp. Avnilability:
Inquiry el5 n2 p142-150 Jun 78.
Longitudinal data are used to describe the characteristics of persons disenroiling from an irmer-eity prepaid group practice,
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the East Baltimore Medical Plan. The study period was the first 23 months of plan operation. Enrollment data, including an individual identification number, month of enrollment, and the most recent month of enrollment, were collected. Rates of voluntary and mandatory disenrollment were developed through use of actuarial analysis. Mandatory disenrollment occurred with the loss of State funding for the prepaid group, even though individuals could (and usually did) continue as patients at the same plan. Voluntary disenrollment consistently reflected a change in views of patients, while mandatory disenroUment reflected State determination of a family's financial status. Results showed that women over 65, all adult men, and families with the youngest child in school all had higher mandatory disenrollment. These groups could have had higher incomes from social security payments or employment of family members which placed the household above the medicaid income ceilings, Voluntary disenrollment was highest among initial plan subscribers. Among the age/sex groups, younger women were most likely to voluntarily disenroll. Data are not available to indicate whether these young women were overrepresented among initial enrollees. Families with adults and children tended to disenroil voluntarily more often than those with only adults or children who subscribed, even when the date of enrollment was consid-
ly funded health center, or health maintenance organization were included in the cost forrnula for reimbursement under part A of title XVIII (medicare). Under part B, reimbursement for services delivered outside institutional settings, such as private practice, has been limited to services provided by an NP or PA under the immediate supervision of a physician (on the premises) and only for those services normally delegated by a physician. Current medicaid reimbursement practices for NP and PA services pose two major problems: (1) changes made in State laws are not recognized in reimbursement practices in the States, and (2) many States have not clearly addressed questions of supervision, training, definitions of NP and PA roles, reimbursable services, or appropriate levels of reimbursement. The article coneludes that State policies regulating the employment of nurse practitioners and physician assistants are greater determinants of their use than are reimbursement policies at present. Further research on consumer acceptance of NP's and PA's is recommended to indicate whether the low number of patients seen by NP's and PA's in remote practice sites reflects the needs of the population or whether most of those in need continue to travel further for services. Four tables and five references are included.
ered. When only part of the total family enrolled, perhaps a more detailed consideration of the relative costs and benefits of joining the prepaid group may have been made by the subscriber. References, nine tables, and 22 notes are provided.
Descriptor(s): Allied health professionals, Present legislation/ regulations, Supply/availability of services, Publicly sponsored/ mandated health plans.
Descriptor(s): Prepaid plans, Participants in health care programs, Participation in health care programs.
219. Doctors and Their Autonomy. Past Events and Future Prospects.
Carleton B. Chapman. 218. Distribution of Nurse Practitioners and Physician Assistants. Implications of Legal Constraints and Reimburse. ment.
1978, 6 pp. Availability: Science v200 n4344 p851-856 26 May 78. This article suggests that since the Middle Ages, the medical
Jerry L. Weston. 1980, 6 pp. Availabilit)': Public Health Reports v95 n3 p253-258 May/ Jun 80.
This paper presents data on the distribution of nurse practitioners (NP's) and physician assistants (PA's) in 1976 and 1977 and explores the legal constraints affecting their distribution and the potential impact of changes in reimbursement for their services, The paper also summarizes a study that found that legal recognition of NP's had not been addressed in many States; most States, except for Mississippi, Missouri, and New Jersey, had moved toward recognizing PA's. The study also found that the salaries of NP's and PA's employed by a hospital, nursing home, federal-
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profession has been gradually required to surrender its autonomy but that an integrated system of peer review need not represent the final stage in the destruction of this autonomy. The article traces the profession's surrender of its autonomy from the evolution of the common law of malpractice to the 20th century legal limitation of the right of the medical profession to control the means by which doctors are paid. The American medical profession is viewed as facing, not further loss of professional autonomy, but routine, judicious peer judgment based on properly defined standards of professional performance. The article reviews several factors that helped accelerate this trend: the passage of medicare and medicaid laws, the rise of the so-called malpractice crisis, and the passage of the 1972 Professional Standards Review Organization (PSRO) law. The article also distinguishes between the two basic ingredients in the peer re-
Health
Care Programs
view process -- the creation of standards and the monitoring process -- and suggests that national mechanisms for the setting
National
of standards are already in place. It states that an integrated system of peer review is needed to reduce the incidence of cornpensable medical injury, identify and control inadequate or unnecessary medical services, and identify members of the profession who are not rendering acceptable care. Thirty-four references are included.
Descriptor(s): Physicians, lyses, Supply/availability health care programs.
This article is a reffsed version of the ooecond Walter B. McDaniel Memorial Philadelphia
Descriptor(s):
Lecture, delivered at The College of Physicians of on January 4, 1978.
Physicians, Present legislation/regulations.
220. Doctors and Their Workshops. Economic Models of Physician Behavior. Mark V. Pauly. 1980, 132 pp. Availability: University
of Chicago Press, Chicago, IL 60637.
Bureau of Economic
Research
Monograph.
Policy initiatives, Cost/benefit anaof services, Demand/utilization of
221. Doctors, Damages and Deterrence. An Economk: View of Medical Malpractice. William B. Schwartz and Neil K. Komesar. Rand Corp., Santa Monica, CA 90406 RAND/R-2340-NIH/RC Robert Wood Johnson Foundation, Princeton, NJ. National Inst. of Health, Bethesda, MD. Jun 1978, 23 pp. Availability: Rand Corp., Santa Monica, CA 90406. Damages awarded in a malpractice suit must be viewed not only as compensating the victim but also as deterring health care providers from negligent behavior. Economic analysis of the malpractice system indicates that awards can send a signal to providers that informs them how much to invest in avoiding
This book investigates the effect of physician input on hospital productivity and shows how doctors, as providers of some elements of medical care, may affect the productivity of other providers. The book also explores the ways in which physicians can affect the demand for their own and other services by altering the advice they give patients. Individual chapters analyze the effects of physicians on the use of medical inputs other than their own input or those they investigate distortions in the prices physicians -- as agents -- face for hospital inputs that arise from either customary forms of hospitalization insurance or from imperfect cooperation of physicians within the hospital. The results of an empirical estimation of a hospital production function for a set of U.S. hospitals are presented, and a model is developed in which the consumer's demand for medical care is based on the content of the advice. The book also examines the availability effect or the assumed relationship between the supply of physicians in a hospital and the use of their own and other medical services. The study found that availability effects were neither
mishaps. The malpractice system is beset by difficulties, but not the ones commonly incriminated. The signal to the physician, as determined by the number of claims and the size of awards ("expected damages"), appears to be insufficient for ideal deterrence. Moreover, the deterrence signal is attenuated because malpractice premiums are set for groups of physicians, not for individuals according to their record of previous malpractice incidents. Replacing the present tort system with a no-fault insurance scheme would not necessarily be cheaper and might well abolish the deterrent signal or distort clinical decisionmaking. Figures, footnotes, and 34 references are provided. (Author abstract modified)
uniform nor pervasive and that availability effects for physician visits are found mainly among the poorly educated in large doctor-rich cities. The analysis suggests that, once a patient is hospitalized, there will be some overuse of hospital inputs relatire to physician inputs. It is therefore concluded that the given stock of physicians could be used more efficiently if physicians spent more time at hospitals, and hospitals eliminated some personnel and nonlabor inputs. Tabular data are given, and an appendix provides three statistical tables. Notes are provided for each chapter,
222. Does America Spend Too Much on Health Care.
Descriptor(s): Economic/commercial influences, Outcome/ evaluation of quality assurance, Providers of health care services.
Ralph L. Andreano. 1979, 7 pp. AvMlabib'ty: Bulletin of the New York Academy v56 nl p19-25 Jan/Feb 80.
of Medicine
The question of whether too large a portion of the American gross national product (GNP) is spent on health cm:e is dis-
1-101
cussed. In the 1970's, the United States spent 9 percent of its GNP on health care. An average of 6 percent was spent by the 24 leading, noncommunist, industrialized developed countries, although the level of several other Western countries almost equalled that of the United States. In Western industrialized countries the growth rate for health exceeds that for almost anything else including national defense, other social welfare programs, and education. Policymakers in the United States and abroad feel that health care costs too much and that the health care system is hobbled by inefficiencies and by an excessively liberal financing mechanism. The 1970's have produced a panopiy of Government regulation and planning in the presumed belief that the rate of growth in health care costs would not be selfcorrecting and that interference with health markets was required. However, one must consider that America has a very large national product. As the per capita national product grows, rich nations tend to spend a higher proportion of those gains on medical care. Indeed, in the language of economists, medical care may be considered a luxury good. From this standpoint, rising shares of national product lavished on medical care may represent public desire for caring as well as curing. Clearly, the health care costs are as much due to the wealth of the American economy as they are to structural inefficiencies in the production and distribution of health care services. Moreover, in the next decade, pressures to slow the rate of growth in personal health expenditures will be great, but no major change in national priorities can be expected to reduce the level of national product devoted to health. National health insurance may well improve equity, but it will not improve production efficiency. With modest real growth, high inflation rates, and stagnant productivity anticipated for the 1980's, it is hard to imagine that less could be spent on health. Seven notes are supplied,
This article was presented as part of the 1979 Annual Health Conference of the New York Academy of Medicine held May 10 and 1L 1979.
This article reviews both current and future trends in national health care policies. The most likely results of both the Comprehensive Health Insurance Plan (CHIP) and the Kennedy-Mills proposal would be a vast inflation of health care costs without a corresponding increase in services. Both plans provide health insurance for virtually everyone and cover almost everything but prolonged mental illness and nursing home care. Both seek to hold down costs by giving individuals a financial incentive to limit use, but neither provides incentives for the medical community to contain costs, other than the heretofore ineffectual importuning to keep costs down. The basic difference between the two plans is that the cost of Kennedy-Mills shows up in the Federal budget, while most of CHIP's costs are diffused throughout the private sector. In the future, the Nation will probably move toward three generic types of health care policies: a mixed public and private system such as presently exists (mixed), total coverage through national health service (total), and income-graded catastrophic health insurance (income.) The mixed system does not impose sufficient discipline on either the individual or the government to face the full costs of health care, although choice is preserved. The income approach is readily reversible and means less bureaucracy and greater choice. However, the total approach could be infused with choice. A single national health service (NHS) could provide three to six competitive, alternative programs. There could be HMO's, foundations under which individual doctors contract with a central service, and other variants. Competition would exist because patients would have a choice of plans. The total sum to be spent each year would be fixed at the Federal level, and each service would be paid its proportionate share according to the number and type of patients it had enrolled. Thus, the worst features of a bureaucratic system would be mitigated and its strengths would be maintained. Fourteen references are provided.
Descriptor(s): Cost containment efforts, Third-party payors, Funding/fmancing of health care programs, Policy/changes re health care, Policy initiatives, Competition/interaction among third-party payors.
Descriptor(s): Demand/utilization of health care programs, Cost containment efforts, National economic conditions, Health care cost trends/projections. 224. Dollars and Sense of Hospital Malpractice
Insurance.
Michael Sumner. 1979, 100 pp.
223. Doing Better and Feeling Worse. The Political Pathology of Health Policy.
Availability:
Aaron Wildavsky. 1977, 19 pp. Availability: Daedalus v106 nl p105-123 Winter 1977.
The radical increase in hospital malpractice insurance premiums is analyzed, and alternative insurance arrangements are assessed. Analysis suggests that the malpractice problem derives from the increase in claims and litigation precipitated by technological
1-102
Abt Books, Cambridge, MA 02138.
Health Care Programs
change, fragmentation of care, decline of trust in physicianpatient relationships, and increasing ease of bringing a successful action. The criteria used to assess alternative insurance arrangements are availability, reasonable cost, the absence of unacceptable social effects, and an effective loss prevention program. An insurance mechanism should also maintain accurate data to promote general acceptance and ease of implementation and be adaptable to changes in the legal system. Studies show that carriers have not made a profit on malpractice insurance, which suggests that investment income is not accruing to the carriers as excessive profits. Investment income alone, therefore, cannot solve the malpractice cost problem. If losses could be forecasted more accurately, then premiums could be set to generate profits, One approach for doing this is the claims-made policy, which covers only claims reported during the policy period, in contrast to the traditional occurrence policy which buys coverage for all malpractice incidents that occur during the policy period. Other malpractice insurance arrangements are for hospitals to captively insure or self-insure. In a captive arrangement, the hospitals own their insurance carrier. Under self-insurance, hospitals independently or jointly insure themselves but do not form an insurance company. Self-insurance carries with it the expectation that losses will occur and be absorbed up to a predetermined limit. A hospital's involvement in its own coverage for malpractice provides an incentive for improving services and reducing the likelihood of malpractice claims. Discussions of actuarial methods and their limitations and methods of determining the appropriate size of the capital fund are appended. Notes and tabular data are provided.
Descriptor(s): Economics of third-party payors, Facilities providing health care, Cost containment efforts, Economic/commercial influences, Health care cost trends/projections, Premium determination/underwriting.
plains such concepts as "rational prescribing," "formularics," and "generic drug products." Next, the characteristics of 16 selected drug insurance or third-party programs in the United States (some private and some governmental) are analyzed to illustrate how policy decisions have influenced the design of programs now in operation. The features of nine programs in foreign countries are briefly surveyed. Another section analyzes drug coverage features in selected bills introduced recently in Congress. No effort was made to include all proposed health insurance legislation. Special attention is focused on cow.-rage of out-of -hospital drugs, since in-hospital drugs are frequently covered now by medicare, medicaid, and private health insarance. The final section deals with major policy decisions that must be faced. For each decision area, the major advantages and disadvantages of various possible options are listed with regard to clinical factors, quality of care, program costs, and the acceptability to consumer groups, physicians, pharmacists, and representatives of the drug industry. The major decision areas include the selection of beneficiaries, selection of covered drug products, cost sharing by patients, reimbursement for acquisition or product cost to pharmacists, reimbursement of dispensing costs, and alternative reimbursement approaches. A detailed analysis of option advantages and disadvantages and 98 bibliographical references are appended. NCHSR
Research
Report Series.
Descriptor(s): National health insurance (NHI), Pharmaceutical services, Plan design/program provisions (under health plans), Private health care plans, Comparisons regarding foreign health policies, Policy initiatives.
226. Drug Prescription Rates Before and After Enrollment of a Medicaid Population in an HMO. 225. Drug Coverage Under National Policy Options.
Health Insurance. The
Milton Silverman, Mia Lydecker and William Diamant. National Center for Health Services Research, Hyattsville, MD 20782 Jul 1977, 147 pp. Availability: Department of Health, Education, and Welfare, National Center for Health Services Research, Hyattsville, MD 20782.
The monograph addresses key problems in the development and implementation of a National Drug Insurance Program. The introductory section presents background information and ex-
1977, 8 pp. AvMlabih'ty: 78.
Public Health Reports v93 nl p16-23 Jan/Feb
The use of health services and drug prescriptions by a medicaid population was evaluated before enrollment in an health maintenance organization 0bIMO) and for 22 months following participation initiation. The study population included 1,000 beneficiaries of Medicaid in the District of Columbia who were voluntarily enrolled in a prepaid group practice in 1971. With respect to medicine use, the evaluation reviewed prescription and physician visit rates, prescriptions by specific drug amt therapeutic category, costs of prescription drugs per capita, _md prescribing quality as compared with that for the 160,000 medicaid
l-loJ
beneficiaries who were the control group. Findings indicate that the enrollees' rates of medicine use and drug costs decreased after enrollment in comparison to their former use and to the nonenrolled medicaid controls, The decrease was greatest among the medically indigent and among women aged 20 to 34 years, A decrease in the average number of prescriptions per visit occuffed as well as a decrease in the average number of physician visits. The decrease in annual prescription rates is associated with a decrease in annual physician visit rates. The study group received a somewhat narrower spectrum of drugs than the controis, but therapeutic categories of the drugs varied little between groups and from national patterns of prescribing. There were only small differences between the groups in the proportions of drugs prescribed generically and irrationally; i.e., not recommended for the purpose for which they were prescribed. Results suggest that strategies to reduce ambulatory patients' visits to physicians are likely to reduce medicine use. Enrolling a medicald group in a prepaid group practice appears to be beneficial
settings and were particularly rapid for registered and practical nurses. Regional differentials in hospital wages are highly correlated with wage differentials for all nonfarm workers, but during the 1960's, the wage gains in hospitals in the East outpaced those in the rest of the Nation. Ten tables, an appendix containing 4 additional tables, 13 notes, and 11 references are given. (Author abstract modified)
in terms of reducing prescribing and other service rates with no apparent diminution in prescribing quality or patient satisfaction with care. Three tables and 15 references are provided. (Author
Harry E. Emlet. Analytic Services, Inc., Falls Church, VA 22041 American Public Health Association, Washington,
abstract modified)
Operations Research Society of America, Oct 1976, 41 pp.
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Medicaid, Pharmaceutical services,
A vMlability: National Technical Information Service, Springfield, VA 22161, HRP-0018874.
Descriptor(s): conditions.
Alfied health professionals,
228. Economic Analysis of Alternative
National economic
Health Care Innova-
tions.
DC.
Baltimore, MD.
Techniques of economic analysis suitable for assessing the cost effectiveness of health care innovations are discussed. Innovation 227. Earnings of Allied Health Personnel. Are Health Workers Underpaid. Victor R. Fuchs. National Bureau of Economic Research Inc., Cambridge, MA 02138 National Center for Health Services Research, Hyattsville, MD. 1976, 25 pp. A vailabilit):" National Bureau of Economic Research v3 n3 p408-432 Summer 76.
Earnings and changes in earnings of allied health personnel (de-. fined as wage and salary workers with less than 18 years of schooling) are measured on the bases of the 1/100 public use samples of the 1960 and 1970 censuses of population. Comparisons with all nonfarm workers standardized for color, sex, age, and schooling reveal that earnings in health were 95 percent of the all-industry norm in 1969, up sharply from 86 percent in 1959. For females, who account for 80 percent of the labor hours of allied health workers, 1969 wages were equal to those in other industries. The increases in relative wages for health workers in the 1960's were much greater in hospitals than in other health
1-104
contribution is measured according to change in health, the way in which the innovation leads to change, the degree of change, and the expected degree of change considering uncertainties inherent in the process leading to the intended change. Anticipated benefits and research costs, as well as total costs, cost benefits, and the probability of success must all be taken into account. Cost effectiveness is applied on four levels: development of a cost-benefit model without formal consideration of parameter relations or result sensitivity, assignment of trial values to the model to see effects of variation, determination of value range for each parameter's true value, and establishment of point values for each parameter. Analysis requires program objective detrmition, alternative identification, measure selection, model formulation, data acquisition, assumption determination, investigation of results' variation sensitivity, and result interpretation. Seven references, and several tables and diagrams are supplied. (NTIS abstract modified)
Presented at the American Public Health Association's Annum Meeting, Miami, FL, October 19, 1976.
Descriptor(s): pacts.
Cost/benefit
analyses,
Medical technology
104th
im-
Health Care Programs
229. Economic Class and Risk Avoidance. Experience under Public Medical Care Insurance.
230. Economic Cost of Illness Revisited.
Barbara S. Cooper and Dorothy P. Rice. R. G. Beck and J. M. Home.
Social Security Administration
Canada Dept. of National Health and Welfare, Ottawa (Ontario). 1975, 14 pp. Availability: Jnl. of Risk and Insurance v43 nl p73-86 Mar
tics, Washington, DC 20203 1975, 16 pp. Availability: Social Security Bulletin v39 n2 921-36 Feb 76.
76.
This paper updates a study completed in 1966 which detailed the methodology for estimating the cost of illness for the major
This paper presents data on the relationship between economic class and risk avoidance under universal public medical care insurance in Saskatchewan, Canada. Both cross section and time series data are analyzed to determine the stability distributions with respect to form, central tendency, and variability. The method of analysis is cross-tabulation of previously unavailable data. Benefit distributions for five income classes are shown to have the common characteristic of asymmetry, with a heavy concentration of families in the zero and low benefit categories, The location of the distributions, however, varies directly with income; the lower the income class, the lower the fair premium implicit in the program. As for relative variability of medical experiences, the program appears to favor the lower income classes. Analysis shows that mean dollar benefits are directly related to family income, while the relative variability of benefits is inversely related to family income. In addition, modest deductibles would have the effect of shifting a substantial proportion of program costs to beneficiaries. However, it should be emphasized that these relationships are elicited through a bivariate analysis. This leaves open the possibility that the observed income effects may be attributable to the influence of mediating variables related to the structure and composition of the family, The overall configuration of the distributions has policy relevance in that it does not support the proposition that a program of "free" medical care leads inevitably to wanton overconsumption of services. Moreover, it follows that introduction of traditional cost control devices, such as deductibles, would shift a sizable proportion of program costs to households and perhaps reduce care consumption below socially acceptable levels. Tables, footnotes, and a bibliography of 11 references are provided, (Author abstract modified)
Paper presented at the 1974 Annum Risk and Insurance Association.
Office of Research and Statis-
Meeting
diagnostic categories. It presents recentand findings based on current treatment modes, disease more incidence, earning distributions as well as a demonstration of the methodology application of its principles in calculating costs for specific diseases. The economic cost of illness is measured in terms of the direct outlays for prevention, detection, and treatment and the indirect costs or loss in output due to disability (morbidity) and premature death (mortality). These are costs to society rather than to the sick individuals or their families. Only the indirect costs resulting from lost earnings, however, represent losses to the gross national product. Because no one has successfully quantified the cost of pain and suffering, that category is not factored into cost computations. The direct cost of illness represents expenditures for prevention, detection, treatment, rehabilitation, research, training, and capital investment in medical facilities. Of the $75 billion allocated for direct costs, diseases of the digestive system represented the largest share at 14.8 percent. Diseases of the circulatory system were the next costly, followed by mental disorders. The largest item of expenditure is for hospital care, representing 45 percent of all allocated outlays. Physicians' services represent the second largest direct cost. Morbidity losses are incurred when illness results in absence from employment, prevents a housewife from performing her duties, or results in disability that prevents individuals from working. Calculation of morbidity costs involves applying the average earning,.; by age and sex to work-loss years, attaching a dollar value to housewives' services, and applying labor force participation rates and earnings by sex and age to persons in and out of institutions who are too sick to be employed or to keep house. In 1972, employed men and women lost 1.7 million years of work because of ill health. With regard to mortality costs, losses amounted to $57 billion; the greatest losses were caused by circulatory d:isorders. Eleven tables and 29 footnotes are included.
of the American
Descriptor(s): National health insurance (NI-II), Comparisons regarding foreign health policies, Cost/benefit analyses, Demand/utilization of health care programs, Participants in health care programs, Deductible/coinsurance.
Adapted from a paper presented at the Annual American Public Health Association meetings in Ctn'cago, IL, November 20, 1975.
Descriptor(s): Trends in health status, Health care costs, Economic/commercial influences.
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231. Economic Foundations of National Health Polic_
1977, 13 pp. Availability: Preventive Medicine v6 n2 p252-264 Jun 77.
Allan S. Detsky. Harvard-MIT Div. of Health Sciences and Technology, Cambridge, MA. Canada Council, Ottawa (Ontario). 1978, 265 pp. Availability: Ballinger Publishing Company, 02138.
Cambridge,
MA
This book examine the foundations of the traditional microeconomic theories of health care in welfare economics. Within the context of standard economic theory, the author analyzes various economic models for public health policy and the ways in which the medical sector violates and extends the parameters of these theories. The purIx_e of the work is to provide a sense of the foundations of health policy proposals in economic analysis, The intended audience includes economists, students of economics and medicine, physicians, policymakers, and other health professionals. The text focuses on three specific policy areas: hospital as an economic institution, redistribution of physician manpower, and the relationship between national health insurance plans and health expenditure containment. It contains an exposition of a theoretical framework, a critical review of the literature, some of the author's own analysis, and policy suggestions in the areas examined. The book notes four kinds of proposals for achieving cost control: cost sharing for consumers, overall supply restrictions of services (e.g., doctors, hospital beds, capital expenditures), regulation of medical technology, and changing the incentive structure facing suppliers. The cost sharing approach of the catastrophic or major risk insurance plans will not be effective in containing costs and expenditures. More direct government intervention will be necessary, and the acceleration of the share of the gross national product devoted to medical services will continue despite the existence of public or private insurance. It is important to collect the kind of information that will be necessary to implement all but the most blunt forms of regulation. Experimentation with peer review, prepaid plans, evaluation methodology, reimbursement for economic disloca-
This article compares cost-effective and cost-benefit calculations of disease prevention and applies these calculations to five health care problems. Cost-benefit calculations, involving measuring reductions in medical expenses and increase in income through disease reduction, and increased output through increased lifespan, are problematical. However, cost-effectiveness, which compares the costs of different programs to achieve a given end, or the outputs of different programs with the same goal, is much easier. Both cost-benefit and cost-effective calculations are presented for six health problems. Cost-benefit calculations for hypertension show that a major national effort to discover and treat this disease would save $4 billion to $6 billion annually. For cancer of the colon, an expenditure of $280 million yearly to change dietary habits would save $280 million in direct and $950 million in indirect costs. Heavy cigarette smoking costs the nation about $20.75 billion in absenteeism, hospitalization, and other problems yearly; art expenditure of $2.75 billion would result in an annual savings of $5.1 billion in a few years. For alcohol abuse, spending $6 billion annually to assist 4.8 million working problem drinkers would save $20.2 billion. For breast cancer, safer screening techniques are needed, since mammography, the most common, is cost-beneficial only for women over 55 and can be dangerous. The economic evidence thus strongly argues that certain types cff primary and secondary prevention would be highly profitable and that in certain areas there should be more spending for prevention and less for acute care. Yet American lifestyles and medical institutions will have to be reoriented for effective prevention to take place. Tables, footnotes, and 60 references are supplied.
Descriptor(s): Preventive services, Cost/benefit in health status.
tions, and meaningful cost data must take place prior to some of these regulatory mechanisms. An index, illustrations, references, and tables are included. (Author abstract modified)
233. Economic Health Plans.
Descriptor(s): Economic/commercial influences, facilities, Physicians, Health care costs, Policy/changes care, Supply/availability of services.
J. Athole Lennie. 1976, 5 pp. A vailability: Health Care ldanagement Summer 1976.
232. Economic
Issues in Prevention,
Marvin M. Kristein. National Cancer Inst., Bethesda,
I-lOO
MD.
Inpatient re health
analyses, Trends
Viability o:fCommunity-Operated
Prepaid
Review v l n3 p53-57
The economic viability of the Government's Family Health Center Program (FHC) is examined through evaluation of data refleeting activities of the 30 existing FHC's. The goal of the FHC is to develop community-based and operated prepaid plans in health scarcity areas. By 1975, 30 such centers were in operation.
Health Care Programs
The target population was economically marginal citizens; FHC grants provided funds to pay a substantial portion of the monthly costs. Three types of patients were enrolled: people with a thirdparty payor, people with a prepaid contract, and a self-paying population. Data based on uniform Federal reporting definitions were collected on all 30 FHC's in early 1975. Five criteria were employed to measure viability. These criteria focused on total earned revenues pins subsidy equal total expenses for operating and developmental activities; total enrollment level vis-a-vis breakeven; appropriate mix of enrollment (i.e., 20 to 75 percent for public beneficiary groups or 25 percent to 80 percent for employed and self-pay enrollees); administrative costs at 25 percent of the total costs; and the proportion of earned revenue to total expense (65 percent earned, 35 percent subsidy) by the fifth year of operation). Analysis revealed that FHC's with different production functions had differing levels of economic viability, Poorly performing FHC's were characterized by delivering their own care, having a high dependence on subsidy funds, having high levels of administrative costs, and having low enrollments, It is concluded that the best strategy to ensure survival is for the new organizations to perform only the insurance company func-
governments working together with the professions and the communities. The Community Support Program of the National Institute of Mental Health represents a major step in the effort to achieve an effective and humane transition from institutionbased systems to community-based systems of care. This transition is essential despite lack of complete data regarding economic considerations. Furthermore, consideration should be given to how the proposed national health insurance can be made relevant to the needs of the chronic mental patient. For example, one model proposed by the National Conference on Social Welfare (1975) included a comprehensive insurance system that would cover (1) diagnostic and treatment services, (2) specialized and extended health services such as skilled nursing and home health care, and (3) supportive services such as meals on wheels and transportation. National health insurance would cover the first two categories. Costs of the supportive services in the third category would be carried by compatible financing arrangements outside the health insurance system, including the patient's own resources and public and private programs. Eight tables and 29 references are included in the article. (Author abstract modified)
tions. As enrollment increases, some services which can be provided more inexpensively within the organization than by contractors can be offered. Four tables and four references are included in the article.
Descriptor(s):
Descriptor(s): Prepaid plans, Plan design/program provisions (under health plans), Evaluations/outcome of health care programs.
Cost/benefit
analyses, Policy initiatives, Mental
health services, Funding/financing
of health care programs.
235. Economics in Health Care.
Lewis E. Weeks and Howard J. Berman. 1977, 416 pp. Availability: Aspen Systems Corp., RockviUe, MD 20850. 234. Economics
and the Chronic Mental Patient. The papers collected here represent a comprehensive selection of
Steven S. Sharfstein and Harry W. Clark.
Economic considerations involved in developing and delivering services and care to the chronic mental patient are discussed in this article. In 1974 the direct and indirect costs of mental illness
major health economics writings published between 1966 and 1977. Some of these articles are already required reading in graduate programs for health services administration, and some are being used as permanent references for practitioners, health planners, policymakers, and legislators. The collection is arranged in six major divisions: introduction, framework of analysis, demand and supply analysis, pricing and efficiency, national health insurance and alternate modes of delivery, and
totaled $36.78 billion; approximately $32 billion of this amount represented the costs of long-term mental illness. However, it is difficult to quantify the costs of chronic mental illness because of problems in defining the population in question and compiling data from varied cost centers. Given a political environment that is concerned with expenditures, cost-benefit and cost-effectiveness methods of resource allocation must be applied to the area of chronic mental illness to justify existing or innovative programs. Funding policies must be articulated and then implemented through the combined efforts of Federal, State, and local
applications. An overview of health care economics is followed by discussions of health and public policy, an economist's view of health, the concept of a political economy of medical care, and a survey of economic models of hospitals. Also discussed are empirical research on health care demand, medical manpower models, a comparison of hospital utilization and costs by types of coverage, multiple health insurance coverage and hospital utilization, and income and the use of outpatient care by the insured. A variety of efficiency incentives, such as incremental pricing, hospital reimbursement, and consumer response to al-
1978, 16 pp. Availability: Schizophrenia
Bulletin v4 n3 p399-414 1978.
1-107
ternative health insurance programs, are considered. Additional papers assess the economic effects of various health insurance designs and the issue of poverty and health. Finally, cost-benefit and cost-effectiveness analyses in specific health programs are examined. Individual articles contain tabular material and reference notes. Graphs, footnotes, and charts are also supplied, Descriptor(s):
Demand/utilization
of health
care programs,
Outcome/evaluation of health administration, Plan design/program provisions (under health plans), Health care cost trends/ projections, Economics of third-party payors, Cost/benefit analyses, Policy/changes re health care, Supply/availability of services, National economic conditions.
236. Economics of Cost Containment. Institute for Health Planning, Madison, WI 53705 Health Resources Administration, Hyattsville, MD. Apr 1980, 9 pp. Availability: Institute for Health Planning, Madison, WI 53705.
Although health care costs in the United States are rising too fast, there has been reluctance to apply governmental controls, The medical care industry has sponsored voluntary efforts, or what amounts to self-regulation, and its sponsors, the American Medical Association, the American Hospital Association, and the Federation of Ameriean Hospitals, claim success. The Federal Government, reluctant to apply external controls, has mandated that area and State health planning agencies not only plan community health services but also pursue cost containing practices, although these agencies have few tools for accomplishing cost containment goals. Congress has assigned the health planning agencies responsibilities both for regulation of the system and for promoting competition. The growth of health insurance and government programs has buffered the consumer from medical expenses. However, the medical care economic system fails to meet four characteristics of a market economy -- consumer responsibility for costs, consumer knowledge for informed choices, a large number of sellers to choose from, and free entry and exit from the market by providers. Two proposals for improving the defective market are promoting competitive market characteristics and promoting regulation where the operation of normal economic forces is impaired. However, approaches designed to improve market characteristics do not address the problem of equity. In the traditional marketplace, those who need a product or service but cannot afford it do without. Since health care is a service people often cannot do without, it is unlikely that a pure market will ever exist for health care ser-
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vices. In most communities, the health systems agency is in the best position to examine tile broad policy alternatives available and promote the most appropriate mix for their community's specific problems. Congress has recognized this and has given these agencies responsibilities both for participation in regnlation where competition is ineffective and for promoting competition where it can be shown to foster cost containment.
Descriptor(s): Cost contahmaent efforts, Supply/availability of services, Impact of third-party coverage, Present legislation/ regulations, Voluntary initiatives, Economic/commercial influences.
237. Economics of Industrial Health. History, Theory, Practice.
Joseph F. Follmarm. 1978, 482 pp. Availability: Amacom,
New York, NY 10020.
The history, theory, and p1_ctice of the economics of industrial health are discussed. Industrial health programs came into focus for employee, employer, and Government when the phenomenal social, economic, and individual costs of disease and accident were realized. In turn, the dramatic increases in the cost of health programs -- over $100 billion in the United States alone -- have led to a search four specific cost-effective programs in preventive medicine. Legislation such as the Occupational Safety and Health Act of 1970 has made the public acutely aware of the need for and the cost of such programs. It is concluded that business can serve society most effectively by balancing the cost effectiveness of prevention against the awesome cost of rehabilitation, disability, or dependent welfare and by better control in research and its application. General topics covered are the history of industrial health care, the health of employed people, the potential of preventive medicine, industrial health programs, what is being done in the area of industrial health programs, and the cost effectiveness of industrial health. A section on the relationship of financing programs for health care and loss of income covers Workmen's Compensation, Social Security disability benefits, medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and the question of national health insurance. In addition, the increasing role of private insurance programs and employee benefits in both prevention and rehabilitation of employees is examined. Appended are the Occupational Safety and Heal*h Act of 1970; established industrial health programs; sources of information, assistance, and guidance; and an annotated bibliography. (Author abstract modified)
Health Care Programs
Descriptor(s): Cost/benefit analyses, Cost containment efforts, Preventive services, Publicly sponsored/mandated health plans,
Perspectives
Private health care plans, Workers compensation, initiatives, Present legislation/regulations.
Descriptor(s): Health care costs, Supply/availability of services, Third-party payors, Hospital services, Inpatient facilities, Physicians, Policy/changes re health care, Demand/utilization of health care programs.
Voluntary
on Economics
Series.
238. Economics of Medical Care. A Policy Perspective.
Joseph P. Newhouse. 1978, 116 pp. Availability: Addison-Wesley MA 01867.
239. Economics of Medical Malpractice. Publishing
Company, Reading,
This book illustrates the application of microcconomic theory to the economics of medical care. Topics considered in the work include the demands for medical services and health insurance, physician supply, the medical marketplace, hospitals and cost, the output of the medical care delivery system, and techniques for managing resource allocation in medicafl care. Today, medical care has become increasingly significant in the Nation's economy, comprising nearly 9 percent of the gross national product. In addition, medical care costs have been rising at above average rates for many years and will therefore remain a major public policy issue. The quantity of medical care demanded is how many services individuals seek to purchase; when combined with the quantity of services supplied or available, the quantity demanded determines actual utilization. Demand for health insurance can be viewed as attempting to convert a large potential random loss into a small certain loss. Purchasing some insurance will improve the well being of risk-averse consumers. It is suggested that studies indicate we are currently training too many physicians, and that the manpower planner must consider demand factors, technological change, and substitution possibilities. The medical marketplace differs from the ideal market in that physicians and other suppliers are not interested solely in maximizing profit, entry into medicine is restricted through lieensing, consumers are ignorant about their medical needs, suppliers can create their own demand, and price competition has been severely undermined with regard to the medical insurance industry. Furthermore, hospital costs, which account for the most expensive portion of medical care, are largely determined by individual physicians who control the application of hospital inputs to specific patients under their care. Three methods of financing or organizing medical care services may be delineated: the status quo, (nearly complete insurance for hospitals and steadily more complete insurance of nonhospital services) a planning or regulatory approach; or reintroduction of price competition. Calls for reform indicate that a choice must be made between the latter two alternatives. Footnotes, references, figures, and an index are included in the book.
Simon Rottenberg. American Enterprise Inst. for Public Policy Research, Washington, DC 20036 1978, 293 pp. A rMIabih'ty: American Enterprise Inst. for Public Policy Research, Washington, De 20036.
The proceedings of a conference sponsored by the Center for Health Policy Research of the American Enterprise Institute for Public Policy Research are presented. The conference papers discuss the various rules for assigning cost when such an injury occurs. These rules are shown to affect the allocation of resources to health care and to alternative activities, the exercise of caution in delivering medical care, and the distribution of income and wealth. The design of such rules is complicated by the imperfect information possessed by patients; by the "authority" of the health care providers; and by the patients carried by health care insurance, which pools health care costs among whole classes of users. A further complicating factor is the professional liability insurance that covers providers of medical care. Some of the conference papers discuss the functioning of the professional liability insurance market and its effects upon medical behavior. This discussion is especially relevant to the withdrawal of some commercial insurance companies from the medical malpractice insurance market, to the rise in professional liability insurance premium rates, and to the differences in premium rates among medical specialists and in different parts of the country. Other papers present an econometric model of medical malpractice, discuss medical malpractice and the supply ofphysicians, and examine theoretical issues in medical malpractice. In addition, discussions focus on medical malpractice and the propensity to litigate, contingent fees in litigation with special reference to medical malpractice, and the cause and cure of medical malpractice. Commentaries, footnotes, tabular data, and a list of participants are provided. (Author abstract modifled) Papers deh'vered at the American Enterprise Institute's conference on medicalmMpractice heldin Washington, DC, December 1976.
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Descriptor(s): Non-employment related plans, Cost containment efforts, Supply/availability of services, Physicians, Economic/ commercial influences.
Health Care Financing
G1_nts and Contracts Report
Series.
Descriptor(s): Medicaid, Present legislation/regulations, Outcome/evaluation of health administration, Cost containment efforts, Medical/surgical services. 240. Effect of a Mandatory Second Opinion Program on Medicaid Surgery Rates. An Analysis of the Massachusetts Consultation Program for Elective Surgery.
Suzanne Grisez Martin, Michael Shwartz, Deborah
241. Effect of Duration of Membership in a Prepaid Group Health Plan on the Utilization of Services.
D'Arpa
Cooper, Anne E. McCusick and John H. Thorne_ Health Care Financing Administration, Washington, DC. Of.. rice of Research, Demonstrations, and Statistics. Commonwealth of Massachusetts, Boston, MA. Dept. of Public Welfare.
Charles E. Yesalis and Philip D. Bonnet. 1976, 13 pp. Availability: Medical Care:v 14 n2 p1024-1036 Dec 76.
Sep 1980, 204 pp. Availability: Health Care Financing Administration,
This study of the Columbia Medical Plan (CMP), a prepaid group practice located in Columbia, Md., shows that the use of medical care services changed with the duration of CMP member-ship. As duration of membership increased, the average number of provider visits per member per year declined from the initial level and subsequently stabilized. Six possible explanations for this trend are decreased financial barriers to seeking preventive services, testing of the plan by new members, effect of health education upon users, shift in behavior associated with a customer of a service becoming a member of a group, modification by providers of member behavior over time, and the nonrepetitive nature of some preventive services such as immunizations. Member vmits to providers appear to reach their peak within the In'st two quarters of membership and thereafter decline and stabilize during the second year of membership. New prescriptions idled per member tend to decrease with time, but there was no stabilization point for this rate. Moreover, walk-ins showed no association with time. The CMP membership, however, has distinct demographic characteristics which are not representative of the entire U.S. population: they are young, educated, and upper middle class. Generalizations, therefore, to other U.S. populations must be made with caution. There is also some indication that differences in use patterns might exist for the group of members who did not remain continuously enrolled during the period studied, October 1, 1970 through December 31, 1973. Nonetheless, information about the relationship between use of services and duration of membership may be helpful to health plan administrators. Being able to predict a significant decrease in use after the s_ond year of membership for prepaid health plans which enroll large groups of people at one time may realize significant savings in manpower, equipment, and facilities. Footnotes, tabular data, graphs, 16 references, and an appendix presenting supporting information are provided. (Author abstract modified)
ORDS
Publications, Baltimore, MD 21235.
This report assesses the effects of the Massachusetts Consultation Program for Elective Surgery during its initial 14-month implementation period. The program requires medicaid recipients without other health insurance to obtain a second opinion as a precondition for reimbursement for surgery. Eight types of surgery, including tonsillectomy, hysterectomy, and hemorrhoidectomy, are involved. In three regions of the State, patients must receive a physical examination (hands-on model); in two other regions, a desk-audit model is used to prescreen patients before consultation. The choice to undergo surgery remains the patient's, regardless of consultation outcome, and provider claims for the operation are to be reimbursed by medicaid. In the first year, a total of 4,864 referrals to the program were made; of 2,758 referred to the hands-on type, 82 percent had consultations; and 86 percent ofthe 2,107 referrals for the desk-audit met the criteria for consultation. To determine if the program was effecting lower operation rates, researchers analyzed monthly surgery rates for each procedure in each region for the period May 1975 to December 1978. Also, a study of the program dispositions of 2,501 patients in 2 regions with 65 percent of the target population were made. A 20 percent reduction in the number of operations was ascertained for the year following program implementation. The program was associated with a reduction of surgery rates for all procedures except disc surgery/ spinal fusion. Of the 2,501 patients studied in depth, 14.5 percent did not have the need for surgery confirmed; 72 percent had the originally proposed surgery. The estimated statewide savings to medicaid during the program's first year was $856,500. Tables and graphs are provided; cost-related calculations are appended,
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Health Care Programs
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Participants in health care programs.
242. Effect of Organization of Medical Care Upon Health Manpower Distribution.
243. Effect of Physician-Controlled
Health Insurance.
Lawrence G. Goldberg and Warren Greenberg. 1977, 31 pp. Availability: Jnl. of Health Politics, Policy and Law v2 nl IM8-78 Spring 1977.
Gerald T. Perkoff. 1978, 13 pp. Arailabih'ty: Medical Care vl6 n8 p628-640 Aug 78.
This paper investigates some of the reasons for the departure from rational, competitive behavior in the health care field. It notes that in the 1930's and 1940's in Oregon, the insurance market was competitive and free enough to generate the spon-
Data are presented from the Medical Care Group of Washington University and from several other organized medical care settings responsible for prepaid health care plan enrollees to determine the effect of organization type upon health manpower distribution. Previous studies of manpower needs in the health care industry have produced widely varying results, from reeommendations that fewer physicians are needed to declarations that a serious lack of all kinds of physicians exists. A review of the literature and data from the Medical Care group of Washington University, the Family Health Maintenance Demonstration (FHMD) experiment at Montefiore Hospital in New York, the Health Insurance Plan of Greater New York, the Kaiser-Portland Prepaid Plan, and the Palo Alto Medical Clinic (PAMC) of Caliibrnia suggest that the accessibility or inaccessibility to specialists drastically alters the pattern of medical care utilization and, along with this, the need for specific types of manpower. For instance, the FHMD study group had a total of 84.3 percent of all visits made to the primary care physician; for MCG, the total was 92 percent, and for PAMC, the total was 60 percent. MCG and FHMD patients have a primary care internist or pediatrician and cannot see a specialist unless referred by their primary care doctor. PAMC, on the other hand, refers patients freely to specialists and also permits patients direct access to specialists. The stricter the control of access to specialists, it appears, the greater the proportion of care provided by primary care providers. Furthermore, the problems patients of prepaid groups bring to their physicians are satisfied by far fewer specialists visits than is true for the general population, The findings draw implications for future research. More investigations into the organization of medical care and physician training, and their effect on medical care patterns are needed, as is study of the tasks appropriate to generalists as opposed to specialists. Thirty-four references are provided,
taneous cost-control efforts expected of a competitive insurance market. The historical development of health insurers, called "hospital associations," is presented, and the chain of events is outlined which culminated in the United States vs. Oregon State Medical Society decision in 1952, bringing an end to competitive insurance markets in Oregon. The record in this antitt_ast case, in contrast with the opinions and conclusions of the courts, is very revealing of the workings of the market for health services and health insurance and the incentives which face the major participants. The hospital associations arose in the early part of the 20th century in response to hazardous working conditions in the lumber, railroad, and mining industries, and were a form of contract medicine similar in many ways to health maintenance organizations of today. The associations were found to have engaged individually in cost-control efforts similar to but possibly more aggressive than today's utilization review under professional sponsorship. The subsequent disappearance of these insurance-initiated cost controls in Oregon is traced to tl_e medicad society's organization of a competing Blue Shield plan as a model of insurer conduct and to a simultaneous boycott by physicians of the hospital associations as long as they persisted in questioning doctors' practices. During the Depression, doetors tolerated the questioning because payment for services was assured, but in 1941, the State medical society introduced a statewide prepaid medical service plan, the Oregon Physicians Service, which effectively destroyed the ability of the.. private plans to control costs. The Oregon State Medical Society case illustrates that competitive cost cutting by private insurers can indeed occur under certain circumstances. Further, in showing that a strong doctor-controlled insurance company can compel private insurers to curtail their cost-cutting procedures, the experience in Oregon suggests that competition among health insurers is apt to be more effective in the absence of physician control of any carder. Two appendices containing extracts from the Oregon ease are provided, along with 116 footnotes. (Author abstract modified)
Presented in part at the annual meeting of the Western Association of Physicians, Carmel, CA, February 4, 197Z Descriptor(s): Demand/utilization of health care programs, Supply/availability of services, Providers of health care services, Medical/surgical services,
Descriptor(s): Cost containment efforts, Impact of third-party coverage, Physicians, Health insurance industry, Competition/ interaction among third-party payors.
I-lll
244. Effect of PSROs on Health Care Costs. Current Findings mad Future Evaluations.
program. They also changed the automatic medicaid eligibility provision under Title XIX of the Social Security Act for the cash assistance population. This article provides information about
Paul B. Ginsburg and Daniel M. Koretz. Congressional Budget Office, Washington, DC 20515 Jun 1979, 89 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 052-070-05002-1.
recent changes in State medicaid caseloads and payments tbllowing implementation of SSI and the possible effects of SSI on such changes. Whenever possible, the data presented cover the 5-year period January 1971 through December 1975. Some background on the SSI program is given in addition to information on recipient caseloads, total medicaid expenditures, factors influencing medicaid costs, changes in the medicare program, changes in State medicaid programs, and other legislative changes. Considerable detail is given about State variations in medicaid coverge as they relate to SSI. Some States provide coverage to all SSI recipients and to the medically needy, some provide coverage to SSI recipients only, and some restrict coverage. This study did not find SSI to be a significant factor in the medicaid changes. For States that aided only SSI recipients and those with lowpayment standards aiding all SSI recipients and the medically needy, the growth in the cash assistance caseload appeared to have had a greater influe_Lce on the medicaid population. For other States with restrictive medicaid eligibility criteria and with high payment standards that aided all groups including the medically needy, growth in medicaid caseloads was limited. Implementation of the SSI program seemed to have had the greatest influence on the caseload tor the disabled. From 1973 to 1975, the cash assistance and raedicaid caseloads for the disabled became the fastest growing adult category. The growth in medicaid payments, resulted p:dmarily from expansion of medical services to include care in intermediate-care facilities and to account for inflation and higher utilization of medical services. Eleven tables summarizing data are provided. (Author abstract modified)
The Social Security Amendments of 1972 established the Professional Standards Review Organization (PSRO)program in order to assure quality of care and reduce expenditures. The program has placed primary emphasis on reducing use of-- and thereby expenditures for -- short-stay hospital care by means of"concurrent review." This consists of examining hospital admissions to certify that, from a medical standpoint, they are appropriate and reassessing each case periodically to determine whether continued inpatient care is warranted. Research shows that concurrent review is reducing the number of days of hospital care for medicare patients by about 2 percent. However, this does not mean that savings have accrued, since a number of factors suggest that further evaluation of the effectiveness and cost-effectiveness of PSRO's is needed. Moreover, the quality of the evaluations of the program require improvement. Unless changes are made soon in both implementation and evaluation, future evaluations of the program will continue to be unreliable, often to such a degree as to be useless in formulating policy. The most crucial improvement in the evaluation of PSRO's would be a more careful use of comparison groups. Alternative patterns of future program implementation that would yield more reliable assessments are discussed. Appendices review case studies of two PSRO's and discuss technical issues. Tables, figures, and footnotes are provided. DesctT"ptor{sg: Present legislation/regulations, Cost containment efforts, Outcome/evaluation of quality assurance, Inpatient facilities.
245. Effect of SSI on Medicaid Caseloads and Expenditures.
Sue C. Hawkins and Donald E. Rigby. Social Security Administration, Washington,
DC 20203
1978, 12 pp. Availability: Social Security Bulletin v42 n2 p3-14 Feb 79.
The 1972 Social Security Amendments replaced the Federal.. State public assistance programs for the needy aged, blind, and disabled with the Federal Supplemental Security Income (SSI)
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Descxiptor(s): Supply/availability legislation/regulations.
of services, Medicaid,
Present
246. Effect of Unemployment Insurance Payments on the Health Insurance Coverage of the Unemployed.
Suresh Maihotra
and John M. Wills.
Battelle Human Affairs Research Centers Health and Population Study Center, SeaV:le, WA 98105 National Commission on Unemployment Compensation, Washington, DC. Jun 1980, 61 pp. A vailabih'ty: Battelle Human Affairs Research Centers, Health and Population Study Center, Seattle, WA 98105.
Health Care Programs
Using data from the 1976 Survey of Income and Education (SIE), this report examines the effect of unemployment benefits on retention of employment-related and other private health insurance coverage. The health insurance coverage of the unemployed is described, and attention is given to labor force attachment and family status characteristics of the workers, Unemployed new entrants and reentrants to the labor force were found to have high health insurance coverage levels, largely because this group has a large percentage of teenagers and second earners who are covered by family health insurance plans, The health insurance coverage among the unemployed is considerably increased by the availability of public plans to the unemployed poor (nearly 15 percent of the unemployed receive benefits from public sources). The unemployed not covered by health insurance tend to be from low-income families unable to qualify for public programs. This suggests that decreasing the qualifying standards for public programs could help the most needy among the unemployed not currently covered. Findings show that unemployment insurance (UI) benefits promote the acquisition and retention of private health insurance coverage; however, changes in the number of workers receiving UI benefits or increasing the amount of benefits would have only a limited effect on coverage levels among the unemployed, since reception of UI benefits is only one of many factors influencing the decision of the worker to retain health insurance during the unemployment period. A large proportion of the unemployed have relatively short durations of unemployment; this group's coverage could be helped by extending the employment health insurance coverage for a period of time after job separation. Because the severity of the health insurance problem among the unemployed varies by family status, wealth, availability of UI income, and several other variables, no one policy short of universal national health insurance can be expected to address the problem completely. Tabular and graphic data, footnotes, and four references are provided. A description and use of the SIE are appended.
Descriptor(s): Participants in health care programs, Non-participants in health care programs, Policy/changes re health care, National economic conditions, Eligibility requirements, Private health care plans.
Even though there are geographic and specialty maldistributions of physicians, the perceived poor quality, efficiency, and effectiveness of medical care in this country are not the result of a physician shortage, but of the lack of organization of responsible medical care. The public's perception of a physician shortage is in reality a lack of access to medical care. It should be emphasized that some form of national health insurance will be enacted within the next few years. For all practical purposes, a finite expenditure for health will develop, without large out-of-pocket sums and uncontrolled private health insurance. In time, these funds will establish a plateaued relationship to the gross national product, essentially growing only as fast as it grows, and in effect, establishing a budget for health expenditures. One populax method of assuring equitable health care to all under these conditions is making medicine a public utility. However, the health maintenance organization (HMO) is another alternative which also embraces many of our contemporary values. There are two distinct types of HMO's. The older and dominant form is the prepaid group practice (PGP). The other form is the foundation for medical care (FMC) in which physicians practice in individual offices under the conventional fee-for-service arrangement. Further, HMO's are one of the few forms of organized medicine that have already experienced allocation of physicians by scale. In addition, the effect of the HMO structure on the various types of health manpower serving populations extends quite naturally to physician substitutes. The organized nature of the HMO makes substitution relatively easy, and the practice is cost effective for the medical group. Finally, national health insurance will produce a profound change in me_lical care through the combination of equal entitlement, comprehensive benefits, and closed-ended funding; the HMO ha_ already demonstrated success and growth under these terms. Over a period of time, there is likely to be a strong evolution of the majority of medical practice to both the FMC and the PGP forms of medical practice. Seventeen references are provided.
Descriptor(s): Supply/availability tional health insurance (NHI).
of services, Prepaid plans, Na-
248. Effects and Costs of Day-Care Services for the C2tronically Ill. A Randomized Experiment. 247. Effect on Future Physician Requirements Policy After National Health Insurance.
of an HMO
Ernest W. Saward. Josiah Macy, Jr. Foundation, New York, NY. 1975, 19 pp. A vai]ability: Jnl. of Community Health v I n 1 p 53-71 Fall 1975.
William G. Weissert, Thomas T. Wan, Barbara Livieratos and Sidney Katz. 1980, 18 pp. AvMlabih'ty: Medical Care v18 n6 p567-584 Jun 80.
Professionals and researchers in the field of long-term c_axeagree that matching patient needs to provider capabilities along a con-
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tinuum of care is needed. Lack of such a continuum results in inappropriate use of institutions, fragmented and discontinuous care, and widespread belief that many patients' needs are not being met. However, this study of day care services suggests that making the match between needs and services should be approached cautiously. The cost of day care, even at $25.09 per day, might not be cheaper than nursing home care if the new service is used by patients who are not really substituting it for nursing home care. Few patients using day care in this study were potential beneficiaries of reduced institutionalization since only 21 percent of the control group was institutionalized in a nursing home. Analysis indicated that day care patients showed no benefits in physical functioning. Institutionalization in skilled nursing facilities was lower for the experimental group, but factors other than treatment appeared to explain most of the variance. At best, the results raise the possibility that day care may have prolonged life for some patients. Services were rendered to a patient population that varied widely in health care problems and apparent need. Most patients used the new services as an add-on to existing health care services, producing significantly higher costs for the experimental group than the control group. Clearly day care should be tested as one service in a continuum
result in higher prices, and this area needs further exploration. Furthermore, regulation of closely related markets can be expected to influence behavior in all the related markets. Higher prices in States that ban advertising are not necessarily due to higher quality. Restrictions that reduce the number of searches benefit all sellers, but primarily the high-cost, low-volume dealer. In States that allow advertising, a greater proportion of purchases are made from large firms. A few sources of information may be sufficient to reduce the average price of examinations since only bans on all adw;rtising significantly raise eyeglass prices. Hence, there are several remedies to the high prices caused by lack of information in the optometric examination market. Six tables and 16 fcrotnotes are provided. (Author abstract modified)
of care rather than provided more or less in isolation as it was in this study. Footnotes, tables and 19 references are provided, (Authors abstract modified)
250. Effects of Financial and Location Decisions.
Descriptor(s): Participation health services.
Mary A. Fruen, Jack Hadley and Samuel P. Korper. 1979, 17 pp. Avnilnbilt'ty: Health Policy and Education vl n2 p143-159 Mar 80.
in health
care programs,
Home
Descriptor(s): Cost/benefit analyses, Vision/hearing services, Outcome/evaluation of quality assurance, Economic/commercial influences.
Incentives on Physicians'
Sl_eialty
This article reviews studies on the effects of financial incentives 249. Effects
of Advertising
Lessons From Optometry.
Roger Feldman and James W. Begun. National Center for Health Services Research, Hyattsville, MD. 1978, 16 pp. A vailability: Jnl. of Human Resources v8 p247-262 Supplement 1978.
This article reviews the effect of advertising bans on the price of optometric examinations. Advertising enables consumers to search the market effectively by discovering lower prices. Using a national survey of more than 1,000 optometrists to disentangle the relationship among price, quality, and advertising, researchers found that price was 5 percent higher in States which ban optometric advertising and ten percent higher in states which ban optician advertising. However, the two effects are not independent, and the price of eye examinations was significantly higher in States where both kinds of price advertising were banned. Little is known about the process by which restrictions
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on physicians' specialty and location decisions. Physicians' incomes differ substantially by specialty and location, although no definitive conclusions can be drawn from available studies regarding the effects of income potential on career decisions by physicians. Very limited, inconclusive evidence suggests that the effect of anticipated income on specialty choice, if any, is weak. Studies on the relationship of both reimbursement levels and income to physician location choice generally conclude that there is a positive correlation between these financial factors and physician density, but the magnitude of the relationship is uncertain. Variables in such studies are often intercorrelated and statistical techniques are not refined enough to identify with confidence the independent effects of any particular variable. Even with evidence of the relationship of variables to specialty or location choice, causality still cannot be inferred. Furthermore, previous studies have focused on aggregate data rather than examining individual decisions over time in the context of the many considerations which might influence career decisions. Results suggest that it could be very costly to use financial incentives to encourage individual physicians to alter specialty choices and that the practice would be of questionable effective-
t lc:llli_ (a_.. :', ......
,:.
ness. Location choices appear to be more responsive to financial incentives, though cost estimates vary widely. If financial incenrives are used to redistribute physicians, the method of manipulating physician earnings must be carefully considered. Both the type and size of the incentive as well as the type of physician targeted should be considered. Also, the implications and repercussions of financial incentives should be thoroughly studied in the context of other policy objectives such as access to medical care and cost containment. (Author abstract modified)
Descriptor(s): Health information/data bility of services, Physicians.
systems, Supply/availa-
251. Effects of Hospital Cost Containment on the Development and Use of Medical Technology.
Kenneth E. Warner. 1978, 25 pp. A vnilability: Milbank Memorial Fund Quarterly/Health Society v56 n2 p187-211 Spring 1978.
and
While there is general agreement that technology contributes to inflation of medical costs, the actual mechanisms linking technology to inflation have been insufficiently studied. To be effective, cost containment policies must address these linking mechanisms. The rapid and indiscriminate adoption oftechnology has been blamed on the profit motive of the sellers, but part of the problem is attributable to the physicians, hospitals, and consumers who do not differentiate between the costs and benefits of the technology they use. Technology users who pay none of the costs will use resources as though they were free. Limiting general inpatient revenue and putting a ceiling on capital expenditures are two hospital cost containment strategies designed to affect hospital resource allocations and prevent excessive and inappropriate use of resources. At the same time third-party payers have been encouraging the use of hospital resources as if they were free, and society has been attempting to implement the principle that health care is a right by incrementally decreasing the out-of-pocket costs of health care. The result is that the demand side of the economic equation has been freed but the free enterprise character of the supply side is endangered. Cost containment represents an attempt to preserve the gains of the past decade made in equal access to care while reintroducing an economic discipline in the provision of care, at least in hospitals, Placing a ceiling on capital expenditures appears to be a means of supplementing relatively ineffective regulatory measures with some policy muscle, but this move discourages capital intensive technology and fails to distinguish between cost-saving technology and cost-increasing technology. However, under a general
inpatient revenue limit, incentive exists for technology researchers and developers to channel their creativity into cost-saving technology. A shift in the mix of technology from cost increasing to cost saving would create a significant change in the delivery of medical care. The likely effects of cost containment policy on medical technology are numerous and significant, but the price paid for controlling the ever increasing costs of care are not neccessarily intolerable. Forty-two references are provided.
Desc_riptor(s): Cost containment efforts, Medical techr_ology impacts, Policy/changes re health care, Inpatient facilities.
252, Effects of Income Maintenance on the Medical Care Utilization and Health Status of Rural Families.
Stuart H. Kerachsky. Mathematica Policy Research, Inc., Princeton, NJ 08540 Wisconsin Univ., Madison, WI. Inst. for Research on Poverty. Nov 1978, 34 pp. A vaJlability: Mathematiea Policy Research, Inc., Princeton, NJ 08540.
This paper reports the findings of a study of the Rund Income Maintenance Experiment and its effect on one aspect of human capital -- health. To determine whether the rural experiment promoted health, researchers analyzed subjects' mexJical care utilization and health status. The study continuously monitored 521 sample low-income families who had constant marital status throughout the 3 years of the experiment. Health data were gathered three times in the course of the experiment. Questions covered a range of topics including hospital, clinic, and physician care; chronic illness; special treatments; dental and eye care; problems in receiving care; expenses; work-time lost; and attitudes. A year's recall of medical contacts, duration of care per family member, and medical expense data were measures of utilization. The results did not show any evidence that program participants' health status had improved. The evidence thus offered little support for the theory that income maintenance will increase the u "tflization of medical care by rural adults, and it offered only weak support for the utilization increase by rural children. An urban New Jersey study, however, found statistically significant income maintenance experiment effects cm the use of medical care. Alternative medical care coverage through prirate health insurance or medicaid, differences in the size of program payments, and differences in the settings may explain the divergent results of the two studies. Extensive tabular material, footnotes, and 15 references are supplied. The appendix conrains additional study data.
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Descriptor(s): Demand/utilization of health care programs, Publicly sponsored/mandated health plans, Outcome/evaluation of quality assurance.
254. Effects of the Payment Mechanism on the Health Care Delivery System. William R. Roy. St. Francis Hospital and Medical Center, Topeka, KS 66606 National Center for Health Services Research, Hyattsville, MD.
253. Effects of Medicare and Medicaid on Access to and Quality of Health Care.
Jul 1978, 146 pp. A vailability: National Techlaical Information field, VA 22161, PB-291 231.
Avedis Donabedian.
One issue in the debate over adoption of national health insur-
Carnegie Corp., New York, NY. Milbank Memorial Fund, New York, NY.
ante (NHI) in the United States concerns the role of the Government under any proposed plan. Papers presented at this conference explore the possibilities for reorganizing the health care delivery system to achieve greater efficiency and effectiveness while reducing the scope of Government regulation. Special emphasis is placed on mechanisms for increasing the field of choice for the health care consumer and consequently increasing the degree of competition in the health care sector. A specific mechanism is the suggested use of Government-issued vouchers for the purchase of health insurance. The papers compare the incentives, disincentives, probable actions, possible abuses, effectiveness, and efficiency of the health care system under current administrative and payment methods with those aspects of the system which may be expected under various health insurance voucher plans. The presentations and ensuing discussions identify issues and problems requiring further research. These are highlighted in the final paper. Tables, graphs, chapter references, and lists of contributors and participants are provided. (Author abstract modified)
1976, 10 pp. Availability: Public Health Reports v91 n4 p322-331 Jul/Aug 76.
This paper evaluates the medicaid and medicare programs in terms of their influence on access to and quality of care. Medicare and medicaid have increased the use of physician and hospital services among segments of the population that had previously been deprived of these services. However, this added push has not achieved equal service for equal need across the nation. The very poor, rural residents, and blacks still have a lower rate of use than the general population. Some urban areas rich in benefits and resources, may have achieved near parity in the volume of care. However, differences persist in the range of choices available regarding sources of care, amenities these sources offer, and technical quality of care that they provide.
Service, Spring-
Furthermore with the increased use of services has come greater exposure to the hazards of unnecessary and inappropriate care. For beneficiaries of medicaid, this hazard may be greater because some practitioners and institutions that serve the poor do so under a variety of handicaps, often in an environment where the incentives for self-control are weak and the mechanisms ofexternal control are absent or ineffectual. The greatest contribution of medicaid and medicare to the quality of care is that they have focused attention on the shortcomings, documented them, and asserted and institutionalized public responsibility for them through the Professional Standards Review Organization. The real significance of the two programs is not so much what they are but rather what they portend for the future expansion of even more far-reaching programs. One graph and 43 references are
Proceedings ofa conference_eld at Skyland Lodge, Shenandoah NationalPark, VA, November 7-8, 1977. Research Proceedings Series, Report No. NCHSR 78-135.
provided.
National Center for Health Services Research, MD.
Descriptor(s): Medicare, Medicaid, Present legislation/regulat ions, Outcome/evaluation of quality assurance, Participants in health care programs.
1-1 16
Descriptor(s): National health insurance (NHI), Competition/ interaction among third-party payors, Methods of payment determination.
255. Effects of the 1974-75 Recession on Health Care for the Disadvantaged. Hyattsville,
Jan 1980, 94 pp. Availability: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782.
Health
Care ProgJam_
These seven studies explore the effects of the 1974-1975 reeession, the worst economic downturn since the end of World War II, on health care for the disadvantaged. Specific subjects studied were public finance, trends in facility use, utilization, use of community hospitals in Rhode Island, access to ambulatory care, and two studies investigating the impact of rising unemployment on the loss of job-related health insurance coverage. In general, the effects were adverse to a significant degree, but not
DC. Commonwealth Fund, New York, NY. Woodrow Wilson International Center for Scholars, Washington, DC. Jun 1980, 64 pp. AvMlabifity: Wisconsin Univ., Inst. for Research on Poverty, Madison, WI 53706.
as severe as anticipated. Although as many as half the jobless lost their health insurance when they became unemployed, most
This paper focuses on factors which led to legislation providing for the National Health Service in Great Britain in 1946 and the
families were able to pay for necessary care out of pocket and postpone some care until reemployed. There was no significant increase in the use of hospital-based primary care. However, public hospitals whose major source of income is direct government subsidies were affected markedly because the subsidies did not keep pace with inflation. On the other hand, private hospitals proved better able to withstand the economic pressures because of their independent resources. The recession had no observable impact upon the utilization of hospital emergency rooms and outpatient departments, even in areas having substantial tmemployment. Exceptions were some of the disadvantaged inner city areas where hospitals are a primary source of care. The recession did, however, affect sources of payment for health care. The
results of its implementation. Pressures to change the system came from such sources as the State Medical Service Association, the Labor Party, the Dawson Commission, and most of the British people, who were alerted to the serious inadequacies in the British medical delivery system as a result of World War II. Despite many coherent plans for changes in medical services which developed between 1918 and 1948, the system which was finally implemented in 1948 was not a coherent, highly coordinated, or rational program of medical care. The National Health Service (NHS) is an example of how traditional practices and structures have persisted despite prolonged efforts to reshape a system. Probably no country in the world has produced so many reports for improvements in the delivery of medical services as has Great Britain; yet, the structures which were implemented in 1948 were not greatly dissimilar to those which existed before the NHS. The most important change which oecurred was the nationalization of hospitals. The NHS did not bring about an integration of curative and preventive health centers, as was advocated by many, and local health services continued to be poorly financed. Moreover, ineffective communication between the hospital-based physician and the general practitioner continued. Although the NHS did much to upgrade the quality of a high percentage of hospitals, it singled out the prestigious teaching hospitals for special treatment. A table and 32 references are provided. (Author abstract modified)
conventional wisdom that health insurance leads to overufilization of health services needs reexamination, as it may well lead to correction of what is really underutilization. Since the country is still far from adoption of a comprehensive national health insurance, the Government could faeiIitatetheexistingjob-related health insurance institutions in covering the unemployed, or encourage some system of supplemental insurance. Federal policy should be designed to take advantage of existing State administrative abilities and provide stronger incentives for States to pursue Federal program objectives. Tables, footnotes, and approximately 45 references are included, NCHSR
Research
Summary
Series.
Descriptor(s): National economic conditions, Participation in health care programs, Supply/availability of services, Demand/ utilization of health care programs, Third-party payors.
256. Efforts to Restructure a Medical Delivery System. The British National Health Service. J. Rogers Hollingsworth. Wisconsin Univ. Inst. for Research on Poverty, Madison, 53706 Department of Health and Human Services, Washington, DC. National Science Foundation, Washington, DC. German Marshall Fund of the United States, Washington,
WI
Discussion Paper, No. 620-80.
Descriptor(s): Comparisons regarding foreign health Evaluations/outcome of health care programs.
policies,
257. Empiricial Study of the Differences Between Family and Individual Deductibles in Health Insurance. Emmett B. Keeler, Daniel A. Relies and John E. Rolph. Rand Corp., Santa Monica, CA 90406 Department of Health, Education, and Welfare, Washington, DC. 1977, 9 pp. Avnilnbility: Inquiry v14 n3 p269-277 Sep 77.
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This report studies the distribution of medical expenses, the way in which these expenses are divided between insurer and insured under various medical plans, and how the type of deductible (family or individual) affects the variance of family out-of-pocket payments. Data were taken from the CHAS-NORC 1970 Medical Expenditures Survey which gives information on the expenses of approximately 3,700 households or 11,287 individuals, The data included demographic characteristics of every individual, a qualitative measure of health status, an indicator of whether or not the person was insured, and the medical expenses .incurred. The study investigated the relationship between the variances of medical expenditures for equivalent individual and family deductible plans and for a variety of coinsurance rates, Study lrmdings indicated that, under certain assumptions, a family deductible plan is less risky for the insured than equivalent individual deductible plans. This result is true with zero or 25 percent coinsurance at all levels of deductibles up to $500 per person for family expenditures when an upper limit, typical of a national health insurance (NHI) plan, is imposed on the survey. Some exceptions appear, however, when an upper limit is imposed. In addition, the model seems to indicate that family
for study. These benefits include paid lunch and rest periods; paid holidays, vacation.s, personal leave, and sick leave; life, accident and sickness, health, and long-term disability insurance; and private pension plans. Survey results indicate that most full-time employees in medium and large private sector establishments work a 5-day, 40-hour week and receive paid holidays and vacations as well as life and health insurance, both of which are financed by the employer. Also provided by most employers are income continuation during disability and pension plans. About 13 percent of the employees covered by the survey received paid lunch periods, while more than 75 percent were provided paid rest time (e.g., coffee breaks). Personal leave was provided to about 19 percent of the employees for 2 to 5 days per year. Health insurance plans that were at least partially financed by the employer covered 97 percent of the workers surveyed. Nearly all participants were insured for hospital room and board, surgery, x-rays, and physicians' hospital visits. Onehalf had some form of dental insurance, and almost 20 percent had vision care insurance:. Twenty tables and a technical note are provided. (Author abstract modified)
deductibles are preferable, but the differences are small. Finally, if the tax laws change, policies with large deductibles may become desirable because of their smaller premiums. Four tables, five figures, and eight notes and references are given.
Report
Summary of "'Choice between Family and IndJviduM Deductihies in Health Insurance. ""
health plans), Private health care plans.
Descriptor(s): Plan design/program provisions (under health plans), Deductible/coinsurance, Participants in health care programs.
No. 615.
Descriptor(s): Participation in health care programs, Source of premium payment, Plan design/program provisions (under
259. Employee Benefits 1979. Chamber of Commerce of the United States, Washington, DC 20062 1980, 36 pp.
258. Employee Benefits In Industry. A Pilot Survey. Bureau of Labor Statistics, Washington,
AvMlability: Chamber of Commerce Washington, De 20062.
De 20212
Jul 1980, 16 pp. Availability: Bureau of Labor Statistics, Washington, 20212.
DC
This publication reports on a pilot survey conducted by the Bureau of Labor Statistics, which focuses on the incidence and characteristics of private sector employee benefit plans in 1979. The survey was designed to represent 21 million employees in establishments covered by the bureau's annual evaluation of professional, administrative, technical, and clerical pay designations. Information was collected on employee work schedules and detailed data were developed on the characteristics (excluding employer cost) of 11 private sector employee benefits selected
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of the United States,
The results of an annual survey of employers regarding employee benefit levels are reported. Questionnaires were sent to business firms listed in Chamber's 1977and 1978 surveys, Standard and Poor's 1979 Register (omitting those with fewer than 100 employees), as well as to medium to large banks, public utilities, and insurance companies. Questionnaires were also sent to a number of hospitals. Employees considered in the study were those who are not exempted from the Fair Labor Standards Act. The questionnaire, to which 922 employers responded fully, requested information concerning legally required payments such as FICA, agreed-upon payments such as pension plans and medical insurance, paid rest periods, vacation, and other leave, such items as profit-sharing plans, employee hours, and business type. The data show that employee benefit payments varied widely
Health Care Programs
among the reporting companies, ranging from less than 18 percent to more than 65 percent of payroll and from under $2,400 to over $9,500 yearly per employee. The average payment in 1979 was 36.6 percent of payroll, or $5,560 per year per eraployee. Payments varied widely according to type of industry, region, and size of company. Nongovernment pensions were among the benefits reported by 86 percent of the companies. All companies reported payments for employee insurance programs, with these payments averaging 5.7 percent of payroll. Employee payroll deductions for benefits included 5.8 percent FICA taxes, 0.1 percent for Railroad Retirement Tax, State sickness insurance, and similar programs, 0.3 percent for pensions, and 0.8 percent for life, hospitalization, surgical, and other insurance. Benefit payments for 182 companies submitting data since 1959 increased from 24.4 percent in 1959 to 31 percent in 1969 and 41.2 percent in 1979. A sample questionnaire, 22 tables, and 4
HMO's, funding, and HMO qualifications are discussed with focus on the Mandatory Dual Choice regulations and their irapact on employers. Instructions are given on how to choose an HMO, with itemizations of the data necessary for making the best choice as well as the sources for that data and a list of key questions to be asked. The final chapter examines the problems encountered to date in HMO development and the future of HMO's. Summaries of the major National Health Insurance proposals and their potential impacts on HMO's are included. The appendices contain the HMO Act and its Conference report, as well as text of other regulations pertaining to HMO's. Other appendices provide lists of operational HMO's, State profiles of HMO activities, and discussions of selected HMO organizational and financial models. Graphs, tables, a glossary, and an index are also provided. (Author abstract modified)
charts are provided. (Modified author's summary) Descriptor(s): Health information/data systems, Participants in health care programs, Source of premium payment,
Descriptor(s): Health care costs, Prepaid plans, Present legislation/regulations, Provide_ of health care services, Facilities providing health care, Health care/services, Funding/financing of health care programs.
260. Employee Health Benefits. HMOs and Mandatory Choice.
261. Employer Acquisition of Health Care Facilities. ible Outcome of Eacalating Premiums.
Jeffrey A. Prussin. 1976, 238 pp. Availability: Aspen Systems Corp., Rockville,
Dual
MD 20850.
This volume is designed to provide employers, employee bargaining representatives and unions, employee benefits consultants, health care providers, government officials, and others interested in health care organization, delivery, and financing with reference material on health care in the United States, particularly emphasizing health maintenance organizations (HMO's). The first two chapters offer an introduction to health insurance, including its history current trends, and traditional health insurance payment mechanisms. The following chapter outlines the reasons for the growth of national interest in health care organization, delivery, and fmancing. Problems emphasized are inflation in the costs of health care, accessibility of health care services, gaps in health insurance coverage, availability of services, and the quality of services. The core chapters of the volume focus on HMO's, beginning with a detailed discussion of the concepts underlying this type of organization, its operational principles, and alternative models for integration of the various components of HMO's. Data on HMO performance is also presented. The Health Maintenance Organization Act is analyzed section-by-section in terms of policy issues encountered in its development. The regulations governing the requirements for
A Poss-
Kenan E. flahin and Amy K. Taylor. Robert Wood Johnson Foundation, Princeton, NJ. Commonwealth Fund, New York, NY. 1979, 15 pp. Availability: Sloan Management Review v20 n4 p61-75 Summer 1979.
Employer acquisition of health care facilities is examined as a means of cost containment in response to the rising premiums paid for employee health care. Employer ownership of health care facilities is not new. Many institutions, such as universities, have maintained clinics or infirmaries that provide limited services to their employees. Employer-financed health insurance is a way of purchasing health services at a fixed price and is no different, from an operations viewpoint, than purchasing other services. Premiums are similar to other components of costs. In all instances, the enterprise has the option of either buying the good or service or producing it internally. In the case of switching from the current mode of buying health insurance to building or buying health facilities to provide health care, the outflows would be the operating costs and the revenues or inflows would be the insurance premiums saved. A conservative estimate of costs and savings shows that construction of in-house health care facilities or acquisition deserves careful consideration as a finandally competitive investment option. A factor to be considered
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in employer ownership of health care facilities is possible employee concern that their freedom of choice in selecting health care providers may be restricted and that employers might be tempted to restrict services unduly. A discussion of the estimation of variables is appended, and references are provided.
Descriptor(s): Funding/financing of health care programs, Source of premium payment, Voluntary initiatives, Facilities providing health care.
262. Employer Provided Group Health Plans and the Unemployed. Suresh Malhotra and John M. Wills. Battelle Human Affairs Research Centers Health and Population Study Center, Seattle, WA 98105 National Commission on Unemployment Compensation, Washington, DC. Jun 1980, 45 pp. Availability. Battelle Human Affairs Research Centers, Health and Population Study Center, Seattle, WA 98105.
Based on a random sample of 901 employment-related group health plans, this study describes the three basic types of employee group health plan eligibility systems (status, tenure, and hours-based) and shows how they lead to lags after employment: before coverage is acquired -- entry lags -- and lags after separation before coverage is lost -- exit lags. Average entry and exit lags are computed for different industries and types of workers. The estimated average lags are combined with data on the distilbution of the unemployed by duration of unemployment to estimate the proportion of the unemployed who lose coveraqe and the average duration of loss of coverage observed at a point in time for various groups. The study found that entry lags average 1.65 months, but go as high as 3 months, and that exit lags differ by industry. For example, the construction and retail trades have the most restrictive entry lags. The most liberal exit lags were found in manufacturing, transportation, and construction industries, especially for layoffs. As unemployment rises so do the proportion of workers losing coverage and the duration of loss of coverage. Clearly, longer exit lags and shorter entry lags could improve coverage for those just entering or leaving employment; however, such proposals would not resolve all the problems, Other options are a supplementary insurance scheme similar to the existing system of unemployment insurance or a more comprehensive national health plan. It is essential that any proposal for public action recognize that the existing employee benefit system evolved in response to a number of economic and administrative factors; these factors will continue to be important
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for the success of any public program in this area. Tabular data, footnotes, and six references are provided. (Author abstract modified)
Descriptor(s): Private health care plans, Participants in health care programs, Non-participants in health care programs, Policy/changes re health care, Eligibility requirements, National economic conditions.
263. Employment Related Health Benefits in Private Nonfarm Business Establishments in the United States. Volume I. Determinants of the Decision by Establishments to Offer a Group Health Plan.
Suresh Maihotra, Kenneth M. McCaffree, John M. Wills and Jean Baker. Battelle Human Affairs Research Centers Health and Population Study Center, Seattle, WA 98105 Department of Labor, Washington, DC. Assistant Secretary for Policy, Evaluation and Research. Labor-Management Services Administration, Washington, DC. Jun 1980, 73 pp. Availabih'ty: Labor-Management Washington, DC 20001.
Services Administration,
This report presents selecte_cl data from the survey of business establishments conducted as part of a study sponsored by the Department of Labor. The study analyzed the determinants of the decision by establishments to offer group health plans and deaeribes the characteristics of establishments with and without plans and the employees who work for them. The study found that there are about 1.5 million establishments, employing 7.5 million workers, that do not offer group health plans. These workers are concentrated in construction, retail trade and setvice sectors, and in smaller establishments. Factors most frequently mentioned as reasons for not offering a plan were the cost of the insurance and the size of the firm. A multivariate regression model estimated that the probability that a company will offer a plan is closely related to its size, presumably because larger group plans offer greater opportunity for reducing the per capita loading fee. The probability that a plan will be offered is also associated with higher proportions of salaried male office workers. The study findings highlight three major target groups which should be addressed in developing policies to encourage estabhshments to offer health and welfare plans to their workers. These are (1) small establishments that are unable to pool with other employers to provide benefits, (2) establishments which have large proportions of low-income workers, and (3) small
Health Care Programs
•
establishments which have high turnover. Stronger incentives to provide benefits to workers among these employers could result in a significant increase in the availability of health and welfare plans to a segment of the labor force not currently covered by such plans. These incentives might include (1) subsidies to employers with small payrolls, (2) premium sharing by the Government for low-income workers, and (3) institution of Government-backed regional groups which all small employers "- could join and which would sponsor group health and welfare plans. Tables, footnotes, 16 references, and appendices, giving a survey and sampling description and choice of estimation technique for the regression model, are supplied. (Author abstract modified) D_riptor(s): Private health care plans, Participants in health care programs, Non-participants in health care programs, Source of premium payment, Policy initiatives, Economic/commercial influences,
264. Employment Related Health Benefits in Private Now farm Business Establishments in the United States. Volume II. Description of Selected Data.
Suresh Malhotra, Kenneth M. McCaffree, John M. Wills and Jean Baker. Battelle Human Affairs Research Centers Health and Population Study Center, Seattle, WA 98105 Chilton Research Services, Inc., Radnor, PA 19089 Labor-Management Services Administration, Washington, DC. Department Labor, Washington, DC, Assistant Secretary for Policy,of Evaluation and Research. Mar 1980, 165 pp. A vailability: Health and Population Study Center, Seattle, WA 98105.
This report presents selected data from a survey of business establishments conducted from 1978 to ofJanuary as part of a study sponsored byNovember the Department Labor. 1979 The purpose of the study was to analyze why businesses decide to offer group health plans and to describe the characteristics of businesses with and without plans and the employees who work in them. According to the data, 60 percent of all establishments in the private nonfarm sector offer some form of group health insurance to some or all of their employees. Coverage varies by industry, however, from a high of 79 percent of manufacturing businesses to a low of41 percent in contract construction. Atotal of 61,116,000 workers (out of a sector labor force of 68,440,000) work for establishments which offer some health benefits. Cover-
age levels are higher for full-time than for part-time workers, higher for salaried than for hourly workers, and tend to rise with worker income. Female employees show essentially the same coverage levels as male employees. A full 71 percent of businesses, covering 66 percent of employees, pay 100 percent of the health insurance premium for the worker, roughly consistent across industries and business-size classes. However, only 45 percent (covering 40 percent of employees) pay 100 percent of the health insurance premium for the worker and the family. In addition to hospital and surgical expenses, most employees also receive coverage for doctor's office visits, lab tests, and drugs. A surprisingly high percentage (91 percent) are covered for normal maternity expenses as well. The principal benefit areas where coverage is low are routine dental and vision care. A total of 90 percent of covered workers have some deductible provision in their health plan, and coinsurance provisions are present in most plans. Similarly, most plans specify an overa[l maximum to benefits, while relatively few place specific maximums on inpatient expenses. Approximately 30 percent of businesses are insured with Blue Cross/Blue Shield organizations, and approximately 55 percent with commercial insurers. Of the remainder, most participate in self-insured trusts. The rate of labor force turnover appears to be a e_gnificant determinant of whether or not firms offer plans. Tabular data and survey instruments are appended.
Dc_tiptor(s): Health care/services, Private health care plans, Participation in health care programs, Participants in health care programs, Plan design/program provisions (under health plans), Source of premium payment.
26.5. Employment, Unemployment, and Health Insurance. Behavioral and Descriptive Analysis of Health Insurance Loss Due to Unemployment. A. James Lee. National Center for Health Services Research, Hyattsville, MD. 1979, 150 pp. Atailability: Abt Books, Cambridge, MA 02138.
The extent and nature of health insurance loss by the unemployed are examined, and policy implications are developed. Three separate descriptive studies were conducted: (1) a tabulation of private health insurance coverage parameters; (2) an investigation of the distribution of health insurance losses due to unemployment; and (3) a determination of whether and how well medicaid substitutes for private health insurance lost due to unemployment. Findings show that 35 to 39 percent of persons covered by health insurance when they are employed lost: it when
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they became unemployed. Further, no more than 10 to 14 percent of the unemployed losing group health insurance substituted individual nongroup health insurance. The probability of health insurance loss is greatest for workers who are young, nonwhite, unmarried, female, poor, have large families, live in central cities, do not live in the North Central region, and are in selected occupations and industries. The unemployed not eligible for medicaid pay 60 percent of health care costs out of pocket, compared to 14 percent for medicaid-eligibles. The principal recommendation is that insurers and employers permit continuation of group health insurance from a former employer so long as the unemployed worker pays the full health insurance premium amount paid by the employer to the insurer plus any costs borne by the employer in continuing the health insurance, If continuation were offered on this basis, neither the employer nor the insurer would be worse off, and unemployed workers could purchase health insurance at something approaching the group rate. Implications of this study for national health insurance are briefly considered. A discussion of the modeling of the incidence of unemployment among household heads is appended; tabular and graphic data, a 49-item bibliography, and an index also provided,
Descriptor(s): Medicaid, Participants in health care programs, Eligibility requirements, Non-participants in health care programs, National economic conditions, Private health care plans, Non-employment related plans,
266. Enrollment Choice in a Multi-HMO Setting. "Hae Roles of Health Risk, Financial Vulnerability, and Access to Care.
S. E. Berki, Marie Ashcraft, Roy Penchansky and Robert S. Fortus. National Center for Health Services Research, Hyat_.sville, MD.
this study, health risk and economic risk factors are treated separately, and the measure of economic vulnerability is per capita income. Enrollees could choose between three HMO plans and a Blue Cross/Blue Shield plan. They could also choose no plan, and 4 percent chose rather to enroll through the spouse's place of employment, llt was found that enrollees in the open and closed panel HMO ]plans tend to be younger and have younger and larger families than Blue Cross/Blue Shield enrollees. They also have significantly lower per capita incomes, lending support to the effect of the financial risk on choice. It is suspected that were previous studies to be analyzed in terms of per capita rather than family income, inconsistencies would be resolved and the findings in this study reaffirmed. The role of preexisting physician relationships is clear. Those who report that their primary source of care is a private physician are less likely to enroll in an HMO plan, and if they do, will tend to enroll in an open panel one which permits continuation of that relationship. The premium cost for all the plans was identical, so the price of the benefit package was not an important indicator in this study. When eraployed, middle-income popula-tions are given a choice of Blue Cross/Bhie Shield coverage and several HMO plans without a premium differential, this study shows that adverse self-selection is unlikely to occur, individuals with somewhat lower incomes are more likely to enroll in HMO plans, and closed panel HMO groups will attract those individuals without private physicians. Choice of plans is likely to be based on access and other nonfmancial, noncoverage plan attributes. Tables, figures and 20 references are provided. (Author abstract modified)
Article is based on a preseotation at the 103rd Annual M_eting of the American Pubh'c Health Association held November 1975.
Descriptor(s): Service ben:efit plans, Prepaid plans, Competition/interaction among l:hird-party payors, Participants in health care programs.
1976, 20 pp. Avai/abili(y: Medical Care v15 n2 p95-114 Feb 77.
With health maintenance organizations (HMO's), the apparent inconsistencies in previously reported enrollment studies can be resolved by analyzing enrollment choice in a broader conceptual framework. Usually the enrollment decision is analyzed in either medical or economic terms, emphasizing either need-related factors such as previous utilization and health status or the differences in the economic costs and benefits of the alternative plans. The relationship between these two factors is usually expressed as the risk-vulnerability hypothesis, positing that those who run a greater health and economic risk will enroll in HMO plans. The measure of economic vulnerability was family income. In
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267. Entering a Nursing Home. Costly Implications Medicaid and the Elderly.
for
Comptroller General of the United States, Washington, 20548 Nov 1979, 181 pp. A vailabih'ty: General Accounting 20548.
Office, Washington,
DC
DC
Three issues which contribute to the nursing home placement of the chronically impaired elderly are explored in this General
Health Care Programs
Accounting Office Report to the Congress. These issues are (1) medicaid's eligibility policies which create financial incentives to use nursing homes rather than community services, (2) barriers encountered by the elderly and their families who attempt to obtain community service, and (3) medicaid assessment procedures for determining an applicant's need for nursing home care. The report proposes establishing a Preadmission Screening Program with the following components: comprehensive needs assessments for all applicants to nursing homes, assistance in planning and obtaining services to help individuals stay in the community, coordination and monitoring of community care, payment for services outside a nursing home, and control over costs and use. Cost controls could be achieved by limiting reimbursement to some percentage of the cost of the appropriate level of institutional care as determined by the comprehensive needs assessment. The program could be located in the Department of Health, Education, and Welfare (DHEW) with responsibility assigned to public health departments at the State and local levels. Because total program costs are unknown, however, communitywide demonstration projects that use this approach are suggested for several areas. Twenty-two tables, and 12 figures are given. Appendices contain DHEW comments, the GAO evaluation of these comments, and a DHEW letter. (Author abstract modified)
tributing to the current ills of the health care system. During the 1940's and 1950's, public health activity shifted from conquest of infections diseases to meeting the needs of the public for medical care. However, it is not treatment but prevention that must be pursued to achieve large declines in morbidity and mortality, and health departments must organize campaigns against noninfections diseases as they once did against infectious diseases. The experience of countries where a complete national health system integrates preventive-therapeutic services indicares that primary and secondary prevention are facilitated by the system. Community-based primary control should be the major focns, and programs should have three basic components: control of the environment, screening, and health education. Public health schools will have to reverse their current overemphasis on the delivery of health services and accept the primacy of prevention. Even though legislatures have failed to give health departments the administrative responsibility for medical care because of pre_ure from narrow, private interests threatened by public health policies, the National Health Planning and Resources Development Act of 1974, Public Law 93-641, indicates that the erosion of this public responsibility is not irreversible. Furthermore, the Canadian example of national health insurance demonstrates that such programs do not have to follow the European pattern of admin_"tration by agencies concerned with payment rather than health. Public health workers should insist
CompUoller
upon the long overdue reorganization of local health units into area and regional health departments and on the appropriation of sufficient resources for those departments to provide effective service. Forty-nine references are provided.
General's Report
to the COnSTeS& PAD-80-12.
Descriptor(s): Medicaid, Long term care facilities, Policy initiatives, Cost containment efforts.
Descriptor(s): Economic/commercial influences, Health care/ services, Publicly sponsored/mundated health plans, Providers of health care services, Policy/changes re health care. 268. Epideminlogic Revolution, National Health Insurance and the Role of Health Departments.
Milton Terris. 1976, 10 pp. Availabih'ty: American Jnl. of Public Health v66 n12 p11551164 Dec 76.
Public health workers need to wage a stubborn campaign to have health planning functions placed in public agencies which will defend the public interest rather than in private corporations pursuing private concerns. The erosion of Federal health agencies must be forestalled, and the establishment of a Federal department of health responsible for all national health programs, including medical care, must be advanced. Prior to World War II, local and State health departments and the U.S. Public Health Service were the guardians of the people's health, but these programs have since been handed over to private interests and agencies lacking public health competence and con-
269. Episodes of Illness and Access to Care in the Inner City. A Comparison of HMO and Non-HMO Populations.
David S. Salkever, Pearl S. German, Sam Shapiro, Ralph Horky and Elizabeth A. Skinner. National Center for Health Services Research, Hyattsvflle, MD. 1976, 18 pp. A vailability: Health Services Research v l 1 n3 p252-270 Fall 1976.
Data from a 1974 household survey are examined to compare accessibility to ambulatory care for residents of an inner-city area (East Baltimore, MD.) whose usual source of care is a health maintenance organization (HMO)and for residents of the
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same area with other sources of care. Accessibility is measured by the probability of receiving care for an episode of illness. Results from multivariate linear and probit regressions indicate that children using the HMO are more likely to receive care than are children with the usual care sources. No significant differences in the probability of receiving care are found among adults, Evidence of a substitution of telephone care for in-person care is also found among persons using the HMO. Data from a 1971 household survey of the same area suggest that selectivity is not an important confounding factor in the analysis. Although the generalness of findings is purely speculative, there are reasons for believing that similar reorganizations of ambulatory services in other inner-city areas would show a greater impact on accessibiiity than reflected here. This is because the East Baltimore area is atypical in several respects. Its population consists primarily of English-speaking, long-time residents. Furthermore, the variety of care sources available in East Baltimore probably results
services by race decreased considerably between 1967 and 1976. This trend was found both at the national level and at the regional level. Overall, the decreases in the disparity measured are noteworthy. By type of service, proportionally more whites than nonwhites still receive reimbursement. However, once nonwhites exceed deductibles, the reimbursements per person using reimbursed services are generally comparable or higher than reimbursements to whites. Tabular and graphic data, and 14 references, axe supplied. (Author abstract modified)
in lower time costs and less inconvenience relative to areas that are totally dependent on one or two large institutions for ambulatory services. Ten references and 10 tables are provided in the article. (Author abstract modified)
271. Equity in Health Services. Empirical Analyses in Social Poficy.
Descriptor(s):
Demographic
features of population,
Trends in
health status, Prepaid plans, Participation in health care programs, Comparisons of health care programs, Supply/availability of services.
270. Equal Treatment and Unequal Benefits. A Re-examination of the Use of Medicare Services by Race, 1967-1976, Martin Ruther and Allen Dobson. 1981, 29 pp. Availability: Health Care Financing Winter 1981.
Review v2 n3 p55-83
In the early years of the medicare program, proportionately more elderly whites than elderly nonwhites used medicare services. This article examines the use and reimbursement of medicare services by the aged between 1967 and 1976 to determine if racial differences still exist. Three measures are studied. The first, the number of persons reimbursed for medicare services per 1,000 enrollees, measures access to medicare's reimbursement system. The second, reimbursement per person using reimbursed services, measures the amount of reimbursement received after persons exceed medicare deductibles. The third, reimbursement per enrollee, indicates the combined effect of access and reim-. bursement and represents a measure of equity for the population at risk. Analysis of the three measures by type of medicare service found that the disparities in use and reimbursement of
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Descriptor(s): Demand/utilization of health care programs, Medicare, Participants in health care programs, Health care/ services, Reimbursement.
Ronald Andersen, Joanna Kravits and Odin W. Anderson. National Center for Health Services Research, Hyattsville, MD. 1975, 295 pp. A vailabib'ty: Bailinger Publishing Company, 02138.
Cambridge,
MA
Based on data drawn from family interview surveys undertaken to study current public issues in the delivery of medical care, findings from several surveys axe compared and related to current problems. The study's major research commitment is to provide a better understanding of the factors that influence the distribution and use of health services. Its policy commitment is to provide a better understanding of the constraints that must be faced in attempting to provide an equitable distribution of health services. The book's contents are organized around the determinants of health service use initially specified in "A Behavioral Model of Families' Use of Health Services" (Andersen, 1968). It suggests that a person's decision to seek medical care and the volume of services received depends on the predisposition of the person to use services (predisposing), the person's ability to secure services (enabling), and the person's need for medical care (need). The chapters are ordered according to major components of the behavioral model (presdisposlng, enabling, and need), with each analyzing the effect of a variable or group of variables on health service distribution. All of the chapters use data from the national study of health services use conducted by the Center for Health Administration Studies and the National Opinion Research Center in 1971. Tlie predisposing factors examined are age, race, education, beliefs, and family size; the enabling factors considered axe income, health insurance status, and availability of health care resources; the need components analyzed are
Health Care Programs
symptoms experienced, disability days experienced, severity of diagnoses for which a physician was seen, and seriousness of dental care required. One section addresses more basic issues which transcend specific determinants and examines broader issues related to use; these issues include whether medical care improves health status, the patterns of medical care use for those experiencing major illness episodes, and methodological considerations which may influence the conclusions drawn about variotis population groups. The concluding section provides a synthesis of the major issues raised in the analyses. Tabular data, over 100 references, chapter notes, and an index are provided.
Descriptor(s): Demographic features of population, Demand/ utilization of health care programs, Supply/availability of services, Participation in health care programs, Policy/changes re health care.
272. Erosion of the Medical Marketplace.
Joseph P. Newhouse. Rand Corp., Santa Monica, CA 90406 RAND/R-2141-HEW Department of Health, Education, and Welfare, Washington, DC. Aug 1977, 34 pp. Availability: Rand Corp., Santa Monica, CA 90406.
This paper examines three potential marketplace models to determine to what degree they are consistent with sustained price and expenditure increases. All focus on the role of health insurance in causing these increases. The t'u'st is the standard eompetitire model; the second is the competitive model modified to account for technological change; and the third is the competitive model modified to take account of search behavior on the part of consumers. If consumers do not reap rewards from freding an efficient supplier (as most consumers now do not for hospital services), increased prices do not diminish the firm's demand. However, if insurance exists for only a small portion of the market, the insurer can agree to pay only a market rate ("usual, customary, and reasonable"). By contrast, with full or nearly full insurance, it becomes impossible to observe a meaningful market rate, and the theory of price determination is awkward. It seems likely, however, that price increases in this model could be well above the competitive model. For research, there are at least four implications: (1) the assumption of a competitive supply curve may not be useful; (2) estimates of welfare loss from insurance that assume a competitive supply curve may be greatly understated; (3) work is urgently needed on the constraints facing the medical t'n'm, especially the hospi-
tal; and (4) the debate over demand-pull versus cost..push as explanations for inflation in medical care may have been largely beside the point. For policy, the models imply three options: do nothing, regulate, or restructure incentives in order to strengthen price competition among suppliers. Such competition would inelude rating hospital and possibly physician premiums on the basis of the unit price of the hospital and physician. Figures, tabular data, and 24 notes are given. Sources of data and 26 references are appended. (Author abstract modified)
Descriptor(s): Economic/commercial influences, Supply/availability of services, Medical technology impacts, National economie conditions, Impact of third-party coverage, Demand/ut'tlization of health care programs, Competition/interaetion among third-party payors.
273. _te of the Impact of Deductibles for Medical Care Services.
on the Demand
Joseph P. Newhous¢, John E. Rolph, Bryant Mori and Maureen Murphy. Rand Corp., Santa Monicz, CA 90406 RAND/R-1661-HEW Department of Health, Education, and Welfare, Washington, De. Oct 1978, 56 pp. AvMlabib'ty: Rand Corp., Santa Monica, CA 90406.
Using data on insurance premiums for policies with varying deductibles, together with a distribution of medical expense, this study estimates the relationship between deductibles and the demand for medical care. The estimates axe limited to deduetibles in the range of $50 to $1,000 per person per year (1975 dollars). The results indicate that demand is quite sensitive to variation in a deductible in the region of $50 and becomes steadily less sensitive as the deductible rises above $75. The study's results are consistent with a theoretical model of demand for medical care given a deductible, as well as with what is known about the responsiveness of demand to variation in coinsurance. The results show that the size of the deductible will have an important effect on the mount of public funds used in a national health insurance (Nrl-II) program and thereby on the distribution of payments among the population in a tax-fmaneed program. Finally, no evidence was found that an increase in the deductible causes increased expenditures by deterring efficacious preventive care, but the data are not well suited to test this hypothesis. The study method included the estimation of the parameters of a distribution that describes medical care expense (out-of-pocket plus insurance payments), given an insurance plan with a $50
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deductible. Tables, graphs, footnotes, references, and appendices of related technical data are provided. (Author abstract modifled)
Descriptor(s): Deductible/coinsurance, Demand/utilization health care programs, Impact of third-party coverage.
availability research, quality assurance, manufacturing standards, and other areas. Overall, total government spending is as likely to be increased as it is to be reduced under MAC. Tabular data and footnotes are provided.
of Descriptor(s): Methods of payment determination, Medicare, Medicaid, Pharmaceutical services, Present legislation/regulations.
274. Estimated Cost of Implementing the Regulations Limiting Payment Under Federal Health Programs to Maximum Allowable Costs (MAC'S) and Estimated Acquisition Costs (EAC'S).
275. Estimates of HMO Growth and Related Cost Savings 1978-90.
Trapnell (Gordon VA 22044
ICF, Inc., Washington, Feb 1979, 73 pp.
R.) Consulting
Nov 1975, 94 pp. Availability: Trapnell (Gordon Falls Church,
Actuaries,
Falls Church,
R.) Consulting
Actuaries,
Availability:
VA 22044.
Results are reported from a study that,estimates the most likely impact of the new maximum allowable cost (MAC) regulations on net spending by Federal, State, and local governments. The new regulations would revise the formula by which payments are made to pharmacies for prescriptions paid for through State medicaid programs and would encourage the dispensing of lower priced chemically equivalent drugs in all Federal health programs. MAC would result in reductions in Federal, State, and local government outlays for medicaid and medicare benefits for prescription drugs; reductions in Government income-related taxes directly attributable to the reductions in benefit outlays; Federal spending to support the Pharmaceutical Research Board and its staff and consultants; increases in Federal and State outlays for administrative expenses of the medicare and medicaid programs; and an increase in research and regulatory expenses (primarily for the Federal Drug Administration). Federal outlays for benefit payments are estimated to be reduced initially under the new payment procedures. A substantial part of these reductions, however, comes from the profits of corporations that pay Federal income taxes, which are correspondingly reduced. Further, major changes in administrative and regulatory policies would be required, giving rise to increased Government administrative costs. Also, the regulations would base payments on data not now available within the system, thereby increasing costs to obtain and process appropriate data. Further, many low-income persons will be forced to use lower priced drugs which were substituted for the products prescribed by physicians. As a result, the Federal Government will assume an increased responsibility for the quality and therapeutic equivalence of the products that might be substituted. The additional Federal responsibility will lead to a higher level of spending for programs in bio-
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DC 20006
ICF, Inc., Washington,
DC 20006.
This report provides estimates of HMO (health maintenance organization) development, enrollment, and related cost savings to society over the period 1978-90. Annual forecasts of the number of HMO's, HMO enrollment, and annual cost savings under four possible development scenarios are presented. The scenarios are a nontargeted HMO development approach, which attempts to reflect a continuation of previous HMO funding patterns by the Department of Health, Education, and Welfare (DHEW). Three targeting strategies emphasize the following alternative primary objectives: attain highest possible community cost sayings from HMO development (high cost savings strategy), attain highest possible HMO ertrollments (high enrollment strategy), or develop the greatest number of HMO's (high HMO growth strategy). Estimates are given for each of these approaches. The methodology used to develop the forecasts involved establishing the current number of HMO's and enrollment; forecasting HMO growth under the nontargeted approach; modifying the forecasts to reflect impacts of the targeting approaches, using a sample of 20 metropolitan areas; and estimating community health care cost savings using equations previously developed. Five appendices provide detailed information about the assumptions used. These assumptions include estimates of the rate and cost of development of different types of HMO's, their rate of enrollment growth, and the rate of private development and potential HMO failures. A final appendix presents a talking point outline of the estimates and methodology. Tables are provided. (Author abstract modified) Revision
of an earlier report dated December
1978.
Descriptor(s): Health care cost trends/projections, plans, Funding/financing of health care programs.
Prepaid
Health Care Programs
276. Estimates of Preventive Versus Nonpreventive Care Demand in an HMO.
Medical
David R. Lairson and J. Michael Swint. 1979, 11 pp. Availability: 1979.
Health Services Research v14 nl p33-43 Spring
Multiple regression analysis is used to investigate whether medical services in a large health maintenance organization (HMO) are distributed primarily on the basis of need and predisposing factors, such as health status, age, and sex, or according to enabling characteristics, such as coinsurance and income of the population. Equations are formulated to estimate the likelihood and volume of preventive visit demand, nonpreventive visit demand, and hospital admissions for a sample of 3,892 individuals enrolled in the Kaiser Foundation Health Plan of Portland, Oreg. Results point to substantially different relationships between many of the explanatory factors and the different types of use represented in the three dependent variables. Predisposing and need factors arc the main determinants of nonpreventive visits and hospitalization, while enabling characteristics are iraportant determinants (along with age and education) of prevenrive use. Marked differences were also found in the impact of explanatory factors on use by dependents (children) versus nondependents (adults). Perceived health status is the most significant factor in the nonpreventive equations. Hospital use is determined primarily by health status factors. Finally, results reconfirm the importance of education as a determinant of preventive care use in a HMO setting. Three tables and 26 references are included. (Author abstract modified)
costs, and changes in State tax revenues directly attributable to the CIPP program. This same methodology is applicable to various national health insurance (NHI) schemes currently being considered because features of CIPP are shared by nearly all proposed (NHI) bills. The only formal cost analysis of an (NHI) plan so far completed is one prepared by Arthur D. Little, Inc., which studied the cost of covering the entire U.S. population with several variants of the Aetna plan available to Federal employees. Although the study produced a valuable data base, the methodology is not directly applicable to estimating the costs of most (NHI) proposals because the benefit structure of the Aetna plans differs from proposed (NHI) plans. Aetna bases benefits on expenses incurred by enrollees taken individually and the benefits do not vary with the income of the insured. In contrast, many (NHI) proposals have benefits that are based on total family expenses and vary according to family size and income. The provisions of the CIPP program are outlined, and the costs to the State are estimated based upon three different assumptions concerning the extent of private health insurance coverage and two different assumptions concerning the size of administrative costs based upon medicare and medicaid experience. The estimated costs are strongly influenced by the level of private health insurance coverage. Some people will drop their private coverage entirely, and perhaps more importantly, the benefit structures of private health insurance will change in order to take maximum advantage of CIPP coverage. In both cases, the effect will be to raise the cost of CIPP above the cost
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Preventive services, Participants in health care programs,
based on the assumption that the level of private health insurance remains unaffected. The true cost is more likely to be in the neighborhood of $4 billion. Were the CIPP plan to become effective, a surge in demand would be produced for medical care that individuals might have put off, and this would further increase costs, but not in the long run. Hence, this cost estimate for 1975 treats demand for services as if the program had been in effect long enough to overcome this surge. Tables, and 17 references are provided.
277. Estimating
Descriptor(s): Health information/data systems, Health care cost trends/projections, Economics of third-party payors, Plan design/program provisions (under health plans), Policy initiatives.
the Cost of Health Insurance Programs.
David M. Barton and Robert H. Smiley. Regional Medical Programs Service, Rockville, MD. 1976, 12 pp. Availability: Inquiry el4 nl p51-62 Mar 77.
278. Ethical and Economic Aspects of Governmental vention in the Medical Care Market.
Inter-
A methodological framework for estimating costs of proposed insurance programs is developed and then applied to a modified version of the proposed Catastrophic Insurance Protection Plan (CIPP) for New York State. Although the costs of raising the revenues to finance the program are not included, the framework considers the costs to the State for claims expense, administrative
Reuben A. Kessel. American Enterprise Inst. for Public Policy Research Center for Health Policy Research, Washington, DC 20036 May 1977, 12 pp. Av_labiffty: American Enterprise Inst. for Public Policy Research, Washington, DC 20036.
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This pamphlet presents the text of a speech made by a prominent scholar of the history and economics of American medical care shortly before his death in 1975. The speech concerns the ethical and economic aspects of government intervention in medicine and is based on academic research. The arguments are especially relevant to the ongoing debate about government health policy, The central theme is that the government is now trying to solve many problems in medicine that have resulted from prior government intervention. It is contended that the concern about rights of access to medical care today is related to a lack of concern in the past about rights of access to physician training, Discrimination in academic medical education is traced back to the pre-World War I period, when the medical profession induced State legislatures to turn over the right to rate medical schools to a subdivision of the American Medical Association and established graduation from one of these schools as a necessary condition for admission to licensure examination. If there had been more concern about the rights of access to medical training and an adequate supply of medical care, there would now be less concern about access to medical care. Provision of
tivity. In addition, it became apparent that successfully combining industrial engineering and other productivity techniques with hospital management was difficult to effect. Notwithstanding these concerns, the consensus was that the importance of productivity within the health services context was increasing, that changes in productivity could be measured without universal agreement on standards, and that the effective incorporation of productivity concepts would require an extensive educational effort. Specific topics addressed in the papers included the concept of productivity, the relationship between productivity and cost containment, productivity and the voluntary effort, using productivity in management, the hospital administrator and productivity, and applications of productivity to the market. Program participants and contributors included hospital administrators, physicians, nurses, and other health care professionals throughout the nation. Hospitals are already beginning, although hesitantly, to apply productivity techniques and measures to their operations. A few footnotes and tables are provided with some papers. Conference participants are listed.
services regarding blood, eyeglasses, and drugs is another
Report of the 1979 NationM AffMrs.
area
where government intervention has restricted the private market to the disadvantage of consumers. The failure to have governmental representation of consumer interests in the medical care market is caused by an imperfection in the political marketplace, where producers consistently outbid consumers for the votes of legislators. Seven notes and 11 references are provided. AEI
Occasional Paper Series, Reprint
Forum
on Hospital
Descriptor(s): Hospital se:rvices, Inpatient evaluation of health administration.
facilities,
of services, Pre-
280. Evaluation of Alternative Payment Strategies tals. A Conceptual Approach. William O. Cleverley. 1979, 11 pp. Availability: Inquiry v16 n2 p108-118 Summer
Hospital
for Hospi-
1979.
Productivity.
B. Jon Jaeger. Duke Univ. Dept. of Health Administration,
Durham,
NC
27710 Duke Endowment, Charlotte, NC. 1979, 82 pp. Availability: Duke Univ., Dept. of Health Administration, Durham, NC 27706. Papers presented at the 1979 National Forum on Hospital and Health Affairs are collected in this volume. The purpose of the forum was to refocus attention on the efforts of health administrators to increase efficiency through improving productivity, Definitional concerns surfaced early in the program, as well as problems regarding the most appropriate measures of produc-
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Outcome/
67.
Descriptor(s): Physicians, Supply/availability sent legislation/regulations.
279. Evaluating
and Health
In this paper, alternative payment systems are evaluated according to their perceived attaimnent of certain criteria. A payment system should promote tlae efficient production of providers' services, offer a level of viable reimbursement for providers, require minimal administrative cost, and provide for equitable reimbursement payments from multiple purchasers. One of the major advantages for prospective as opposed to retrospective rate setting is the presumed incentive provided for efficient operations. However, these improvements are limited in the main to improvements in technicM efficiency, input combinations, or reductions in input prices. One of the primary outcomes of prospective rate-setting is the shifting of risk from third-party payers to hospitals. This transfer of risk would likely increase the probability of failure, especially in the short run. The condition could be moderated by action, such as establishing initial high rates, allowing liberal retrospective adjustments, or reimbursing the
Health Care Programs
maximum of costs or the prospectively set rates. In each case, the improvement in viability is likely to reduce the incentive for efficiency. However, an analysis of this trade-off suggests that more would be gained by prospective rate setting in terms of improved efficiency than might be lost through impaired liability. Prospective rate setting would also require greater administrative costs than retrospective rate setting. It would also use both retrospective and prospective data in the decisionmaking process. Therefore, highly skilled administrators should be eraployed to minimize anticipated cost increases. This paper coneludes that a prospective cost-based reimbursement system predicated on departmental budgets would be the optimal form of reimbursement. Since these budgets reflect a fixed-dollar amount, some method of apportionment among payers must be developed. For major third-party payers, such as Blue Crossmedicare, and medicaid, actual or projected percentages of departmental utilization could be used. For self-pay patients or small third-party commercial insurance companies, an actual approved unit rate could be developed by dividing the approved budget by anticipated volume. Finally, some adjustments could be made to reflect actual differences in volume or costs if they were noncontrollable, such as increases in liability insurance premiums or fuel costs. Over 30 references and notes are provided.
Desclqptor(s): Inpatient facilities, Commercial health insurance plans, Service benefit plans, Impact of third-party coverage, Voluntary initiatives, Outcome/evaluation of health administration, Methods of payment determination.
pertinent literature; a review and evaluation of comments on the criteria; a report on an independent analysis of the criteria using a Canadian data set; and, drawing upon all the earlier pieces, final conclusions regarding the usefulness of the criteria and suggestions for improvement. A major conclusion of the evaluation is that the HMSA criteria permit entities to be designated that are characterized by quite different economic market conditions without explicitly identifying them by such characteristics. As a result, a "health manpower shortage area" cannot be clearly defined. Moreover, the same remedial policies are not likely to be appropriate for all of the types of market conditions that the criteria are likely to identify. The source of this problem may be the criteria's attempt to respond to several sometimes inconsistent policy objectives. Notwithstanding this important underlying shortcoming, a number of possible improvements to be made in the current criteria were identified. Extensive tabular and graphic data are supplied. Over 100 references are included. (Author abstract modified)
Descriptor(s): Supply/availability of services, Outcome/evaluation of health administration, Demand/utilization of health care programs, Present legislation/regnlations, Comparisons regardLug foreign health policies.
282. Evaluation of Health Manpower Shortage Area CYiteria. Literature Review.
Barbara H. Kehrer, Natan Szapiro and Judith Wooldridge. Mathematica Policy Research, Inc., Princeton, NJ 085.40 281. Evaluation of Health Manpower Shortage Area Criteria. Final Report.
Mathematiea Policy Research, Inc., Princeton, NJ 08540 Health Resources Administration, Washington, DC. Div. of Manpower Analysis. Jul 1979, 362 pp. Availability: Mathematica Policy Research, Inc., Princeton, NJ 08540.
Designation of Health Manpower Shortage Areas (HMSA's) plays a key role in Federal programs to effect a redistribution of health manpower. Criteria for designating such areas were developed by the Department of Health, Education, and Welfare in accordance with guidelines provided in the Health Professions Educational Assistance Act of 1976. This report is the result of an evaluation of those criteria, conducted under contract with the Health Resources Administration. The report consists of five major pieces: a detailed exposition of the criteria; a review of
Bureau of Health Manpower, Hyattsville, MD. Sep 1979, 89 pp. A vMlability: Mathematiea Policy Research, Inc., Princeton, NJ 08540.
As part of an evaluation of criteria for identifying Health Manpower Shortage Areas (HMSA), literature on access to health care, availability of health manpower, need for health care, and rational service delivery areas was reviewed. Initially, definitions and measures of access were addressed. Several ratios of population to health resources used to indicate adequate access were identified; the 30-minute travel time to a physician was found to be a widely used measure. Discussions of process measures, such as office waiting times and prices of care, were assessed, as were outcome measures. The only outcome indicator used in the HMSA standards is low utilization of office visits. Because the HMSA criteria focus on the availability of health manpower and the need for health care, these areas were examined in detail. A particular area for concern was criticism of ratios which use unadjusted population and manpower counts. The literature on
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need contained both direct and proxy measures, such as morbidity rates, mortality rates, years-of-life-lost indices, infant birth weights, demographic descriptors, and income of population. Studies showed that high need for health care may not always be expressed in effective demands, particularly when barriers to access exist. The review of methods to defme rational health delivery areas described the hierarchical nature of service areas
Descriptor(s): Cost containment efforts, Private health care plans, Plan design/program provisions (under health plans), Voluntary initiatives, Methods of payment determination, Government employee plans.
and providers' positions. Many studies concerned difficulties in defining market area boundaries. Overall, the HMSA criteria
284. Evaluation
emphasize
Howard S. Frazier and Howard H. Hiatt.
availability, but the regulations
for assessing availa-
of Medical Practices.
bility have been widely criticized. Measures for need appear to be adequate, but a major gap in service delivery research was identified as the definition of an urban geographical shortage
1978, 4 pp. Availability:
area. Tables and about 120 references
Evaluation of the efficacy of a medical intervention requires valid measurements of bot]a its benefits and risks as compared with those of alternative fiarms of management. The requisite measurements are more difficult to make than this simple description suggests, and the accumulation of information is further inhibited by certain characteristics of our pattern of health care. These features include, for example, discontinuous care by a variety of unrelated providers, inadequate records, the autonomy of physicians as decisionmakers, financial disincentives, ambiguities in what we mean by "experimental" and "accepted" forms of therapy, and failure to see continuing evaluation as a necessary component of the cost of providing good medical care. Although no single change will solve all the problems of evaluation, several offer promise of improving our ability to choose from among medical interventions those most likely to be useful. These include organizing medical services so that primary care
Descriptor(s): Supply/availability tion of health care programs,
283. Evaluation
of Market
are included.
of services, Demand/utiliza-
Mechanisms
of Cost Control.
Jon M. Kingsdale. Government Research Corp., Washington, DC 20036 1979, 67 pp. Availability: Government Research Corp., Washington, 20036.
DC
Science v200 n4344 p875-878 26 May 78.
This report evaluates the practical difficulties and the potential advantages of four private sector models for financing and delivering health care services. The models include (1) a capitated primary care network in which the insured's personal physician assumes some control over and financial stake in the cost and
and comprehensive health data collection are available to all citizens, keeping record systems in uniform or compatible fashion, and using new procedures on an experimental basis only until their usefulness has been validated. In addition, methods should be developed that enable all physicians and patients in-
quality of all health services for that patient; (2) an individual practice association (IPA) in which an organization of local physicians practice systematic utilization review and financial risk sharing; (3) a per-case payment system, consisting of a reim. bursement arrangement which rewards the physician in charge of an episode of care for containing the institutional cost of that episode; and (4) a capitated specialty group, consisting of a per capita reimbursement arrangement with an existing group practice for most specialty services. Individual sections provide a description of the model, a summary evaluation, and a detailed evaluation. The detailed evaluation discusses such factors as
volved in a new intervention to participate in organized trials. Medical education should be broadened to include quantitative analytic methods, and society must understand that a major investment is desirable to develop ways to collect, analyze, and store medical data. Twenty-seven notes and references are included. (Author abstract modified)
front-end capital requirements and administrative costs and problems, self-selection of high-risk beneficiaries, legal problems, minimum enrollment requirements, and impact on the cost of care for enrollees and nonenrollees. Other factors include nonfinancial incentives and disincentives for employee participa_ tion, incentives and disincentives for employer and provider par.. ticipation, evolutionary prospects, and financial outlook. Charts and tabular data are given.
I- 130
Descriptor(s): Outcome/ewaluation cians, Cost/benefit analyse_.
of quality assurance,
Physi-
285. Evaluation of the CAT Scanner and Other Diagnostic Technologies. H. David Banta and Barbara J. McNeil. Henry J. Kaiser Family Foundation, Palo Alto, CA. James Picker Foundation, Mamaroneck, NY. 1978, 13 pp.
Health Care Programs
Availability: Health Care Management Winter 1978.
Review v3 nl p7-19
Medical technology as a whole is a major contributor to increases in the cost of medical care. The development and diffusion of the Computer Assisted Tomography (CAT) scanner illustrates the need for careful evaluation of new diagnostic procedures. The CAT scanner, introduced into the United States in 1973, has been hailed as the greatest advance in radiology since the development of x-rays. It produces a cross-sectional image of the human body and has been used to diagnose a wide variety of pathological conditions. It has been accepted by the medical community with extreme rapidity and enthusiasm, but it is extraordinarily expensive, and despite the growing number of manufacturers and the increasing number of machines, neither the selling price nor the fee per examination seems to be decreasing. The case of the CAT scanner clearly illustrates the need to formulate a precise set of criteria for evaluating a priority the magnitude of the benefit that is likely to be achieved from the introduction of a new technology. Measuring the diagnostic value of new tests is relatively easy compared to measuring health outcomes. However, evidence of benefit is needed before widespread diffusion of a new technology is allowed to occur, Mechanisms already exist for determining efficacy of medical devices through the 1976 Medical Device Amendments to the Food and Drug Act, but information being collected under these provisions is almost entirely technical. In the absence ofinformation about medical efficacy, local health planning legislation or public and private third party payers could restrain diffusion, With the CAT scanner, many third party payers are withholding payment for body scans until more information is available, Even with constrained diffusion of a new technology, additional steps should be taken to assure proper utilization through professional standards review organizations. Thus, it is clear that expanded efforts on the national level are needed to develop appropriate diffusion of new technologies. Figures, tables and 38 references are provided. Parts of this article were presented at a conference, "'Health Care in the American Economy. Issues and Forew._sts, "Hilton Head, SC, January 18, 1977. Descriptor(s):
Medical technology
impacts, Diagnostic services.
286. Evaluation of the Formation and Operation of Health Care Delivery Systems for Public Assistance Beneficiaries Enrolled in Prepaid Health Plans in California. Terry M. McGann. 1975, 256 pp. Availability: University
Microfilms International, Ann Arbor,
MI 48106. This dissertation presents findings from a study focusing on the formation and operation of prepaid health plans (PHP's)in California. In August 1974, questionnaires were mailed to 42 PHP's throughout the State. The 16 respondents had average enrollments for the 1-year presurvey period of approximately 5,000 members. No fmancial statements or operational records were examined, although all respondents were in positions ofauthority within the PHP's. PHP's were established for the purpose of reforming existing public assistance medical care programs, as specified in 1971 State legislation. Since its inception, the PHP program has been the subject of controversy and criticism, and most observers agree that much of the criticism is justified. PHP's lose approximately 6 percent of their eligible members, each month and because of high membership turnover, are not as effective as health maintenance programs. In addition, the State administration of the PHP program is almost universally condemned. Major fmdings of this study, as concluded from questionnaire responses, are generally consistent with previous inquiries into the PHP program. The survey included 4!; primary questions in 8 areas: respondent, organization, investment, contract negotiations, decisionmaking, finance, enrolhnent, and consultants. Medical groups represented the major participants in the development of PHP's, but most of the tasks necessary to formulate and operate PHP ventures were assigned to management companies. The average amount of working capkal available for PHP ventures was approximately $140,000, of which over half was expended in door-to-door enrollment activities. Most PHP's viewed one another quite negatively. State administration was perceived as very inadequate by 15 of 16 respondents. Study findings should be considered with caution, due to t]ae limitations of the number of respondents and the fact that no records of the PHP's were personally reviewed. The PHP survey, 202 footnotes, and 24 exhibits are provided. (Author abstract modifled) Submitted in partiM fulfillment of the requirements [,'orthe degree of Doctor of Philosophy to Claremont Graduate School, 1975. Descriptor(s): Outcome/evaluation of health administration, Prepaid plans, Publicly sponsored/mandated health plans, Participants in health care programs.
287. Evaluation of the Maximum Allowable Cost (MAC) for Drugs Program. Phase I Report. Final Design Report and Report of Pilot Study Analysis. A. James Lee, Dennis L. Hefner and Ralph Hardy. Abt Associates, Inc., Cambridge, MA 02138
1-131
Health Care Financing Administration, Washington, rice of Research, Demonstrations, and Statistics. Aug 1980, 318 pp. Availability: Health Care Financing Administration, Publications, Baltimore, MD 21235.
DC Of-
ORI)S
Various companies' programs for improving employee health are described. Studies using experimental and control groups have shown that employees using daily exercise programs show greater job productivity and sal:isfaction than employees not participating in such exercise. These findings have led many corporations to invest in equipment, facilities, programs, and
This Phase I report gives the final research design for evaluating the Maximum Allowable Cost (MAC) for Drugs Program. It also reports results from the Massachusetts pilot study, including the finding that the Massachusetts medicaid program was saving between $1.2 and $2.2 million annually, or 3.2 and 5.9 percent respectively, of total drug reimbursement expense. The data for the survey of medicaid drug programs were obtained through a telephone survey of program managers. The survey explored (1) reimbursement methods, (2) program restrictions, (3) program administration, (4) pharmacy participation, (51)substitution, and (6) data availability. The results are presented in tabular form. The pilot study evaluating the MAC/EAC (Estimated Acquisition Cost) program's impact on State medicaid expenditure in Massachusetts is based on the program's Price File and Drug Analysis Profile_ The results indicate that the MAC/EAC program has achieved a substantial saving in the State. During the 12 months ending March 1979, the program saved the State between $688,479 and $1,185,400 and should save the State between $1,276,766 and $2,248,150 during tlhe 12 months ending March 1980. Savings occurred through the: substitution of lower priced generic products. Manufacturers affected by the MAC program do not appear to have raised prices on other products within the same therapeutic category. The pilot study clearly demonstrates the feasibility of compiling State claims data for use in evaluation of the MAC program. The
personnel that will improve employee physical fitness. One company has an annual 2-week physical training retreat for executives to help them develop and maintain healthful activities.
study includes complete data used in the evaluation, an overview of the pharmaceutical marketplace, and a review of relevant
William Pollak. Urban Inst., Washington, UI-1215-11
literature. Atx)ut 70 tables and footnotes are included. A bibliography of 35 citations and the survey instrument used in the State survey are appended. Health
Care Financing
Grants and Contracts
Report
Sends.
Descriptor(s): Cost containment efforts, Medicaid, I'harmaceutical services, Outcome/evaluation of health administration, Health information/data systems.
288. Executive
Fitness Aids Corporate Health.
David Clutterbuck. 1979, 4 pp. Availability: International 80.
I- 132
Management
v35 n2 p19-22 Feb
Other companies design individual fitness programs for executires based upon comprehensive physical exams. Improvements in health are regularly monitored. Meditation exercises are taught in some company health programs, so that employees can better handle job pressure_ that might cause mental and physical deterioration. As incentives for participating in company health programs, competitive goals oriented toward good health are set by some corporations. One company pays employees for each mile they cycle, walk, run, or swim. The article notes that some managers who are highly competitive may attempt too much and injure themselves. However most companies with controlled health management programs carefully monitor this type ofemployee and offer counsel on how to set safe personal health goals. Descriptor(s):
Cost containraent
efforts, Preventive
services.
289. Expanding Health Benefits for the Elderly. Volume I. Long-Term Care.
DC 20037
Administration on Aging, Washington, DC. Ford Foundation, New York, NY. Feb 1979, 97 pp. Availability: Urban Inst., Washington, DC 20037.
This monograph is one of a series developed for the Department of Health, Education, and Welfare's Administration on Aging. The purpose of the series is to bring together information on health policies affecting the elderly for use by policymakers, researchers, and the general public. Long-term care, the topic of this work, refers to health and social services that are provided within or outside an institution over an extended period to chronically ill, functionally ivapaired persons, most of whom are elderly. It is widely recognized that public financing of long-term care, primarily through medicaid, emphasizes institutional care. Although many persons have advocated coverage of noninstitutional services, little attentiola has been paid to certain critical issues in the design of a more comprehensive program. In this
Health Care Programs
work, options regarding services that can be offered, criteria for eligibility and service allocation, organization of service distribution, patient cost sharing, and administrative location of a broadened long-term care program are explored. Limited evidence on service costs indicates that expanding present coverage of noninstitutional services would increase public expenditures because services would be used by persons not presently receiving formal or covered long-term care. With estimates of program costs ranging as high as $27.1 billion for 1985, the need for mechanisms to encourage cost-effective service delivery is obvious, Several organizational options are discussed, all of which are based on the channeling of long-term maintenance, social, and personal care financing through a single social agency. Local agencies may receive funds either through a fixed budget plan or through open-ended financing. In allocating benefits, a local agency may subsidize consumers or pay providers directly. In addition to making financial decisions, a cost effective long-term care program must assign responsibility for the coordination of services to each beneficiary. Finally, a structure for cost sharing and departmental responsiblity for long-term care are considered. Four tables and 76 footnotes are included in the monograph. (Author abstract modified)
denotes one of the major gaps in medical insurance available to the elderly. Currently, medicare's Part B benefits package exeludes outpatient drugs despite support for inclusion by many sectors. Support for inclusion is based on the magnitude of the elderly's drug expenditure and the inadequacy of available thirdparty insurance plans. For some individuals, annual prescription costs absorb a significant portion of income. Elderly enrollment in private insurance plans offering drug benefits has increased steadily in the last decade. In addition, most State rrtedicaid programs offer drugs as a covered benefit for the elderly indigent. However, both of these sources of payment fall short of adequate protection. Expansion of private insurance plans or more uniform medicaid drug benefits across States are two alternatives for increasing third-party coverage. A third alternative would be a public program designed specifically to pay the costs of prescription drugs for the elderly. Detailed policy analysis is required to maximize advantages while minimizing risks, such as increased unnecessary use of drugs. Various aspects of program design, including terms of eligibility, scope of the benefits package, and distribution mechanisms, are discussed. Overall, the evidence indicates that a drug insurance program will work if its design is carefully considered. Six tables and 96 footnotes are included. (Author abstract modified)
Health Policy and the Elderly Series. Health Poh'cy and the Elderly SeaT"es. Descriptor(s): Demographic features of population, Health care costs, Home health services, Intermediate care facilities, Long term care facilities, Policy initiatives, Medicaid.
Descriptor(s): Third-party payors, Pharmaceutical services, Exclusions from coverage, Ftmding/finaneing of health care programs, Policy initiatives, Medicare, Present leglslatiort/regulatious, Private health care plans.
290. Expanding Health Benefits for the Elderly. Volume H. Prescription Drugs. 291. Expenditures Karen Lennox. Urban Inst., Washington, UI- 1215/3
for Health Care. Federal Programs and
Their Effects. DC 20037
Administration on Aging, Washington, DC. Ford Foundation, New York, NY. Feb 1979, 72 pp. Availability.. Urban Inst., Washington, DC 20037.
This monograph is one of a series developed for the Department of Health, Education, and Welfare's Administration on Aging. The purpose of the series is to bring together information on health policies affecting the elderly for use by polieymakers, researchers, and the general public. This work examines policy mechanisms, including reimbursement, distribution, cost sharing, utilization review, and claims administration, with sensitivity to the risks as well as the advantages of expanded drug coverage. Lack of coverage for out-of-hospital prescription drugs
Stanley Wallack, Bonnie Lefkowitz, Sinclair Coleman
and
William L. Duma. Congressional Budget Office, Washington, DC 20515 Oct 1977, 76 pp. A vnilability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 052-070-04164-1.
This paper reviews the trends in health expenditures, the effectiveness of current regulatory efforts, and possible cost.containment strategies with particular reference to hospital expenditures. Between fiscal years 1950 and 1976, personal health costs increased from $10.4 to $120.4 billion. The increases can be attributed to population growth, higher medical care prices, and increased use of medical services. Higher l:_ricesfor
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medical care explain 55 percent of the increase over the eatire period but 78 percent in the past 3 years. Demand per person has been spurred by higher incomes, more insurance coverage, and Government subsidies for health care. In 1976, insurance covered about two-thirds of all personal health expenditures, up from about 28 percent in 1950. In 1977, medicare and me&caid, the major Federal health care f'mancing programs, will e.ack_pay for the care of roughly 25 million persons at a cost to the Federal Government of about $32 billion. These two programs, along with other Government programs, directly encourage or subsidize greater use of health care by the aged and the poor, two groups who used to have only limited access to such care. Increases in both private and public insurance coverage, i_ the number of hospital beds and physicians, and in the complexity of medical care technologies have acted together to raise total and per person hospital expenditures. Due to the prevaler:ce of health insurance, more than 90 percent of hospital revenut_ are received from third parties, so little incentwe exists for patients or physicians to limit hospital usage. Thus, three limited regulatory programs have been adopted to try to contain hospital expenditures. These efforts attempt to reform reimbursement procedures, arrest the growth of hospital facilities and equipment, and eliminate overuse of hospital services. Alternative strategies for containing health costs are also discussed. "fables and footnotes are supplied.
1trick%round Paper. Reprint
of repolr Jat_
292. Expenditures for Health Care of Ch_!2-xe_ and. _t'eut_! i__ the United States.
v17 n! p4044
_an 7_.
Health care expenditures for children and youO__in tt_e U,lited States are described and analyzed_ In fiscal year 1975, AmeNcans spent an estimated $103.2 billion for personal health care. Fifty-six percent of health expenditures were for those aged 19 to 64 years, 29 percent were for those age 65 and over, and 15 percent were for children and youth under 19 years. Although children and youth represented 34.7 percent of the U.S. population in 1975, they received only 149 percent of total health
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Descriptor(s): Publicly sponsored/mandated health plans, Medicaid, Policy initiatives, ]Health care cost trends/projections.
Aog_._t _97Z
Descriptor(s).. Demand/utilization of health care programs, Health care cost trends/projections, Cost containment efl0rts, Impact of third-party coverage_ Medicare, Medicaid, P_ ivate health care plans, Present legislation/regu_ati_,:_, H:_pii_i setvices, Inpatient facilities,
Helen M. Wallace. 1977, 5 pp. AvMlnbilitk:. Clinical Pediatrics
e,_penditures. This suggests that the present policy of allocating health expenditures by age group needs review. This is especially true m view of the vulnerability of children and youth and of the need for basic preventive services in this age group. In addition, the increase in per capita expenditures for health care for children and youth rose from $175.66 to $212.14. Public sources supplied 24 percent of total laealth expenditures for children and youth in 1975. Medicaid and the U.S. Department of Defense through the CHAMPUS (Civilian Health and Medical Programs of the Uniformed Services) program alone provided threefourths of all public funds. ]3"orchildren and youth, two-thirds of all health expenditures were for hospital care and physicians' services. The article notes that no iegislation, comparable to the newly proposed Hospital Cost Containment Act of 1977, has been proposed to limit expenditures tbr physicians' services. The article further suggests comparing the $212 per capita expendirare figure with per capita expenditures for health care in selected programs, such as that of $139 for the national Head Start program. Five tables and four references are given. (Author abstract modified)
293. Exploratory Study of the Acceptance of Current Federal Health Care Policy by Hospital Administrators, Trustees, and Physicians.
William J. McCawley. t980 244 pp. _,__'a_Tability:University M[ 48106.
Microfilms
International,
Ann Arbor,
This study focuses on the acceptance of current Federal health care polic2_ by hospital administrators, trustees, and physicians. _t'he research is based on the assumption that hospitals' acceptante of the National Health Planning and Resources Development Act of 1974 (Public I,aw 93-641), can be determined by surveying the opinions of t:_ustees, administrators, and physicians of 33 hospitals in the health systems agency (HSA) of Northeastern Pennsylvania. The survey instrument was mailed to a random sample from these three groups of professionals; the overall return rate was 61 percent. The survey instrument was t_ased on reviews of the literature and the law and interviews with experts in the field. Reliability was tested by factor analysis. Extensive analysis resulted in five separate indices: regional planning, quality of health cart;, general cost containment, cost/ duplication of services, and physician extender. The survey indicated that the goals of planning, cost containment, and quality
Health Care Programs
of health care are acceptable to the hospital groups, but the means of achieving these goals (i.e., HSA regional planning) are not. The attitudes of the three groups tend not to differ significantly on most health planning indices, except doctors scored significantly lower than trustees and administrators on the quality of care index. Acceptance of health planning seems to depend more on being hospital dominant than on position. Correlation and regression analysis were used to determine whether background or demographic variables account for differences in response by position. No background factor was found to be significant on all indices for any of the respondents. A three-way •analysis of variance was undertaken to determine if organizational factors such as location and auspices of a hospital influenced health planning attitudes. In general, voluntary hospitals were more favorable to health planning, except for State hospital doctors on quality items. It is concluded that cost containment should be the major thrust of future Federal efforts, that a national health service should be sought, and that future study should focus on other HSA regions. Footnotes, 49 tables, a glossary, a bibliography of approximately 240 references, and appendices are included. (Author abstract modified)
fer wealth to upper income groups without significantly improvhag the utilization of health care services. A study of drug manufacturing and retailing systems in Canada and of the structure of dental services suggests that wasteful methods ofser_dce delivcry are a key factor in the high costs of pharmacy and dentistry. Changes in the process of delivery could lower per capita costs by 30 to 40 percent. Potential annual savings in phamaacy and dentisty together in Ontario run into the hundreds of millions of dollars. A combination of competitive pressures and selective public intervention can be used to rationalize the delivery system, but such potential savings will be forever unrealized if a public-insurance type of program is introduced which freezes the existing system in place and forecloses the options of either public provision or private market competition. Footnotes, figures, 9 tables, and a bibliography of about 200 references are provided. Appendices include an analysis of risk-spreading and the gains or losses from insurance, an estimate of the cost of a deductible pharmacare program compared with Manitoba experience in 1975; some current price data on retail pharmacy and a discussion of care utilization and dental health. (Author abstraet modified)
Submitted in partial ful[illment of the requirements for the degree of Doctor of Social Work to Adelptu" Univ., Graduate School, 1980.
Ontario Economic
Council Research
Studies Series, No. 13.
Descriptor(s): Dental services, Comparisons regarding foreign health policies, Pharmaceutical services, Cost/benefit analyses. Descn'ptor(s): ties.
Present legislation/regnlations,
Inpatient facili-
295. Fact Book on Aging. A Profile of America's Older Population. 294. Extending Canadian Health Insurance. Options for Pharmaeare
and Dentieare.
R. G. Evans and M. F. Williamson. 1978, 276 pp. Availability: University of Toronto Press, Buffalo, NY 14203. This study explores the policy options a Provincial Government might consider in extending health care coverage to the purchase of prescription drugs and dental care. It examines the major public policy objectives involved, such as spreading risk, redistributing wealth, and reducing the barriers to care, and evaluates alternative programs in terms of their costs and efficiency as well as their realization of the basic social objectives of health care. Using varied statistics, some drawn from schemes in other Provinces, it estimates what different packages of pharmaeare and denticare would have cost in Ontario in 1975. The results indicate that universal coverage may be one of the most costly and least effective options. Based on current modes of service delivcry, a universal pharmacare and denticare program would trans-
Carole Allan, Elizabeth Douglass, Charles Harris, Valinda Jones and Jeffrey Lewis. National Council on the Aging, Inc., Washington, DC 20036 Weyerhaeuser Foundation, Inc., St. Paul, MN. 1978, 263 pp. Availabih'ty: National Council on the Aging, Inc., Washington, DC 20036. This volume deals with eight aspects of the older population in America: demography, income, employment, physical and mental health, housing, transportation, and criminal victimization. The surveys, studies, and literature used to compile this compreheusive volume reveal a great variance within the older population and its failure to conform to the stereotyped myth of the aged as sick, frail, poor, victimized, and unproductive. Their problems are deemed to stem from the inevitable natural decremerits of old age, the income and tax structure, housing policies, and the judicial and law enforcement systems. Specific information in the chapter on demography addresses age distribution
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and trends, social characteristics such as sex and race distribution, marital status, living arrangements, geographic distribution, and education. The elderly can generally be described as a low-income group with nearly 25 percent in the categories poor or near poor The effects of inflation and special income needs of the elderly are analyzed at length. Employment figures justify the projection that by 1990 one in six males over 65 will be unemployed. Information provided on the health status of the elderly covers mortality statistics, specific kinds of impairments, utilization of health services, and health care costs in terms of expenditures and sources of funds, particularly medicare. Under mental health issues, life-crisis reactions, functional disorders, and organic brain disorders are considered along with special factors leading to mental illness among the elderly. Mental health services are analyzed in terms of trends and needs. Additional chapters point out the need for improved housing and transportation for the elderly and the importance of victim compensation or emergency assistance programs for the elderly in addition to crime prevention strategies. Extensive charts and
priced services or an increase in the number of services could cause the total medicare reimbursements per beneficiary to continue rising at an inflationary rate. The study also found that the average allowed charges affect not only reimbursements but also the proportion of beneficiaries who reach the deductible, which relates to disparities by State. The highest priced areas tend to be the same each year, and these areas will have the highest percentage of medicare beneficiaries who receive benefit payments; the reverse is also true. Low-priced areas will consistently have the lowest percentage of medicare beneficiaries. Tabular data and footnotes are supplied.
tables are provided and references are given.
297. Factors Affecting the Choice Between Prepaid Group Practice and Alternative Insurance Programs.
DesczT)Ttor(s): Demographic
features of population,
De,'criptor(s): Medicare, Methods of payment determination, Present legislation/regulations, Participants in health care programs, Reimbursement,
Medical/surgical
services.
Trends in
health status, Demand/utilization of health care programs, Medicare, Health care/services, Health care costs.
296. Factors Affecting Differences in Medicare Reimbursements for Physicians' Services.
Richard Tessler and David Mechanic. Milbank Memorial Fund, New York, NY. Robert Wood Johnson Foundation, Princeton, NJ. 1975, 24 pp. Availability: Milbank Memorial Fund Quarterly/Health
and
Society v53 n2 p149-172 Spring 1975. This paper examines the basis for the selection of prepaid group
Marian Gornick, Marilyn Newton and Carl Hackerman. 1980, 23 pp. A. vailability: Health Care Financing Review vl n4 p15-37 Spring 1980.
Under Medi_are's Part B program, wide variations are found in a,,erage reimbursements for physicians' services by demographic c:aaracteristics of the beneficiaries. Average reimbursements per beneficiary enrolled in the program depend on the percentage of enrolled persons who exceed the deductible and receive reimbursements, the average allowed charge per service, and the ri umber of services used. This study analyzes differences in average reimbursements per beneficiary for physician's services in 1975 and discusses allowed charges and use factors that affect average reimbursements. Differences in the level of allowed charges and their impact on meeting the annual deductibh_ are a_so discussed. Data used in the analysis were obtained from the /dill Summary Record System, representing a 5 percent smnple of medicare beneficiaries. The information used in this relx_rt is confined to the medicare population aged 65 and over. Study findings indicate that a shift in the mix of services to higher
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practice in a dual-choice situation and the social, attitudinal, and health characteristics of populations choosing prepaid programs in contrast to other plans. Data were gathered in telephone interviews with subjects of a sample drawn from a major metropolitan area. Data analysis found that deterrents to selection are preexisting ties with a private physician, impersonality of care, and physical distance fi'om the prepaid facility. There are no significant differences in the two groups in terms of respondent's age, sex, employment status, religion, ages of children, or family income. However, enrollees in the prepaid program are better educated and more likely to be unmarried. Different studies have indicated that married people are more likely to enroll in prepaid plans than single ]_ople. The majority of those who enrolled in the prepaid plans were satisfied with previous coverage but liked the centralization of all medical care in one place, insurance against risk, and the availability of care on nights and weekends in the prepaid plan. The study did reveal that children of prepaid respondents were more fully immunized at point of entry into the program, than children of respondents who elected to remain in the fee-for-service program. There was little indication that choices were being made on the basis of disability, major illness, or hospitalization, although spouses and children
Health Care Programs
of low-income respondents in the prepaid plan had more chronic illnesses than low-income people in the fee-for-service plan. Even though the overrepresentation of persons with chronic illnesses in the prepaid plan is statistically small, the actual numbers are significant because these persons tend to be heavy users of medical services. In the final analysis, this study shows that prepaid group practice and fee-for-service enrollees are basically the same in their propensities to use preventive services and in their attitudes toward care. It should be noted, however, that the people studied were drawn from an employed population and that the Blue Cross-Blue Shield fee-for-service alternative was quite liberal with respect to outpatient coverage. Possibly choices would vary where the savings between the two plans were more clear cut. Eleven tables comparing the 2 groups and 19 refer-
distance to the provider. The preference for the Kaiser plan increased as income decreased. Similarly, as distance from the Clinic increased and distance from a Kaiser facility decreased, the preference for the Kaiser plan increased. However, proximity to the provider was a more important factor for the higherincome Clinic plan subscribers. The data also show that the longer availability of the Clinic plan had a long-term effect on enrollment. A substantial proportion of long-time Stanford employees who might have been expected to prefer the Kaiser plan stayed with the Clinic plan. Tabular data, 12 referenc_, a cornparison of the benefits and services of Stanford University Prepaid Plans and Travelers Insurance Major Medical Plan, and an explanation of the study methodology are provided.
ences are provided.
Descriptor(s): Prepaid plans, Comparisons of health care programs, Participants in health care programs.
Descriptor(s): Participants in health care programs, Demand/ utilization of health care programs, Prepaid plans, Service benefit plans, Comparisons of health care programs. 299. Factors Which Affect the Utilization A Review and Analysis of the Literature. 298. Factors Affecting the Choice Between Two Prepaid Plans.
Anne A. Scitovsky, Nelda McCall and Lee Benham. Social Security Administration, Washington, DC. National Center for Health Services Research, Hyattsville, MD. 1978, 22 pp. Availability: Medical Care v16 n8 p660-681 Aug 78.
This study examines the factors affecting the choice between two comprehensive prepaid plans of medical care available to the staff of Stanford University (California). One is a Kaiser plan, offered since 1969. Under the other, the Clinic plan, medical services are provided by a predominantly fee-for-service praetice, and hospital services are covered by a standard Blue Cross hospital policy; the Clinic plan has been available since the 1950's. The Kaiser plan has only a token copayment for office and home visits while the Clinic plan has a 25 percent coinsurante provision applying to all physician and outpatient ancillary services. The study population (926 Kaiser and 890 Clinic plan families and single subscribers) were interviewed on such informarion as demographic and socioeconomic characteristics, health status, health attitudes and behavior, reasons for the choice of the particular plan and against choosing the alternative plan, satisfaction with the plan, and out-of-plan use of medical services. Additional information on the study population's characteristics was obtained from medical records. The results indicate that the two major factors affecting choice were income and
of Dental Services.
Jeffrey C. Bauer, Arthur P. Pierson and Donald R. House. Colorado Univ. School of Dentistry, Denver, CO 80262 Health Resources Administration, HyattsviUe, MD. Div. of Dentistry. May 1978, 71 pp. Avail,_bility: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order nuraber 017-022-00638-3.
Results of a study designed to identify, review, and evaluate reported findings of research on dental service use are presented. The study began with a search of five on-line bibliographic resources. The bulk of the literature identified appears in the form of articles or short sections of books dealing with a broader topic; only I of the 44 sources was a book devoted entirely to the topic of use of dental services. The literature indicates that the dental sector of the health care industry appears to be in a period of growth. The corresponding increase in the demand for dental care can be met with minimal difficulties if it can be predicted accurately. Review of the literature identified 37 different independent variables which have been used to explain use of dental services. These factors may be categorized into five classifications of demographic characteristics, economic factors, personal and psychological background, structural characteristics of the delivery system, and epidemiological factors. Analysis reveals some fairly consistent patterns in the relationship between various measures of use and income, age, sex, education of head of household, and race or ethnicity. However, these results must be interpreted with caution due to definitional prob-
1-137
lems with the utilization concept, demographic changes which have occurred in the United States since most of the data were
301. Family Health in an Era of Stress.
collected, the absence of information about the effects of the delivery system, and the absence of controls and validation efforts for many studies. Future research should be oriented toward developing tbe definition of standardized measures of use and toward analysis of the economic concept of demand. A bibliography with about 300 citations, four tables," 56 references, and an appendix listing factors which affect use of dental services variables and codes are provided,
Yankelovich, Skelly and White, Inc, New York, NY 10022 General Mills, Inc., Minneapolis, MN. 1979, 192 pp. Avallability: General Mills, Inc., Minneapolis, MN 55440.
.Health Manpower
References.
Descriptor(s): Demand/utilization Dental services,
of health
care programs,
Results are reported from a study designed to give statistically reliable insights into a wide: variety of issues in family health, including exercise, nutrition, preventive medicine, stress within the family, medical costs, _,;atisfaction with health care, overmedication, the government's role in family health, and motherfather roles in health parenting. Major topics covered include the impact of inflation on family health attitudes and concerns, bartiers to good health, personal values and their impact on health attitudes and behavior, preventive versus crisis health care, physical fitness, health parenting, and mental illness. The exploratory phase of the study, which was qualitative in nature, consisted of 4 parts: 7 focus group discussions with parents and teenagers throughout the country, interviews with 77 experts on all aspects of family health, the formation of an advisory panel
300. Facts At Your Fingertips. A Guide to Sources of Staffstieal Information on Major Health Topics. Fourth Edition.
consisting of 10 of those experts, and a review ture. The purpose of this phase was to generate tested in the survey phase. The survey phase of ed of interviews with a national probability
National Center for Health Statistics, Hyattsville, MD 20782 DHEW/PUB/PHS-80/1246 1979, 135 pp. Availabib'ty: National Center for Health Statistics, Scientific and Technical Information Branch, Div. of Operations, Prince George's Center, Hyattsville, MD 20782.
families representational of all families in the United States. A total of 2,181 interviews were conducted, 1,254 with a primary adult, 664 with spouses of primary adults, and 263 with teenage children (12-17 years) of tlhe primary adults. Overall, results show that the majority of American families are ready to accept in principle a new and more active approach to health and health care -- one which would require supplementing traditional means of health care with new approaches aimed primarily at
This is the fi3urth edition of a guide identifying major health care topics of interest and listing sources of statistical and, in some cases, nonstatistical information on them. Under each topic, National Center for Health Statistics (NCHS) publications or data are cited first, followed by other Department of Health and Human Services publications, other Federal agency publications, and then publications by private organizations and associations. One hundred and ten topics are included, ranging from abortions, absenteeism, accidents, aging, and hospital charges to health care expenditures, health insurance, medicaid, and social security. The following NCHS publications are highlighted: Vital and Health Statistics Series, Monthly Vital Statistics, Vital Statistics of the United States, and ADVANCEDATA. Complete addresses, telephone numbers, contact persons, and publication titles are listed for private organizations and associations.
preventing health problems. Only a minority are even beginning to put these new beliefs into action.
Descriptor(s): systems.
1-138
Trends in health status, Health information/data
General Mills American
Family Report,
of relevant literahypotheses to be the study consistsample of 1,254
1978-79.
Descriptor(s): Health care cost trends/projections, services, Demographic features of population.
302. Feasibility and Cost-EfTeetiveness Term Care Settings.
of Alternative
Preventive
Long-
Neill F. Piland. SRI International, Menlo Park, CA 94025 SRI/URU-3567 Health Care Financing Administration, Washington, DC. Ofrice of Policy, Planning and Research. May 1978, 230 pp. Avallability: National Technical Information Service, Spring-
Health Care Programs
field, VA 22161, PB-294 583.
Findings and recommendations are reported from a pre "hminary pilot study that assessed research methodologies for measuring the relative cost effectiveness and identifying the determinants of viability of alternative forms of long-term health care (forms other than traditional skilled nursing facilities or intermediate care facilities). Eight long-term care programs considered to be alternatives to traditional care were selected for analysis of their cost effectiveness relative to traditional long-term care. The types of alternative programs represented are multilevel-care residential communities, multipurpose health and social support programs, rehabilitation centers, a geriatric mental health project, and nonresidential multilevel care. The research methodology proved to be workable and reliable. Its main dements are (1) patient classification in terms of functioning and mental awareness, which was a scale of activities of daily living, a behavior index, and a mental status index; (2) identification of variable costs for each patient classification and each cost center; and (3) comparison of costs for each classification of patient between paired alternatives and comparison settings (traditional programs in the same region as the alternative program). The most cost effective settings were found to be noninstitutional. The study concludes that many sources of initial funding are available for alternative programs; however, substantial planning is required for the continuing operation of both institutional and noninstitutional alternative settings. The expansion of medicare's and medicaid's scope of services could enhance the cost effectiveness of each of the settings evaluated. The Federal grants program for demonstration purposes should be continued for the initial funding of alternative programs, and programs receiving such grants should obtain Government help in locating nongrant fund sources. Tabular data are provided for each of the case studies.
This report reviews the development of Part 19 of Title 45, (MAC), the Federal Government's drug cost-containment program and describes the controversies surrounding its implementation. Implemented by the Department of Health, Education and Welfare (DHEW), MAC was established in 1974 to save Government funds for drug reimbursement under Federal medicare, medicaid, and Public Health Service programs and to encourage lower drug prices through fostering drug company competition. The components of MAC include (1) maximum allowable cost limits on multisource drugs, (2) actual acquisition cost reimbursement for single source products (limiting reimbursements to pharmacists), and (3) publication of a price guide comparing costs of frequently prescribed products (Physician's Price Guide). A discussion of MAC regulations covers the kinds of drugs regulated, the role of the Food and Drug Administrtion (FDA), which drug and drug-related costs are regulated, and methods of reimbursing pharmacies and physicians. Additional sections describe the public reaction to the MAC program,, drug equivalency, setting cost limits for MAC groups, estimated acquisition cost, a physician price guide, and the cost-effectiveness of Part 19. The report concludes that the most significant factor influencing the form and rate of development of MAC has been the adversarial relationship that exists between Government and the drug industry and health care providers. The report suggests that, pending completion of two major evaluations, DHEW should provide the Pharmaceutical Reimbursement Board with information on prescription prices paid by the general public. In addition, DHEW should monitor State fee adjustments more closely and should conduct studies that would lead to the development of a model methodology for setting fees that could be used by State medicaid departments. Tables, and approximately 165 references are included. Four appendices contain lists of members of the Task Force on Prescription Drugs, the Dunlop Committee, and the Pharmaceutical Reimbursement Advisory Committee as well as MAC regulations.
Descriptor(s): Cost/benefit analyses, Cost containment efforts, Publicly sponsored/mandated health plans, Intermediate care facilities, Long term care facilities, Funding/financing of health care programs, Comparisons of health care programs.
Descriptor(s): Cost containment efforts, Publicly sponsored/ mandated health plans, Pharmaceutical services, Policy initiatires, Present legislation/regulations.
303. Federal Control of Pharmaceutical perienee.
304. Federal Government's Role in Ambulatory Services Development. A Management Perspective.
Costs. The MAC Ex-
Jean Paul Gagnon and Raymond Jang. Health Issues, New York, NY 10019 Roche Lab., Nutley, NJ. 1979, 76 pp. Availability: Health Issues, New York, NY 10019.
Arthur A. Berarducei. Robert Wood Johnson Foundation, Princeton, NJ. 1978, 12 pp. Availabih'ty: Jill. of Ambulatory Care Management vl n2 pl12 Apr 78.
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Written by a practicing ambulatory care manager, this article encourages other ambulatory care managers to explore funding programs offered by the U.S. Department of Health, Education, and Welfare's Health Services Administration (HSA) as asource of venture capital for ambulatory services development. A brief historical survey is given of Federal categorical programs from 1969 to 1974, including community health centers, migrant health, the National Health Service Corps, family planning, and maternal and child health. Next, Federal initiatives from 1975 to 1978 are examined. A milestone in the Federal Government's involvement in ambulatory services development occurred with the development of the Rural Health Initiative in 1975. Through this initiative, money and manpower from the following programs were coordinated: Community Health Centers Program, Migrant Health Program, Health in Underserved Rural Areas (HURA) Program, Appalachian Health Program, and the National Health Service Corps. In 1976, HSA developed a similar initiative for urban health in 1976 to 1977, called the Urban Health Strategy. It featured technical assistance and coordination of existing Federal categorical grant dollars. Satellite health centers and primary care centers were encouraged as service alternatives under this initiative. On December 29, 1973, the Health Maintenance Act (Public Law 93-222)was enacted, calling for grants and contracts for feasibility studies, for planning, and for initial development costs. It also increased access to enrollment markets. Another pertinent law for ambulatory care managers was the 1973 Emergency Medical Service System Act (Public Law 93-154), which provided for Federal grants and contracts to assist communities with feasibility studies and planning, initial emergency services response operations, expansion and improvement of existing emergency medical services systerns, and research and development in emergency medical services. To date, it appears that the Federal Government is preparing for the eventuality of national health insurance by making an investment in "capacity building," that is, the development of sufficient ambulatory care programs to accommodate future consumer demand. Thus, a significant investment source for expansion of existing ambulatory care programs and the development of new service settings is available. Five tables, 15 references, and a list of suggested
readings are supplied.
Descriptor(s): Present legislation/regulations, Outpatient facilities, Supply/availability of services, Outcome/evaluation of health administration.
305. Federal Health Dollar, 1969-1976. A Charthook Analysis of Activities Supported and Strategies Pursued in Federal Expenditures
for Health.
Michael S. Koleda, Carol S. Burke and Jane S. Willems. National Planning Association Center for Health Policy Stu-
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dies, Washington, DC 20009 Robert Wood Johnson Foundation, Princeton, NJ. Feb 1977, 72 pp. Availabih'ty: National Planning Association, Washington, 20009.
DC
Data and information are provided for Federal health care activities and expenditures from 1969 through 1976. In 1976, Federal health expenditures totaled $42.4 billion, an increase of 154 percent over the 1969 level of $16.7 billion and 43 percent above the $29.6 billion reached in 1974. The chartbook examines the traditional Federal health care activities funded, such as research, construction, training, and financing of services. Outlays are considered in terms of four determinants of health status: human biology, lifestyle, environment, and the health care system. The second section of the presentation deals with Federal outlays by activity funded aecording to the categories used by the Office of Management and Budget in the official tabulation of health spending. Combining graphics and text, the book depicts changing trends in Federal health spending in current and constant dollars for the period 1969 to 1976. The constant dollar figures were developed using price deflators whose source or derivation is described in the appendix. The accompanying text includes, as appropriate, a brief review of the legislative history, other details of major programs and agencies, and a summary of selected contemporary issues whose resolution will determine future expenditure levels in these areas. The concluding section considers Federal health expenditures in the context of the current debate on the determinants of health status. While the figures in this section are of necessity less reliable than those of the preceding section, they do provide an initial insight into the implicit expenditure strategy of the Federal Government with respect to the determinants of health. The appendices provide information on price deflators, the allocation of funds from major programs to the health determinant categories, data sources, and the National Planning Association. Tabular and graphic data are provided.
Descriptor(s): Health care cost trends/projections, sponsored/mandated health plans, Funding/fmancing care programs, Policy/changes re health care.
306. Federal Taxation and Regulation Plans.
Publicly of health
of Health Insurance
Unionmutual Life Insurance Co., Hartford, CT 06106 Jun 1979, 44 pp. A vMlabih'ty: Unionmutual Life Insurance Co., Hartford, CT 06106.
Health Care Programs
This guide presents general information about Federal taxation and regulation of disability and health insurance under laws, regulations, and rulings in effect as of Jan. 1, 1979. Areas coyered include tax treatment of individual health insurance; busi-
programs which deeply involve physicians, both salaried group (SG) HMO's and FFS HMO's. Since the majority of physicians in the United States practice FFS medicine, the potential for health care cost containment in the FFS HMO should be ex-
ness health insurance plans, with pertinent information given on the Employee Retirement Income Security Act of 1974 (ERISA) affecting accident and health plans covering employees; and eorporate wage continuation plans (disability plans). The guide also discusses a medical reimbursement plan and disability buy-sell plans. The individual health insurance plan is essential to workers who rely upon their ability to work as their source of income, Business health insurance for any type of business -- sole proprietorship, partnership, or corporation -- protects the needs of all types of businesses. It may include disability income insurance, employee wage continuation plans, and overhead expense insurance. For a wage continuation plan to qualify under the law for tax benefits, it must originate and be put into effect prior to any disability, it must be communicated to all parties concerned, and there must be evidence that the terms of the plan have been established. Furthermore, it must be in writing. Normally, a corporation wage continuation plan will provide for ownership by the insured. A medical reimbursement plan is a fringe benefit program established on top of a regular hospital and major medical plan. In these plans, the employer agrees to pay for (or reimburse) dental costs, prescriptions, eye glasses, and other medical costs that are not covered by the basic medical care coverages. It is a form/d plan established under Section 1050a) and 105(h) of the Internal Revenue Code. Finally, the disability buy-sell plans are designed for owners of businesses. Premiums paid for disability insurance to fund a buy-sell are not tax deduct-
plored. Both types of HMO's are characterized by prepayment with capitation for comprehensive health services, but they differ organizationally. In SG HMO's, participating physicians are employees of the HMO and are paid salaries. In many FFS HMO's, enrollees select a single participating primary care physician and ambulatory care is provided at that physician's office on a FFS basis. The apparent effectiveness of FFS HMO's in containing costs results from application of rigorous peer review, risk sharing on the part of participating physicians, and capable management by experienced administrators. A marked advantage to FFS HMO's is that enroUees can often continue to see their current physician and avoid having to travel to a distant HMO site. Nonetheless, problems exist for FFS HMO's. Antitrust issues have not yet been litigated, but FFS HMO's could be challenged for exclusionary practices and for l_heir fee schedules. Physician apathy or hostility to the HMO concept can be serious. Recent legislation has made it somewhat easier for HMO's to operate, but many States do not provide sufficient funds for their medicaid populations to participate in HMO's. Scores of large corporations are now looking closely at HMO's as possible frameworks to begin their own health care dollar management, promising to develop interesting hybrid HMO's involving both in-house corporate clinics and FFS offices of physicians practicing at both locations. One table and 19 refer¢nees are provided.
ible, but the benefits are received free of income tax. Mortality and disability tables, a list of abbreviations, and an index are included, along with specimen forms and footnotes.
Descriptor(s): Prepaid plans, Physicians, Methods of payment determination, Voluntary initiatives.
Descriptor(s): Private health care plans, Source of premium payment, Present legislation/regulations, Trends in health status.
307. Fee-For-Service
Health
Maintenance
Organlzations.
Richard H. Egdahl, John Friedland, Anthony J. Mahler and Diana Chapman Walsh. 1978, 4 pp. Availability: Jnl. of the American Medical Association v241 n6 p588-591 9 Feb 79. The frequently heard reference to a choice between health maintenance organizations (HMO's) or fee-for-service (FFS) medicine is an artificial dichotomy. Any assessment of broad range health care cost containment reinforces the need for HMO
308. Fee-for-Service Physician Payment. Analysis of Current Methods and Their Development.
Jonathan A. Showstack, Bart D. Blumberg, Steven A. Schroeder and Judy Schwartz. Henry J. Kaiser Family Foundation, Palo Alto, CA. 1979, 17 pp. AvMlability: Inquiry v16 n3 p230-246
Fall 1979.
The current dominance of the fee-for-service method of paying doctors is likely to continue for many years, and virtually all proposals for national health insurance and medical cost containment assume fee-for-service payment. However, it may be possible to create incremental changes in this inflationary payment system, especially if these changes originate at the Federal level. A basic need of all insurers is to predict with reasonable
1-141
accuracy the amount of benefit payments to be made. Health insurers use two basic methods. The traditional one is a maximum benefit schedule, sometimes referred to as a fee schedule, The insurer generally pays the lesser of the listed amount for a service, either the actual charge or the limit. An alternate method is the variable fee screen in which the insurer pays the amount charged by the doctor or the fee screen limit, which ever is less. These fee screens are generally based upon what doctors usually charge, and are sometimes called the usual, customary, and reasonable (UCR) reimbursement system. The UCR system is generally more acceptable to physicians because it recognizes the differences among specialties and geographic regions. The U.S. is the only country to use a UCR payment system; it encourages increasingly higher charges, is difficult and costly to administer, and sustains historical differences in fees. Because of these problems, there has been increasing interest in the major alternate method of setting reimbursement levels, the maximum benefit schedule which sets a f'Lxedpayment for a service and applies it uniformly without regard to specialty or region. This is the method used almost universally in European countries and Canada. An important charge in the maximum benefit schedule has been the separation of relative values among services from final dollar payment through the use of relative value studies (RVSs). Value among services is expressed in units and multiplied by arbitrary conversion factors to arrive at real dollar amounts. Recently, RVSs have come under attack by the Federal Trade Commission as a form of price fixing. With the increase in third-party payments, the system of paying for physicians services has become increasingly formalized and rigid. However, the fee-for-service reimbursement system does provide policymakers with a variety of opportunities for influencing physician decisionmaking, chiefly through financial incentives. Thirty-six footnotes are provided,
Descriptor(s): Claims administration, Methods of payment determination, Private health care plans, Impact of third-party coverage, Policy/changes re health care, Physicians.
and presents specific reconamendations for ambulatory care reimbursement for 1980. In New York State, ambulatory care constitutes the single largest and most important component of the overall health care system, with aggregate expenditures of approximately $9.5 billion from all sources. Yet, it remains the least understood and controJLled element of the system. Despite the size and diversity of ambulatory care services and providers, they are not distributed in sttch a way that they are available to all residents. Institutions are a major source of ambulatory care services throughout the State. Because institutional ambulatory care is costly to provide and existing payment sources and insurance for these services are inadequate, institutions providing such care have incurred si_,mificant deficits. Knowledge gaps exist regarding where servio_ are rendered, to whom they are rendered, and their relative costs; questions remain concerning the appropriateness of alternate care settings. During the past year, OHSM advances have included implementation of the Primary Ambulatory Care Pro_'am, development of improved reporting systems for hospital-based and free-standing clinics, and development of a project to test the effectiveness of a revenue cap approach to ambulatory car,.'. Imperatives for the coming year include establishment of a reimbursement strategy for ambulatory care that is flexible, provides maximum incentives for efficient operation, and enhances access to primary care for residents living in care shortage areas. In addition, better data concerning the system must be generated, and alternative approaches to financing ambulatory care must be tested. Tabular information and appendices are includexl in the report. (Author summary modified)
Descriptor(s): Outpatient facilities, Reimbursement, Policy initiatives, Demand/utilization of health care programs.
310. Financial Analysis of/dternative Group Medical Benefits.
Methods
of Funding
David B. Kelsey_ 309. Final Report to the Legislature on Ambulatory Care.
New York State Dept. of Health Office of Health Systems Management, Albany, NY 12237 Jan 1980, 117 pp. A vai/ability: New York State Dept. of Health, Office of Health Systems Management, Albany, NY 12237.
This report of the Office of Health Systems Management (OHSM) of New York State provides new data and information on ambulatory care, reviews significant steps taken by OHSM,
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1978, 7 pp. Availability: Jan 79.
Chartered Life Underwriters Jnl. v33 nl p54-60
This article examines several financial devices designed to deal with alternatives to convent_ional insurance. The purpose is to analyze the impact of such approaches on corporate earnings, setting aside all benefits and employee relations objectives. A corporation whose ownershit, resides in 1,000,000 shares of outstanding common stock is hypothesized. The model constructed for examination covers 2 consecutive years. In both years the corporation has $5,000,000 of earnings prior to considering the
Health Care Programs
cost of medical insurance program. The two variables introduced are a year in which the emerging level of claims paid is very favorable, and a year in which the claim experience is very high.
Edition Number Management.
Factors considered include the insurance premium, paid claims, unrevealed reserve, increase in reserve, incurred claims, reten-
Descriptor(s): Cost containment efforts, Inpatient facilities, Facilities providing health care, Outcome/evaluation of health
tion, cash flow earnings on reduced premiums and reserves, adjusted cost benefits, corporate earnings after medical benefits, corporate earnings after taxes, requirements to establish a reserve, earnings after reserve is established, and earnings per
administration, Funding/financing
share. Various possible conditions are considered. For example, one funding vehicle illustrates the results that the corporation would anticipate if its benefits were fully insured and the compa-
312. Financial Management Under Third Party Reimbursement.
ny continued to remain with the same carrier. Under another condition, a minimum premium payment plan under which the client sets up a bank account upon which claims are paid by the insurance carrier is considered. It is concluded that it will be generally difficult for a corporation to buy quality claim handling services for a price much less than can be obtained from
Karl D. Bays, William J. Breen and Aharon R. Ofer. 1976, 110 pp. AvMlability:Topics in Health Care Financing v3 nl Fall 1976.
an insurance carrier. The only significant potential savings lies in the reduction of State premium taxes. Three exhibits are provided in the article,
Descriptor(s): Third-party payors, Source of premium payment, Premium determination/underwriting,
311. Financial Management of Health Care Organizations. Referenced Outline and Annotated Bibliography.
A
Association of Univ. Programs in Health Administration, Washington, DC 20036 Kellogg (W.K.) Foundation, Battle Creek, MI. Jun 1978, 237 pp. A vailability: Association of Univ. Programs in Health Administration, Washington, DC 20036. An outline and an annotated bibliography of approximately 590 references on the financial management of health care organizations are given. This publication includes an introduction that defines financial management, delineates some daily operational requirements of health care financial managers, speaks to the requirements of a longer strategy, and explains the purpose of the outline and bibliography. The outline has been divided into five major subject areas: payments to health care institutions; planning, budgeting, and controlling; management of current operations and working capital; the investment decision; and sources of financing. The outline has been referenced with texts and journal articles that have been annotated by the five subject areas identified. Most of the literature cited was published in the 1960's and 1970's. This publication is intended primarily for an academic audience, although the concerns of practicing managers are also addressed. An index to the outline is included,
Three by the A UPHA Task Force on Financial
of health care programs.
Academics in the field of health care finance and leading practitioners in hospital administration and hospital finance discuss the effects of third-party reimbursement on various areas of financial management. The mixture of self-pay and third-party payments introduces unique circumstances in collecting receivables, in managing the operating budget, in choosing new equipment, and in financing new equipment and working capital. An overview of financial management and third-party reimbursement considers reimbursement mechanisms, management problem areas, inventory management and short-term borrowing, selection of capital projects, and long-term financing. An analysis of problems in receivables treats factors affecting accounts receivable, the effect of consumer legislation on collection, thirdparty payment and accounts receivable, self-pay accounts, outpatients, establishment of a payment policy, and the financial program. Topics considered in the section on maximizing cash flow through receivables management are impact on cash flow, the nature of receivables management, the magnitude of the problem, solutions, and assessment of the results. Capital budgeting in health care institutions, cash flow vs. accounting: income, and investment projects are discussed in the section on the impact of reimbursement on hospital cash flow. In the discussion of the effect of cost reimbursement on capital budgeting decision models, the subjects reviewed are capital investment, the accounting rate of return, payback method, time value of money, internal rate of return, and net present value. Other major discussions consider third-party reimbursement and the evaluation of leasing alternatives and hospital debt management and cost reimbursement. Supplementary material is appended, and supporting tabular and graphic data are provided. References are provided for some of the chapters. Descriptor(s): Third-party payors, Economics of third-party payors, Physicians, Impact of third-party coverage, Outcome/ evaluation of health administration, Facilities providing health care, Methods of payment determination.
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313. Financial Projection in Prepaid Dental Care Plans.
Joseph Boffa and Mitchell J. Burek. 1977, 7 pp. Availability: Health Care Management Winter 1977.
Review v2 nl p59-65
Methods of forecasting patient mix and costs are discussed in relation to management of prepaid dental care plans. In the last • decade, there has been a steady growth of prepaid dental care, with projections of at least 70 million persons insured for dental care by 1980. To prepare for this growth, managers must develop systems that will enable them to analyze costs of providing denhal care. Under dental capitation, a fixed payment per person or family is made for a specified fiscal period without regard to services rendered. The two requirements that are essential for sound financial management under a capitation plan are an appropriate method of costing services to allow proper pricing of benefit packages and a cost-monitoring model. Dental capitation uses the concept of compensation for available dentist and hygienist time, as the costs of operating a dental office remain approximately the same regardless of what specific services are provided. In pricing dental care needs for a given population, it is essential to translate service needs into time requirements. By placing a cash value on time, the manager can then convert time into dollar costs. It is also important for the manager to have some indication as to the relative mix of patients who will be treated, as dental needs vary according to patient age and initial versus maintenance care. The manager must estimate the probability that the various patient types will demand care and the cost impact of patient demand. Analysis should be based on the conditional probability to determine expected dollar value. Because different mixes of patients represent differing costs to the dental practice, and the fluctuation of plan membership influences the nature of the patients seeking care, the manager should update calculations using lists of members or eligibles on a regular basis. Six tables and eight references are included in the article.
DescrTptor(s): Prepaid plans, Dental services, Health care cost trends/projections,
314. Financial Status of Social Security Program After the Social Security Amendments of 1977.
A. Haeworth Robertson. 1977, 10 pp. AvMlabilit),: Social Security Bulletin v41 n3 p21-30 Mar 78.
1-144
The Social Security Amendments of 1977 resulted in substantial improvements in the current and projected financial conditions of the old-age and survivors insurance (OASI) program and the disability insurance (DI) program. This article reviews the causes of the recent operating deficits, describes the effects of the amendments that most influence the program's financial status, and gives projections of income and expenditures under the new law. The revised benefit formula eliminates the "over-indexing" expected to occur under the old provisions and results in stable earnings-replacement ratic_ under practically all future economic conditions. About one-half of the long-range actuarial deficit was resolved by this step alone. Increases in the contribution and benefit base, along with tax-rate reallocations and increases, prevent the imminent depletion of the OASI and DI trust funds. Increased income due to the higher wage bases is partially offset in later years, however, by greater benefit payments based on the increases in the coverage of total earnings. Overall, under the new law the disability insurance programs combined (OASDI) are projected to be financed adequately for about 50 years, but significant operating deficits are expected after that. The financial condition of the hospit_l insurance program was substantially unchanged by the amendments, however, and the hospital insurance trust fund is expected to be exhausted in1988. Tabular data are supplied. (Author abstract modified) Descriptor(s): Medicaid, Funding/financing grams, Present legislation/regulations.
of health care pro-
315. Financing Health Care. New York Times Information Service, Inc., Parsippany, NJ .07054 1980, 83 pp. A vailabih'ty: New York Times Information Service, Inc., Parisppany, NJ 07054. This report, one in a series on health care in the United States, contains over 400 annotations gleaned from current newspaper and magazine articles and editorials on the public policies, broad trends, and ethical issues surrounding health care financing. Private sector, government, political, and health care industry concerns are presented. Trends in health care technology, hospital and outpatient care, and economic and commercial influences are also covered. Each summary also contains a full bibliographic reference including the name of the journal, the date of publication, section, page, and column. In addition, many of the summaries contain a notation indicating the length of the original article. There is also an index to subjects, personal names, organizations, and geographic locations. (Author abstract modifled)
Health Care Programs
A Report on Current Issues and Trends from The New York Times Information Service.
317. Financing of Health Care. Lewis E. Weeks, Howard J. Berman and Gerald E. Bisbee.
Descdptor(s): Characteristics of U.S. health care system, Plan design/program provisions (under health plans), Economic/ commercial influences, Funding/financing of health care programs, Third-party payors, Providers of health care services, Private health care plans, Policy/changes re health care, Publicly sponsored/mandated health plans, Evaluations/outcome of health care programs, Health care/services, Facilities providing health care, Health care costs, Participation in health care programs,
316. Financing of Health Care. Herbert E. Klarman. 1977, 20 pp. Availability: Daedalus
v106 nl p215-234 Winter 1977.
Health care expenditures in the United States have moved steadily and markedly upward. Since 1968, the rate of increase has also accelerated. In relation to the gross national product (GN-P), the trend in the United States is similar to that in most developed countries. It is reasonable to expect that national health insurance (NHI) would lead to an increase in expenditures for health care. The size of the increase depends on the enrollment provisions of the particular plan and on the breadth and depth of the benefits provided. In addition, the size of the increase would depend on the regulations promulgated in order to implement the plan and on the future expansion of health care resources. Therefore, steps should be taken to constrain further increases in health care expenditures, whether NHI is enacted now or in the future. The important question to consider is how much the country chooses to spend on health care. However, there seems to be no objective, scientific way to determine how much a country is to spend on health care either in toto or in its individual categories. Among the prominent approaches that have been proposed to curb future increases in health care expenditures are
1979, 537 pp. Availability: Health Administration 48109.
Press, Ann Arbor, MI
A comprehensive treatment of the issues involved in health care financing is presented in this volume. It begins with attempts to define general boundaries and identify major topics. The unique character of Blue Cross plans as a third-party payer is then highlighted. Within the perspectives established in these initial sections, health care expenditures and the implications of different financing mechanisms on health services use are examined. The payment system, the question of incentives and controls within the hospital payment system, the general use of prospecfive payment, and results of recent experiments related to payment are then addressed. Next, the role of the Government in health care financing is studied. The volume scrutinizes the operational impact of medicare and other medical programs and the continuing issue of national health insurance from the perspective of national health strategy, design, and cost. Finally, operational implications of health care financing issues are considered, such as the effect of certificate of need legislation on hospital investment and the use of a computerized projected cash flow statement to plan hospital expansion. The volume brings together previously published articles by a variety of individuals working in the area of health care financing. Most articles include extensive notes and references, tables, and figures; an index is provided for the work. (Author abstract modified) Inquiry Anthology
Series.
Descriptor(s): Health care costs, Economic/commercial influences, Third-party payors, Inpatient facilities, Funding/financing of health care programs, Policy/changes re health care, Service benefit plans, Publicly sponsored/mandated health plans.
cost sharing by consumers, changes in the mechanisms and formulas for reimbursing health care providers, curtailment of illture expansion of health care resources, and promotion of HMO's. In considering alternative NHI plans, sources of financ-
318. Findings and Implications of Field Visits to Six Welfare Benefit Plan Administrative Organizations. First Interim Report.
ing are always an issue. However, when the distribution of the total tax burden is kept in mind, the proportion of the burden
Kenneth M. MeCaffree, Suresh Malhotra, John M. Wills and Jean Baker.
imposed on most taxpayers is approximately equal. Tables and 19 references are provided. (Author abstract modified)
Battelle Human Affairs Research Centers Health and Population Study Center, Seattle, WA 98105 Touche Ross and Co., Seattle, WA 98101 Labor-Management Services Administration, Washington, DC. Department of Labor, Washington, DC. Assistant Secretary
DesciT"ptor(s): Health care cost trends/projections, Funding/financing of health care programs, National health insurance (NHI), Cost containment efforts.
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for Policy, Evaluation and Research. May 1979. 218 pp. A vailability: Battelle Human Affairs Research Centers, Health and Population Study Center, Seattle, WA 98105.
319. Forecasting. A Cost ,Control Tool for Health Care Managers.
Everette S. Gardner and Curtis P. McLaughlin. 1980, 8 pp. Availability: Health Care Management Review v5 n3 p31-38 Summer 1980. This document describes data gathered in site visits to six organizations in order to provide the necessary information to design the sampling strategy, to determine the survey techniques, and to develop survey instruments for a later examination of the administrative costs and characteristics of welfare benefit plans and plan sponsors. At each organization visited, the following characteristics were examined: general plan attributes, the administrative organization of plans and the functional responsibilities of each administrative unit, the nature of plan eligibility determination and verification systems, the nature of plan claims processing/appeals systems and procedures, the type of accounting and other recordkeeping systems, the manner in which the Employee Retirement Income Security Act of 1974 (ERISA) affected plan administrative activities, and the types of cost and claims statistics maintained by plans and limitations on the use of these statistics. The six plan administrative structures visited were self-administered and self-insured, self-administered and commercially insured, contract-administered and self-insured, contract-administered and commercially insured, Blue Shield/ Blue Cross administered and insured, and commercial insurance carrier administered and insured. Results indicated that welfare benefit plans would be an undesirable universe of sampling because the great diversity and heterogeneity of plans and plan packages would prevent reasonable generalization. The impact of ERISA on administrative and other plan costs was minor and would not justify substantial expenditures of funds to obtain more precise estimates. No discernable trends were found in post-ERISA welfare plan benefits, provisions, administrative procedures, or structure and cost elements that could be clearly attributable to ERISA. Comparisons before and after ERISA for most data categories were not possible. As a result of these and other findings, the following alterations were made: the primary, sampling unit was defined as the plan sponsor rather than the plan; an additional sampling frame of sponsors of small welfare benefit plans was created; the questionnaire was expanded to ascertain the variation in coverage and benefits within a plan; the survey was conducted by telephone rather than mail questionnaire. Tabular data and site visit reports are appended,
Descriptor(s): Service benefit plans, Commercial health insurance plans, Outcome/evaluation of health administration, Claims administration, Present legislation/regulations,
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This article discusses importance of adapting the appropriate forecasting technique to a health care environment as an essential element of cost control. The central issue in forecasting is deciding how to use the data available in the organization to make predictions that are as accurate as is economically practicable. Control of costs is closely related to the ability of the health care manager to predict the demand for services over the short run. Effective forecasts go well beyond revenue forecasts and are complimentary to prediction efforts. Aspects to be considered in selecting forecasting approaches include costs in user time, preparer time, computer time, and data collection; data availability; accuracy; problem characteristics; and sophistieation of users with respect _o their understanding of forecasting methods. Examination of the experience of the Clinical Coagulation Laboratory of the North Carolina Memorial Hospital at Chapel Hill, N.C., with forecasting illustrates the fact that forecasting is a feasible techniqae for reducing health care costs. The laboratory had experienc_ a growing and highly variable demand for its services in reagent months, and the director sought to avoid repeating major errors in budgeting and in the purchase of perishable supplies. The first question was whether the data on aggregate demand should be dealt with or whether the demand for each type of activity should be studied. Fortunately, it was determined that three types of tests made up 85 percent of the total demand. Next, the data were coded and run with a standard statistical package. Corrected data were then analyzed according to 25 possible mqxlels, and performance was analyzed on both a short-run and long-run basis. The method of evaluation was the mean-squared error. The models which were examined included linear regression with or without seasonal factors, exponential smoothing models on raw data, exponential smoothing models on deseasonalized data, and "Box-Jenkins" models. Forecasting performance over a l-year period has been excellent. There are dozens of forecasting methods available, the least complex of which are often the most useful. One table, 2 figures, and 10 references are included.
Descriptor(s): Cost containment efforts, Health care/services, Health information/data systems, Demand/utilization of health care programs, Facilities providing health care, Outcome/ evaluation of health administration.
Health
Care Program_
320. Forward Plan for Health FY 1978-82.
321. Foundation for Health Care Regulation. PL 93-641.
Public Health Service, Washington, DC 20201 DHEW/PUB/0S-76/50046 Aug 1976, 137 pp.
David A. Dittman and Jeffry A. Peters. Department of Health, Education, and Welfare, Washington, DC.
Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-000-00172-8.
1976, 11 pp. Avai/abifity: Inquiry v14 nl p32-42 Mar 77.
This third in a series of Forward Plan for Health developed by the Public Health Service (PHH) presents a coherent frame of reference within which the PHS can examine major health issues. Issues considered include control of health care costs, development of new knowledge, prevention of disease, improvement of the health care delivery system, and quality of care. The Forward Plan is theofculmination of a year-round effort, including the solicitation recommendations and comments on last year's Forward Plan and an extensive program planning process within the agencies of the PHS. Followin 8 a review of the past year's events, a profile is presented of the health status of Americans. A discussion of preparation for national health insurance examines cost-containment issues and PHS service program integration and transition. Major problems which must be addressed if the health care system is to be improved are identified as rapidly rising health care costs, uneven quality of care, and unequal access to high quality care. Strategies discnssed for iraproving the health care system are oriented toward ensuring access to quality health care; reducing unnecessary institutional care; providing for primary care services, especially for residents of rural or medically underserved areas; ensuring appropriate, effective, and efficient facilities and services; consumer involvement; patients' rights; and malpractice. Ensuring the quality of health care is considered in a major section under the topics of ensuring the competence of health professionals and the quality of health care facilities and special settings. Other major issues examined in detail are prevention, knowledge development, tracking and evaluation, and PHS management. Appended are discussions of dental health, long-term care, international health, consumer activities in the PHS, a list of organizations solicited for comments on the Forward Plan, and organization and terminology symbols. Graphic and tabular data accompany the presentation. Forward
(Author
abstract modified)
PL 92-603 and
Key provisions of Public Law 92-603 establishing Professional Standards Review Organizations (PSRO's) and Public Law 92641 establishing the National Health Planning and Resource Development Act are discussed. The PSRO examines the care provided to patients covered under several government programs and assesses the necessity of the services, the appropriateness of the facility, and the quafity of the care. Public Law 93-641 ties in with the PSRO legislation by regulating the supply of health institutions in a given area. Therefore, a mechanism exists to potentially regulate the overall demand for service,_ and to ensure that the overall mix being demanded will more closely approximate the characteristics for which the institution was designed. The ultimate effect if the regulatory mechanism is fully utilized will be a more efficient allocation of federally insured patients to institutions providing the most economical service. The PSRO data may be used by physicians as well as by health systems agencies. Expansion of PSRO review to encompass "all patients should reduce utilization for all groups. In the short run, the average cost per patient day may increase because the total reimbursable cost will be spread over a smaller number of patient days. However, in the long run, Public Law 93-641 may well increase utilization by elimination of underutilized duplicate facilities. To date, some priorities stated in Public Law 93-641 have no proposed implementation. A national health planning information center is to be developed to collect information concerning planning, practice, and development of health resources. A uniform cost accounting system must be established as well as a cost-based, inclusive rate reimbursement system. Nonetheless, a mechanism now exists for regulation, although its ability to reduce the rapidly rising cost of health care is not assured, and a reduction in utilization may possibly cause a rapid increase in the cost per patient day in the short run. Twenty-six annotated footnotes are provided. Descriptor(s): efforts.
Present legislation/regulations,
Cost containment
Plan for Health Series, No. 3.
Descriptor(s): Trends in health status, Health care cost trends/ projections, Cost containment efforts, Supply/availability of services, Dental services, Preventive services, Facilities providing health care, Providers of health care services, Policy initiatives, National health insurance (NHI).
322. Foundations for Medical Care. An Empirical Investigation of the Delivery of Health Services to a Medicaid Population. John Holahan.
1-147
Department of Health, Education, and Welfme, Washmi_ton, DC. Office of the Secretary= 1977, 17 pp. Availabilio: Inquiry v14 n4 p352-3o8 Dec 77.
Based on an examination of scrvi,:;es provided to medicaid patients by the San Joaquin Foundation for Medical Care iCahfornia) in 1969 to 1970, this paper contends that indi+idual practice associations (IPA's) are not effective mecnanisn_s for long-term control of costs. Considerable literature on prepaid group practices has appeared in recent years. However, fete studies have focused on IPA's, although they are growing at a much faster rate than other group practices. Because an IPA is prepaid, costs are controlled by extensive use of audits and peeI review. Data from the California Medicaid paid claims system was used to analyze the impact of the San Joaquin project on utilization rates for physician visits, surgery, laboratory, _--ray, and other diagnostic se>,'ices; hospital inpatient care; hospital outpatient care; and prescription drugs. A dummy vaAab[e for the San Joaquin County population was employed to test whether utilizatio,t rates for various services would have been different ira prepayment project did not exiM. Controls were instituted for public support, physician supply, d_stribution of physicians among specialities, and hospital beds per capita. A 2 percent '.,ample was randomly selected from all cases eligible for Medicaid during fiscal years 1969 and 1970. The study [bur_d no evidence that the San Joaquin Foundation had any effect on the percentage of eligibles seeing physicians, the numbers of visits, or the costs of visits. Regression analysis using data fron all Califonlia counties produced no differences in the use of laboratory, x-ray, and other diagnostic services. Other results indicated _.hat hospitalization rates in San Joaquin were no lower and that ase rates for outpatient services were unaffected. Limitation of the study are detailed, but the paper concludes that peer review does not control costs and can actually increase the provision of some ._ervice_.
This proposal was destgned to constrain the :,upply ut major rr_edical faciliIies and eqmpmcn_ as park _,f uE_o,,crall clli,l! to .l'_oderate the rise in health-care _pending. qi,c pr_p()sal incitation, a national doiiar ceiling on capital inve_,tment attd planned redactions m ex_:ess capacit2;. The first pha_c of the propelled program would involve tile _mposition of a national n[oratorium on m_or capital expenditu:'es, except tbr those in,_olving prior obligations and correction of urgent safety hazards. The moratorium would apply to all government agencies as well as plJ_'are concerns. In the secoIld phase, the DepaJtment of Health, Education, and Welfare (DtiEW) would calculate an interim capital expenditures ceiling designed to achieve zero net growth in major capital assets of the health care sector. The mterim dollar ceiling would be sufficient to allow replacement of existing assets or acquisition of different types of capital assets. Each State would be released from the moratorium as DttEW approved changes in that State's determination of need program, allowing it to implement the interim capital expenditures ceiling. In the final phase, DHEW could calculate a 5-year National Capital Expenditures Ceiling at a level designed to promote that rate of growth in total spending for health care which Congress determined to be appropriate. This ceiling would be allocated to the States and implemented principally through their own octtificate of need or 1122 review programs and through new State capital limits programs. Each+State capital limits program would specify a dollar limit on determination of need approvals, priorities |br allocating this ceiling, statewide supply and use standards for medical facilities and equipment, and a phased plan for achieving those standards. The States would develop their own programs tbr approval by I)HEW. (Author abstract modified)
Descriptor(a): Cost contain_aent efforts, Inpatient facilities, Policy initiatives, Eaaonomic/commercial influences.
324. From Charitable Immunity to Public Accountability. A _evie_ of Setected Solutio_as to the .Malpractice Problem. Descriptor(s): Prepaid plans, Cost/benetit anaiyse_, Cost containment eflbrts, Medicatd, Demano/utilizatio_t of health care prug_ams, t._alu,_fions/ou+ct_ne t,f hcahh ,_ate program,,
323. l;ram_.:vt+rk ft)r Capital C_mtcMs in _feaith Care+
Government Research Corp., Washington, DC 20036 Mar 1978, 27 pp. ,4 va.,_ability. Government Research C_-rp., Wa._hington, I)C 20030.
l - 148
l-rederlck l'. Darnel, Bruce tt Suler and Glenn 1 _lrover :u,77:34 pp 4 +_t:?-_b,h_v-Topics in l-tea th Care Financing v3 n4 p t-34 ";ummc,- }.)77
Ne_ fi_'_msof insuring the ma!practice ask, modifications of the {o_t law syslem, and mec_unisms to control malpractice are discussed. The limited availability of malpractice insurance, the high cost of malpractice premiums, and the question of how health care providers will control malpractice risk compose the crisis associated with medical malpractice. Although some t:avor modifying or even eliminating the tort, system in medical real-
Health Care Ptom an,_
practice, constitutional issues pose barriers to any significant change. Solutions to the crisis must therefore lie in financially underwriting and reducing the risk. Hospital self-insurance approaches appear to offer the most promising approach for financially underwriting the malpractice risk. Because of complications in other self-insurance approaches, hospitals would be wise to use only the trust fund and the mutual company as insurance methods, particularly from the perspective of medicare reimbursements. Self-insurance programs insure on a claims-made basis rather than on an occurrence basis. While this basis provides a hedge against future economic inflation, it does not provide the hospital with a protection against the "risk tail," which would arise at the termination of such an insurance program; however, the provider can eliminate this problem by continuing with another claims-made basis insurance program or by setting aside a reserve fund sufficient to cover future potential losses. Self-insurance programs also have a built-in incentive for the provider to manage the risk of malpractice in the institution, since success in managing risk will directly affect financial sayings. Such risk reduction programs would cover not only the standard governmental cost-control programs like Utilization Review and Professional Standards Review, but would also inelude voluntary efforts, like the Joint Commission on Accreditation of Hospitals, the continuing professional education
during the 17th and 18th centuries, diverged in the 19th century. In the first 2 decades of the 20th century, economists became increasingly involved in health affairs, particularly in the issue of compulsory insurance. This involvement was demonstrated in research, articles in professional journals, and service on committees. During the second period, from the 1920's until just after World War II, professional economists were generally uninterested in research and reform relating to medical care. This lack of interest was a result of forces within and external to the discipline of economics. In the third period, which began in the 1950's, economists became increasingly active in health care research issues. Attention has frequently focused on allocation of resources to and within the health sector. Increasing specialization of social scientists and of economists in particular characterizes the period beginning in the 1950's. Approximately 90 references are included.
programs, and numerous other institutional to reduce patient injuries.
326. Functional Value Analysis. A Technique for Reducing Hospital Overhead Costs.
programs designed
Descriptor(s): Economic/commercial influences, Funding/financing of health care programs, Inpatient facilities, Non-employment related plans.
Descripto_s): Characteristics of U.S. health care systena, Economic/commercial influences.
James E. Bennett and Jacques Krasny. 1977, 20 pp. Availability: Topics in Health Care Financing Summer 1977.
v3 n4 p35-54
325. From Reform to Recidivism. A History of Economists and Health Care.
Functional value analysis (FVA) is presented as a way of reducing hospital nonmedical overhead costs, which typically account for 30 to 50 percent of the hospital's annual operating expendi-
Daniel M. Fox.
tures. FVA is a technique developed and proven in industry to
1979, 40 pp. A vailability: Milbank Memorial Fund Quarterly/Health Society v57 n3 p297-336 Summer 1979.
and
The changing assumptions of social scientists concerned with health services and medical care are explored through an historical survey of attention given to these subjects by professional economists in the United States during the past century. The major theme of this paper is the uneasy relationship or tension between advocacy and objectivity as purposes for research in economics; economists throughout history have espoused both purposes. There are three distinct periods in the history of the relations between the disciplines of economics and medicine, Economics and medicine, which were linked in several ways
achieve lasting 15 to 20 percent reductions in overheads. In FVA, total nonmedical expenses are broken down into cost centers with budgets of not more than $500,000. A full-time task force assists the head of each such "unit" in conducting: a disciplined idea-generating process that must result in identification of a 30 to 40 percent saving. Cost reduction ideas are then evaluated by all managers who use the unit's services, and finally, senior hospital management selects the ones that will be implemented. The process takes some 4 to 6 months. This article briefly outlines why nonmedical costs should be top priority and why FVA is likely to be successful in reducing overhead. The organization and implementation of FVA are described, and a concluding discussion is designed to help hospital administrators decide whether the FVA technique is appropriate for their hospitals. Steps in the FVA technique are graphically iUustrated.
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Descriptor(s): Cost containment efforts, Inpatient Funding/financing of health care programs.
facilities,
327. Fundamental Issues in the Practice of Dental Public Health.
Kenneth L. Chung and David F. Striffler. 1980, 1 l pp. AvMlability: Family and Community Health v3 n3 pl-11 Nov 80.
Descriptor(s):
Dental ser_¢ices, Trends in health status.
328. Fundamentals of Second Opinion Programs for Elective Surgery.
Eugene G. McCarthy and Madelon Lubin Finkel. 1979, 60 pp. AvMlability: Internationad Foundation of Employee Plans, Brookfield, WI 53005.
Benefit
This book describes the spiraling costs of U.S. health care, sugFundamental issues in the practice of dental public health relate directly to the primary goal of preventing dental oral diseases, primarily dental decay (caries) and periodontal disease. Other important but less prevalent problems of concern include malocclusion (crooked teeth), cleft lip and palate, oral cancer, and occupational hazards (radiation and mercury hygiene). Dental decay affects over 95 percent of the U.S. population; nearly one-half of the adult population between the ages of 18 and 74 has overt periodontal disease, the most common cause of tooth loss after the age of 35. Levels of dental disease prevention are differentiated into three levels: primary, secondary, and tertiary, Primary preventive activities forestalling the onset of oral diseases, include fluoridation of public water supplies, use of fluorides applied topically or directly to the teeth, the application of sealants (protective plastic films) to the pits and fissures of teeth, and the removal of dental plaque from the teeth. Secondary preventive measures control the progression of existing disease, usually through early recognition and prompt, effective treatment of disease. These activities include restorations (fillings and crowns) which arrest the progression of decay, periodic prophylaxis (teeth cleaning) to remove tartar formations that eventually result in periodontal disease, and periodic visits to the dentist to promote early diagnosis and treatment of dental needs, Tertiary preventive activities include restorative measures such as making bridges and dentures, and advanced periodontal surgery. Fundamental goals that dental public health professionals
gests four basic strategies to contain costs, and provides explanations and a possible solution for the increase in surgical utilization. The book argues that although the system of thirdparty payments has become so comprehensive that most of the hospital bills and physicians' fees are paid for, it is this very system that is largely responsible for the escalation in the costs of health care. Four strategies, based on industrial efforts to contain costs, are describe_: cost containment through administrative control, the alteration of utilization of services, control of charges, and alternative delivery systems. The book also discusses reasons for the 34 l:ercent increase from 1971 to 1977 in elective surgical procedures and presents findings from the Cornell second opinion program showing that such a program can screen surplus surgery and can contain costs. The variations in administrative and organktational structure of second opinion programs are also discussed, such as the organizational requirement that patients seek a second opinion consultation before their operation, or the organizational inclusion of the benefit as an option in the health benefit package. Finally, the book reviews the importance of promotional strategies that must be designed to reach all of the eligible population and of evaluation studies that assess program effectiveness. A figure showing the breakdown of national health expenditures and two tables on the number and rate of operations performed for inpatients discharged from short-stay hospitals are included.
should aim for are (1) using known primary preventive measures to the fullest, (2) continuing research for more effective measures of primary prevention, (3) educating the public to comply and support known preventive measures, (4) monitoring and adjusting the supply of dental health personnel to meet the dental demands of the community, and (5) defining the future roles of
Descriptor(s): Claims administration, Cost containment Trends in health status, Medical/surgical services.
dental specialists in the provision of dental health services. Another goal should be to improve the efficiency of dental health services to the community by studying the feasibility of using expanded-function dental auxiliaries, alternative systems for providing services, and alternative financing mechanisms. A table and 34 references are supplied.
329. Funding Rural Nurse Practitioner
I- 150
Elizabeth Davis. 1977, 4 pp. Availability: Nursing
efforts,
Care.
Outlook v25 nl0 p628-631 Oct 77.
Health
Care Programs
This article describes how the Visiting Nurses Association (VNA) provides primary health care for Grand Isle County (Vermont) in this pilot project which is reimbursed by Blue Shield. Steps for organizing the system included (1) defining community, family, and patient needs; (2) involving commtmities and patients in assuming responsibility for their own care; (3) creating rules and standards by which all care providers must abide; (4) training or employing a capable staff; and (5) creating a system of regular record and system audits. After operating on grants for the first year, the program ran into financial problems, It became clear that if the problem of third-party reimbursement could not be solved, the idea of the nurse practitioner, as an extension of the health care system in rural areas could not be implemented. As a result of a session of hearings on the problem, Blue Shield representatives visited the health center and offered a reimbursement pilot project proposal. The health center now bills its charges directly to Blue Shield for all but screening services to policy holders and is reimbursed directly. In addition, at the end of the year, Blue Shield will look at the costs of total services and the number of Blue Shield beneficiary visits. Blue Shield will then pay the center the difference between the total cost of operating the center and the percentage of these beneficiary visits. A Vermont senator has also introduced a bill which would make possible medicare reimbursement for rural health centers staffed primarily by nurse practitioners and physicians' assistants. The article emphasizes that the program must have completed the five steps listed above before applying for reim-
with cost effective health care delivery its goal. A key I_rend in health care is the increasing age of the population, a situation that leads to greater demand for and costs of care. Furthermore, medical technology will make possible the treatment of increasingly complex cases at greater costs. Technology will make information management easier by contributing to better diagnostic and treatment success and improve monitoring capabilities by the government and third party payers. At the same time, the public seems to be holding health care providers less in awe and placing greater emphasis on personal responsibility for health. A steady increase in the number of mid-level health professionals along with a greater willingness of physicians to function as part of a health care team, is likely to occur. In all of these trends, management becomes a major issue. Health care financing is likely to continue toward more uniform coverage and further separate the consumer from direct payment for medical services and strengthening the demands for cost containment by public, private, and third party payers. Three elements appear critical to the future health care environment: emphasis on producing health rather than treating sickness, integrated health care delivery, and successful management. Although such a health care organization does not yet exist, hospitals need to consider their long-range futures and prepare for diversification beyond traditional functions and services. Administration by enlightened and capable management is critical. One table and 13 references are provided.
bursement.
Based on a presentation at the _ Annum Vail Symposium on "The Future of the Hospital Sector, " sponsored by the Centers for Health Services Research of the Unive_ty of Minn_.ota and the University of Colorado, Vail, CO, Jsnuary 25-27, 1979.
Based on a speech given at USPHS Region I sponsored conference on nursing innovations in the delivery of umbulatory care at Auburn, MA, November 1976.
Descriptor(s): Supply/availability of services, Service benefit plans, Reimbursement, Allied health professionals, Methods of payment determination,
330. Future Health Care Organization.
Descriptor(s): Demand/utilization of health care programs, Supply/availability of services, Outcome/evaluation of health administration, Facilities providing health care, Providers of health care services.
331. Future Issues in Health Care. Social Policy and the Rationing of Medical Services.
Robert E. Schlenker. 1980, 6 pp. Availability: Health Care Management Spring 1980.
Review v5 n2 p69-74
Management will be the most critical ingredient in the future health care organization. Current trends suggest that the type of health care organization most likely to succeed in the future will be an integrated facility offering not only major medical care, but also wellness-oriented services, such as nutrition counseling,
David Mechanic. 1979, 194 pp. Availability: Free Press, New York, NY 10022. This book examines cost containment problems in the context of impending problems of health need and medical care. It emphasizes that understanding behavior is important in designing and implementing social policy, because the perceptions and responses of those affected ultimately determine the fate of all
1-151
policy. Cost containment can be achieved only by a long-term purposeful effort to affect the behavior of patients and physicians through the design of incentives that will not be diverted or perverted. The central concept of the book is "rationing", a concept used to describe alternative methods of allocating limited medical resources. The analysis considers two basic forms of rationing -- implicit and explicit -- and delineates the probable advantages and limitations of each. Implicit rationing involves limiting the fmancial and facility resources available for health care, thereby putting pressure on providers to make allocation choices. A variety of secondary, nonmedical factors, howeve:_, may influence physicians' judgments, raising serious questions of equity and adversely affecting doctor-patient relationships. With explicit rationing, administrative decisions are made regarding limitations on what services will be provided or covered under health insurance. Involving such mechanisms as advance review of expensive procedures and concurrent utilization review, explicit rationing departs from traditions of physician aut:onomy and clinical responsibility. Any system of national health insurance is deemed likely to require a mix of rationing by implicit and explicit methods. Specific topics considered in this light
by patients and physicians is good. Although the National Academy of Sciences argues that an increase in training rate of NHP's is undesirable because of the projected rise in physician supply, several reasons make it unwise to decrease or hold steady the supply of NHP's. First, no matter how large the projected increases in number of physicians, there is still substantial disagreement over whether there will be an actual surplus of physicians. Second, the increasing number of physicians in primary care will require NHP's |o assist them in their work. Third, NHP's tend to locate in medical shortage areas such as nonmetropolitan or inner-city communities. Fourth, the Federal and State governments are incr _sing their efforts to provide medical services in underserved areas; many such areas cannot economically support a physician but could support NHP's. In addition, there is the major and obvious factor of the lower employment cost of NttP's. In terms ef a realistic look into the future, due to the great independence efforts of the nursing profession, nurse practitioners may experience a greater extension of their role and independence in patient care, while physician assistant roles may decrease. Eleven tables and 13 references are included.
include patient attitudes towards the medical marketplace and ways to change them; behavior models in health education; and problems of the mentally ill, the aged, and others requiring long-term care. Also discussed are the desiqn of mental health benefits under national health insurance; ways of monitoring the health system; ethics in service delivery and approaches to ac-
Descriptor(s):
countability; the role of research in improving health and in understanding the health care system; and finally, the politics of change in health care. An index and a bibliography of 17_ references are provided.
333. Future of Private Ttdrd-Party
Descriptor(s): Cost containment efforts, Demand/utilization of health care programs, Providers of health care services, Policy/ changes re health care.
332. F_ture of New Health lPraetitioue_-so
Laa_rence Miike. 1979, 14 ,pp. Availab¢7/ty: Nov 79. Family a_td Community
Health v2 n3 p6_.-78
It is argued that the so called new health practitioners (NHP's) make important contributions to health care and that their training and practicing capacity should not be restricted. Nurse practitioners (NP's) and physician assistants (PA's) are capable of taking the place of physicians in certain types of care; studies show that: the quality of NHP patient care and their acceptance
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Supply/availability
of services,
Allied
health
professionals.
Reimbursement
Jeffrey A. Prussin and Jack C. Wood. 1975, 9 pp, A vaiiability: Topics in Health Care Financing Fall 1975.
Systems.
v2 n 1 p81-89
This article relates the future of private third party reimbursement systems to national health insurance (NHI) and trends in health care, organization, delivery, and financing systems. Legislation reviewed includes the National Health Care Services Financinq and Reorganization Act which would provide for State regulation of hospitals and physicians but would permit the continued use of private third party payers and would encourage the establishment of Health Care Corporations (HCC's); the Health Securib' Act which would establish a publicly funded, publicly administered NHI system to all, but eliminate the prirate health insurance industry; and the Health Care Insurance Act (Medicredit), which would retain the present system of payments to providers on a usual and customary basis but would include utilization and Ix*r review procedures. The article also describes the i.mplieations for third party payers of the Comprehensive Health Care Insurance Act of 1975, the National Healthcare Act, the Cata,;trophic Health Insurance and Medical Assistance Reform Act, the Comprehensive Health Insurance
ttealth
Care Programs
Act (CHIP), and the Comprehensive National Health Insurance Act. In addition, the article reviews the enactment of several catastrophic State health insurance plans, outlines some NHI
From "Skills Development for the HMO Managers 1980% "p 3-8, 1980, edited by Eugenia Warhol.
debate issues, and briefly describes two important trends which may affect private third party reimbursement systems: alternatives to institutional care and integrated health care delivery systems. Three references are provided.
Descriptor(s): Prepaid plans, Present Policy initiatives.
Descriptor(s): (NHI).
335. Geographic Variation in Physicians' Fees. Payments to Physicians Under Medicare and Medicaid.
Third-party payors, National
health insurance
of the
legislation/regulations,
Ira L. Burney, George J. Schieber, Martha O. Blaxall and Jon R. Gabel. 334. Future Roles for the Federal Government in the Development of HMO's.
1978, 4 pp. A v_ilability: Jnl. of the American Medical AssociatJLon v240 n13 p1368-1371 22 Sep 78.
Howard R. Veit. 1980, 6 pp. A vailability: Group Health Association of America, Inc., Washington, DC 20036.
To study geographic differences in physician fees re_3gnized by the medicare and medicaid programs, this study analyzed physician reimbursement rates at the national, regional, State, and county levels. Data were obtained from similar surveys of the 47 medicare carriers and the 50 State medicaid programs. To condense the voluminous amount of fee information on individual
In assessing the future roles of government in the development of health maintenance organizations (HMO's), this article first reviews its past accomplishments. Since 1974, the Federal Government has spent $103 million on grants and committed $170 million in loans to advance prepaid health plans. Of the 230 plans now operational, 110 are Federally qualified, and 80 of these have been recipients of grant and/or loan assistance. Determining success, however, requires approximately 9 years, and many of these programs are still small and striving for financial self-sufficiency. To obtain a preview of program success rates, this study examined the current status of HMO's funded during 1975 and 1976. It was found that 73 percent of the dollars spent aided the operation of qualified programs, even though 45 percent of the organizations originally funded were terminated. If continued compliance with the HMO Act is taken as a measure of success, 70 percent of qualified HMO's are developing in accordance with their enrollment and financial projections. The success of currently operating and developing HMO's is considered as the top priority of the future. Technical assistance, management training, expansion funding, and vigorous national promotion should be done on behalf of plans already in existence. New implementation funding should be funneled to areas where HMO's have not yet been developed, and special emphasis should be on medically underserved and rural populations. In addition, the Department of Health, Education, and Welfare's regulatory activity should be expanded and strengthened. Private investment should be encouraged to stimulate competition through new plans where some HMO's have already been developed. The grant process needs to be streamlined to remove paperwork burdens and help HMO's become operational faster,
procedures into useful summary measures, researchers calculated indexes of physician fees for each county for both general practitioners and specialists. The results indicate that on a nationwide basis, medicaid specialist fees are 77 percent of medicare specialist fees. Medicare specialist fees in metropolitan areas are 23 percent higher than those in nonmetropolitan areas, but there are no differences under medicaid. State medicare specialist fees varied from 73 percent to 132 percent of the national medicare average, while medicaid specialist fees ranged from 49 percent to 179 percent of the national medicaid average. State medicaid fees for specialists ranged from 39 to 100 percent of medicare specialist fees. These results indicate that under national health insurance, fees set at national or statewide levels could have notable effects on physician remuneration in some localities. Two references and a table of specialist fee indexes for medicare, medicaid, and medicaid/medicare, 1975, are given. (Author abstract modified)
Descriptor(s):Medicare,
Medicaid, Reimbursement,
336. Going Bare. Continuance Health Insurance.
Physicians.
and Conversion Provisions in
George B. Flanigan and Joseph E. Johnson. 1978, 5 pp. Av_labib'ty: Chartered Life Underwriters Journal v32 n3 p52-56 Jul 78.
1-153
The growin G reliance of Americans upon grouf: health L;a:c financing is addressed in this article. The increasing dependmce on health insurance arranged through the work situation has as its implication a dangerous vulnerability to the cyclical turns m the economy that appear inevitable. Unemployment frequently means that workers lose their insurance when they !ose _heir status as work group members. In 1975, the Nations1 Ass_ciation of Insurance Commissioners (NAIC) adopted the Model Group Health Insurance Conversion Law to alleviate socF:,.eof the problems that result from the tendency for Americans it, rely on group medical expense insurance. The NAIC model is a_,plicable to persons insured under group hospital e
i)escr/ptor(_): sign/program um payment, plans, National tions.
Participation in health care programs, i?ia: deprovisions (under healti_ pla_s), Source of p:_emlHealth insurance industcy, Private health care economic conditions, P_esent iegMation/re,gula-
West Germany is highlighted. Through understanding how a major industrialized nation _'ith a similar per capita gross nationai product has coped with social welfare, the functioning of such a system in the United States is clarified. Social security in the United States is not charity; benefits are based on the presumed financial needs of retirement. Most beneficiaries receive far more than they contribute or than an annuity would have provided. Pr_ections of the fnancing of social security outgo are ba.-.ed oa moderate inflation, a steadily declining birth rate, and a s :e0.,!ily im reusing proportion of senior citizens to the general pcJpulation. A_ Luarial assumpUons in0acate that the system will be stable until at least 2010. Demographic uncertainty and pred_c_i,-m_of [t)_ itife engender deficit projcction_ after 2025. In (::m_parison, the West German social security system works like a ,::ombination of an American pension plan and American social ,ecurity 1i,__.contributions nude h_ r.he past arc adjusted in a wage scale to _he: present, a, eraged, and then multiplied by 1 5 oerceI t per y_ar of credited service. Employee contributions amounting to 9 percent of covered salary are matched by the employer. The U.S. system provides a 50 percent spouse benefit, whereas the German social security system provides nothing. As medicare is an adjunct to American social security, so German national health insurance is an integral part of German social services expenditures. It is concluded that the U.S. has had no real direction or planning in the area of national health care. The health care planning that has existed has been characterized as a battle between Federal, State, and local governments. A study of the German social welfare system is useful in presenting the American system in perspective. The United States can afford catastrophic national health insurance, and since the concept has bil_artism- support, national aealth care will inevitably be enacted
D_sc_lptor(_): Comparisons regarding foreign health Fundii_g/finar, cing of healtt care programs.
_38. Graduage Medical Education National mittee, Interim Report. 337, Go_er._nent
Health and Welfare
policies,
Advisory Com-
Pre-_c**i_.sin_he Cdt_
ed States and West Germany.
Heal_- Resources Administra(ion, r.'.,HEW/PUB/H}O.-79/633
Mitchell I. Serota. i97% 4 pp A vMlability: Benefits International
Apt 1979, 329 pp. .4 _'ailability: Health Resources Administration, Office of Graduate Medical Education, Hyattsville, MD 20782.
v9 n6 o 15-18 Dec 79.
The proposed National Health Care Act is discussed in ter_:.°_sof cost, source of funding, and coverage; social se_ urity is cc,nside_ed as an example of the success in predicting uncertain costs, and the national health care system of the Federal Republic of
1-154
Hyattsville,
MD 20782
This interim report reflects the present status of the Graduate Medical Education National Advisory Committee's review and analysis of the issues related to graduate medical education. The committee, an advisory body to the Secretary of the Department
Health Ca_-e Pr_ grama
of Health, Education, and Welfare, was created in 1976. The committee's strategy in working on this project has been to collect and organize all available data on physician supply, supply projections, and physician requirement estimates. It has analyzed such data and examined all models for projecting physician supply and requirements. It has reviewed the literature to assess the potential impact of using nonphysieians on the need for physicians, and it has undertaken extensive review of the current financing picture and the relationships between physiclans' incomes and the choices of specialty and geographic loeation. The premise of this report is that the supply and distribution of specialty training-positions available to medical school graduates will directly influence the future supply of specialists. Modification of the number and distribution of these positions may become an important influence on the future supply of physicians. Other means to influence manpower supply are also being studied, such as changes in the reimbursement system and changes in the educational environment. Projections indicate that the supply of active physicians is expected to continue to grow rapidly, reaching nearly 600,000 by 1990. Extensive tables, charts, figures, and footnotes are included with two appendices delineating preliminary committee's deliberations,
assumptions
to guide the
Descriptor(s): Supply/availability of services, Physicians, Policy initiatives, Nurses, Allied health professionals, Present legislation/regulations.
Descriptor(s): health status.
Demographic
features of population,
Trends
in
340. Group Benefit Survey. Plans Covering Salaried Empioyees of U.S. Employers, 1980.
Wyatt Co., Washington, DC 20006 1980, 38 pp. Availability: Wyatt CO., Washington,
DC 20006.
This study compares the results of two Group Benefit Surveys conducted in 1978 and 1980. The studies analyzed the various designs and modes of financing for death, disability, medical,
339. Graying of America. Stanley J. Brody. 1980, 5 pp. Availability: Hospitals v54 nl0 p63-66,123
a year for a total ofover 10 million admissions and 38.8 percent of inpatient days. About 5 percent of the aged live in long-term care institutions. In addition, 80 percent of all home health care is given by families. Health care issues raised by an increasingly aging population include the role of rehabilitation in care of the aged; the need for a broad spectrum of services including nursing home care; the role of hospitals, nursing homes, and families; and the need for new services, such as home health care, to expand the family role. Currently there is no broad-based support in medicare or medicaid or in the current national[ health insurance (NHI)proposals for preventive care, mental health services, health education, home health services, and nursing home care. Three references are given.
16 May 80.
This article examines the demographic characteristics, economic and geographic status, and living arrangements of the growing elderly population in the United States and relates the effects of this growth to specific health care issues. By the year 2000, almost 32 million elderly or 12 percent will compose the anticipated population of 260 million. Characteristics of the aging population include a greater proportion of women to men, an income of about half that of families with an under-65 head, residency in metropolitan areas (about half the aged now live in the central city), a greater vulnerability to chronic and degenerative diseases, and a greater demand for medical services. Aged persons are subject to more disability, see their physician 50 percent more often, and have twice as many hospital stays lasting twice as long as those of the younger population. Currently, almost 5 million aged use hospital inpatient facilities at least once
and other benefits for salaried U.S. employees. For the 1980 survey, a total of 903 companies, or 46 percent of the total, responded to the questionnaires. For the 1978 survey, 807 tompatties, or 49 percent of the total, responded. The report noted that fewer death benefit plans required employee contributions for standard coverage; that the mounts, maximums, and durations of long-term disability benefits have continued to increase; and that more medical benefit plans provide "reasonable and customary" reimbursement for surgery, physician's calls, and outpatient diagnostic benefits. In addition, maximum benefit limits on major medical coverages have increased. Separate dental benefit plans are provided by an increasing percer.ttage of respondents: 59 percent in 1980, 46 percent in 1978, and 28 percent in 1976. The proportion of plans covering 100 percent of preventive dental care has also increased. There has also been a significant move toward self-insuring medical plans: 36 percent in 1980 compared with 23 percent in 1978. The report also notes the effects on employee benefit plans of the Pregnancy Discrimination Amendment to the Civil Rights Act of 1964 and the Age Discrimination in Employment Act. Survey data are provided.
1-155
Descriptor(s): Private health care plans, Plan design/program provisions (under health plans), Present legislation/regulations, Premium determination/underwriting, Health care/services, Dental services,
341. Group Dental Expense Insurance Experience.
Richard E. Ullman. 1979, 20 pp. A vailabih'ty: Transactions p287-307 1979.
of the Society of Actuaries vXXXI
This paper develops net claim costs for each major type of dental service, using experience data under Blue Cross/Blue Shield group dental contracts covering 250,000 persons. The period of the experience is mid-1974 through mid-1977. The great majority were insured through groups; a few had individual contracts, In order to study the frequency of dental services, thirty of the larger groups were selected. The procedures studied were: diagnostic, preventive procedures other than restorations, restorations, endodontics, periodontics, prosthodontios (removable), prosthodontics (fixed), oral surgery, and repair procedures other than oral surgery.
Tabular data are provided,
Descriptor(s): Dental services, Demand/utilization care programs, Service benefit plans.
preexisting medical conditions, discouragement of unnecessary surgery by underwriting the cost of second opinions, emphasis of preventive care measures, and implementation of the copay insurance feature. Disability insurance considerations focus on selection of an appropriate definition of disability to prevent and discourage malingering, extended elimination periods for insured coverage, and careful integration of disability benefits with other income sources, such as retirement plans. The real cost of any employee benefit program is equal to the benefits paid plus administrative expenses minus the investment return. To iraprove corporate cash flow or to reduce costs permanently, comparties may consider such strategies as premium lag, pooling, flexible funding, minimum premium, retrospective rating, and self-insurance. In addition, a great deal can be accomplished with administrative controls such as review of utilization reports, independent verification of claims, employee communications programs, preventative programs, and awareness of legislative issues in health care. It is emphasized that self-insurance or self-assumption of risk often creates an immediate awarehess and need to control the welfare benefit program among employers.
Descriptor(s):
Cost containment
efforts, Private
health care
plans, Source of premium payment, Third-party payors, Voluntary initiatives, Plan design/program provisions (under health plans).
of health
343. Group Practice Recommendations of the Committee on the Costs of Medical Care. A New Look at an Old Issue. 342. Group Insurance Cost Containment
Strategies. Steven A. Schroeder.
Edward J. Emering. 1980, 6 pp. Availability: Jnl. of Pension Planning and Compliance p468-473 Nov 1980.
v6 n6
Cost containment strategies that corporations can use when developing basic employee insurance benefits packages are discussed. Various strategies are examined in reference to plan design considerations, plan financing, and administrative and claims control measures. For example, the manner in which a plan of group life insurance benefits is structured can have a significant impact on the plan's cost. One popular design consists of a multiple of pay benefits schedule with or without a maximum dollar benefit. Other design considerations that can impact on the cost of group life insurance benefits include eligibility provisions, employee contributions, voluntary insurance, retired life coverages, and ancillary benefits. Some medical insurance aspects that must be addressed include exclusion of coverage for
I- 156
National Center for Health Services Research, Hyattsville, MD. 1978, 18 pp. Availability: Milbank Memorial Fund Quarterly/Health and Society v56 n2 p169-186 Spring 1978.
In 1932, the Committee on the Costs of Medical Care proposed a broad and visionary concept of prepaid group practice by physicians in association with othdr health professionals. In contrast, the prevailing form of group practice today is distinguished by a limited scope of services provided by medical specialists under fee-for-service fmancing. Among changes in medical care which have contributed to its current organization and to discussions concerning its reorganization are the increasing degree of medical technology used in hospital practice and the increasing specialization of physicians. Due to the escalating costs of health care, recent national policy discussions have been centering on cost containment methods. One Federal effort promotes the
Health Care Programs
growth of health maintenance organizations (HMOs), but past failures of prepaid group practice raise fundamental questions, Do people really want to change the organization of medical practice and what new forms and differences would result. Given the lack of public mandate for fundamental changes in the organization of medical care, a real danger of major reform may be to undermine public trust in government. Perhaps the major issue facing policymakers and reformers is the process of change itself. Attempts at fundamental change in the organization of medical care will undoubtedly be met by severe resistance from
The most notable risks involved with specific and aggregate coverages are (1) problems in obtaining adequate data to underwrite the aggregate coverage, (2) the claim volatility underlying an excess risk product, and (3) the difficulties in pricing the product. The rewards for marketing this coverage include a healthy expected profit margin, the minimal competition for business, and the ease of administering and marketing the product. Marketing strategies, pricing the product pricing, and insurance plan administration are discussed.
organized special interest groups such as doctors, hospitals, and health insurers, unless they perceive the changes to be in their favor. These largely unopposed groups will predictably weaken, if not cripple, any intended reforms. Thus, reformers must recognize that involvement in the political process is as essential as defining optimal goals. If a fundamental change in the organization of medical practice is desired, then a broad political constituency must first be developed. The best focal point might be the financing rather than the organization of medical care. Approximately 40 references are provided. (Author abstract modified)
Descriptor(s): Commercial health insurance plans, Plan design/ program provisions (under health plans), Deductible/coinsurance, Premium determination/underwriting, Claims administration.
345. Guide to Medicaid Data Sources. Volume One. Joan M. O'Brien. Trapnell (Gordon R.) Consulting Actuaries, Falls Church,
From a presentation at the conference "Health Care for the American People. Unfinished Agenda, " held in Warrentown, VA, May 18-20, 1977.
Descriptor(s): Prepaid plans, Physicians, regulations, Policy initiatives.
Present
legislation/
344. Group Specific and Aggregate Sto0-Loss Insurance. An Attractive New Market. Howard J. Bolnick. 1979, 5 pp. Availability: Best's Review v79 n12 p28,78,80,82,84
Apr 79.
The nature and the advantages and disadvantages of groupspecific and aggregate stop-loss health insurance are discussed, Because of rising medical care costs and the consequent acceleration in medical insurance premiums, many policyholders are seeking relief in self-insured programs. Group-specific and aggregate stop-loss insurance is an innovative product which will enable insurers to maintain a profitable health insurance business in the face of this trend. Group specific stop-loss insurance reimburses an employer for certain claims in excess of a stated deductible paid on behalf of an individual covered by the selfinsured program. Group aggregate stop-loss insurance reimburses the employer for certain claims in excess of a stated deductible paid on behalf of all individuals covered by the plan.
VA 22044 Health Care Financing Administration, Washington, DC. Div. of Medicaid Cost Estimates. Sep 1980, 94 pp. A vailabill'ty: Trapnell (Gordon R.) Consulting Actuaries. Falls Church, VA 22044. This volume presents a comprehensive guide to the. major sources of State medicaid program data available to the Federal Governnent, and provides a narrative description of each of the data sources. The introductory section outlines the major parameters of the medicaid program, summarizes the major data requirements of the program, and describes the data sources included in the volume. The major financial reporting forms are also described. These data are used to determine the Federal share of expenditures, document the disbursement of Federal funds, and prepare projections of the Federal share. Also described are statistical reports collecting aggregate statistics on numbers of recipients, counts of enrollees, medical vendor payments, and other program characteristics. In addition, those programs that generate relevant data at the Federal h.wel are described, including comments on the Professional Standards Review Organizations Hospital Discharge Data Set, the medicaid quality control system, and the annual hospital report. Several projects and demonstrations which the Federal Government has initiated to upgrade the quality of medicaid data sets are discussed, and several household surveys, which have been conducted or are planned for the near future, are included. Also, relevant surveys of medical care provicters are examined and three medical care models which are operating or under development are described. Exhibits are provid_l.
1-157
Descriptor(s): Health information/data systems, Medicaid, Funding/financing of health care programs, Participation in health care programs,
Providers
of health care services
346. Guide to Selected References on National Health and Socialized Medicine (1930-1973). Prakash C. Sharma. Jun 1979, 15 pp. Availability: Vance Bibliographies,
Monticello,
Care
IL 61856.
This reference guide on health care and socialized medxcine is divided into two parts: part one contains over 100 selected citations published chiefly during 1930-1964; part two contains nearly 75 selected references on studies related to national health care and socialized medicine published chiefly during 19651973. Each part of the reference guide is divided into two seetions: section one lists books and section two lists articles in journals and periodicals. Subjects covered in the book section of part one include the issue of compulsory health insurance, the management and development of dispensaries, the English health service, medical care and health insurance, and the fundamentals of good medical care. Subjects covered in the articles section encompass medicine and public health in China, health services in Israel, health insurance programs and plans of Western Europe, and the effects of the national health service on physician utilization and health in England and Wales. Part two lists books on varied aspects of health care planning in the United States and abroad, in addition to articles on national health care insurance, physicians and medicare, medical care systems in the United States and abroad, and health manpower. This unannotated bibliography is intended for persons engaged in health care and socialized medicine research studies. References are arranged alphabetically, tion are included. Public Administration Descriptor(s): regarding
and price and availability
field, VA 22161, HRP..0300901. This bibliography of app:roximately 500 citations is a source book of guidelines for providing health services in specialized areas of health planning. It does not propose to establish sets of standards and criteria for these specialities, but rather it makes available various planning methodologies which can serve as guidelines for health planners throughout the country. The references included data from the 1970's and have been gathered from searches of the computer files of the National Health Planning Information Center and from the MEDLINE and CATLINE files of the National Library of Medicine. Other materials have been added from manual searches in libraries and from agencies and associations working in specialty areas. To facilitate the use of the bibliography by health planning agencies, the first five sections of references have been organized to correspond to the standards discussed in the National Guidelines for Health Planning. The 15 sections are: general hospital beds, maternal and child care, cardiac care, radiation services, end-state renal disease, ambulatory care, burn care, emergency care, health maintenance organizations, home health care, long-term care, mental health services, rehabilitation services, general, and miscellaneous. The annotations generally run between 200 and 250 words. Ordering information is also provided. Hecdth Planning Bibliography
Descriptor(s): Health care/services, Facilities providing health care, Evaluations/outcorn e of health care programs.
348. Health. A Victim or Cause of Inflation.
informaMichael Zubkoff. Milbank Memorial
Series Bibliography
Series, No. 9.
No. P-268.
Fund, New York, NY.
1977, 399 pp. Availability: Prodist, New York, NY 10010.
National health insurance (NHI), Comparisons
foreign health policies.
Rita Fox.
A series of presentations examines issues associated with the relationship between inflation and health care in the United States. Efforts made to contain costs are presented and analyzed in an overview and history of inflation in the health industry, The section of papers on ilkflation and the consumer is concerned with the impact of inflatiion on the health care of low-income families and the elderly 1Door,along with the probable reaction of consumers to inflation. A third section deals with inflation
Bureau of Health Planning, Hyattsville, MD 20782 DHEW/PUB/HRA-79-14003 Oct 1978, 250 pp. Availability: National Technical Information Service, Spring-
and the provider. Each author discusses one of the following components in the delive:ry of health services: hospital services and capital investment, physicians' fees, inflation's impact on medical training program:s, inflation and health insurance, infla-
347. Guidelines Bibliography.
1-158
for Planning
Health
Services. An Annotated
Health Care Programs
tion and the Fedral role in health and inflation and health care quality (including the case of professional standards review organizations, PSRO's). The concluding section looks toward the future, addressing the politics of medical inflation and presenting an analysis of the gaps in knowledge that must by filled in order to deal with the problem of inflation and health. A discussion of the conference on inflation and health, education, income securi-
Descriptor(s): Policy initiatives, Private heahh care plans, Cornparisons regarding foreign health policies, Present legislation/ regulations.
ty, and social services held September 19-20, 1974, in Washington, DC, is appended. About 300 references, tabular data,
350. Health and Health Insurance. The Public's View.
footnotes, and an index are provided.
Health Insurance Inst., Washington, DC 20006 Dec 1980, 34 pp. Availability: Health Insurance Inst., Washington,
Contains revisions of seven papers presented at the HEW Conference on the Effects of Inflation and Anti-IntIationary Policies on the Health Sector held September
15 and 16, 1974.
Descriptor(s): Cost containment efforts, National economic conditions, Publicly sponsored/mandated health plans, Inpatient facilities, Physicians, Present legislation/regulations, Voluntary initiatives, Policy initiatives, Economics of third-party payors,
349. Health and Health Care. Policies
in Perspective.
Anne R. Somers and Herman M. Somers. Robert Wood Johnson Foundation, Princeton, NJ. 1977, 528 pp. Availability: Aspen Systems Corp., Rockville, MD 20850.
This volume presents a comprehensive view of health care covering developments of the past quarter century. It introduces the principal actors and some of their problems, focusing on the physician, the modern hospital, and the consumer-patient, and delineating their characteristics, roles, problems, and relationships. The text reviews the historical development and controversies of health care programs in the 1950's and 1960's, when the Nation's primary goal was assuring greater access to medical care. The role of private health insurance, including Blue Shield and health maintenance organizations; the growth and variety of public programs, such as Medicare and national health insurance; and innovative approaches to improve delivery systems, such as the "franchised" hospital, are examined. In addition, regulatory activity resulting from frustrations with the health care system is described, and several potential new policies, ineluding consumer health education and homemaker services, are explored. Relevant experiences in the United Kingdom, Sweden, and Canada are also examined. Finally, a framework is presented for redesigning the Nation's health policies and practices in accordance with changes in health care, society, and public perceptions. Footnotes, appended statistical tables, and an index are supplied.
DC 20006.
A 1980 survey, based primarily upon a national sample of 1,549 persons selected by the area probability method, was conducted to determine public views on the health care system. Since World War II, perhaps the most significant change in the American health care system has been the emergence of third-party paymeat. According to this and every survey undertaken by the Health Insurance Institute, Americans have consistently been satisfied with the quality of health care, but dissatisfied with medical care costs. This concern crosses all socioeconomic levels of society. Furthermore, those people surveyed expressed significant interest in placing more emphasis on prevention. They also expressed a high degree of satisfaction with their health insuranee coverage and service, although they did not seem to have clearly defined views about health insurance companies -- a high proportion of respondents expressed no strong opinions on company-related questions. However, people did not see health insurance companies as markedly more efficient than medicare or medicaid programs. While respondents' support for a comprehensive health insurance program declined, their support for a catastrophic program increased. Clearly, the public had reservations about a major new health insurance program if it is costly, raises taxes, or is run entirely by the government. A section on demographic patterns and a technical appendix is included, as well as 14 footnotes. Each chapter contains many statistical tables.
Descriptor(s): Demographic features of population, Third-party payors, Participants in health care programs, Private health care plans, Health care/services.
351. Health and Labor Power. A Theoretical
Arthur Schatzkin. 1978, 21 pp. A_Mlability: International 233 1978.
Investigation.
Jnl. of Health Services v8 n2 p213-
1-159
This aJ-tit-lc di_cus.ses health care as a drain on profits, or surplus value, which capitalism must b,zar to maintain lal,or, but which it _eeks to miuil_nze, especially during times of unemployment when laborers are more plentiful. From a historical-materialist viewpoi,t, health care i:_an element of labor power, or capacity to work, altd mw_stment in health care is part of the c¢_st of mai_ttaining _tlabt_r force. The primary determinant of the level of health and medical care under capitalism is the tendency toward maximization of the rate of exploitation. The absolute level of health and medical care tends to decline as unemploymerit rises and individual workers become more replaceable. Health differentials by socio-economic status are similarly explained by the easier replacement of lesser skilled workers. Medical care se_ vices in the context of the capitalist system constitute a drain on surplus value. In periods of economic decline, attempts are ,nade to conserve surplus value through reductions in mcdi_ al sere'ices t,r "social wages." Institutional and ideologica! raci_,m yield additional suqqus-value _vings and weaken pttbhc lcsisra:ice to medical ca_e retrenchment. The profit_ of' health-related indtkstries arc show_ to be merely partially recoupe3 surplu_ value losses. Moreover, tbe social eptdemiology of capitalism is characterized as social murder, as capitalist exploitation puts many workers under conditions that cause their premature death. The solution to these and other health problems lies in ending worker exploitation system and using social resources to improve workers' conditions and health, rather than regarding their conditions merely as means to promote capitalist goals. Barring this change, however, significant public health reforms include shortening the working day, eliminating racial discrimination, and decreasing unemployment. Footnotes and 65 referenct_ are included. (Author abstract modified)
tions, the health-retiremeni relationship is somt-wt'.a: li_i_c_a. Retirement should not be considered an irrew_abic ¢ltolt:._, alld policies should be designed to permit individuals c_n.,idcrable flexibility in leaving the labor force. The effects of rctirctucid depend on a number of factors; e.g., someone who an.:icipates poverty in retirement is less likely to be enthusiastic than someone who anticipates a secure tiJture. Historically, retirement is a new concept; as recently as 1930 over 50 percent of all males over 65 were in the labor fi3rcc. Retirement policies of the last 30 years have largely depended on the state of the economy. Recessions of 1958 and the early 1960's reactivated the trend toward compulsory retirement. In general, this practice was justiffed on the ground that most workers who are forced to retire have adequate retirement income. The divergent theories which explain and predict individtLal respo_se_ to retirement share the basic assumption that retirement is a significant life change requiring considerable adaption on the part of the individual. Activity theory and disengagement theory are the most frequently cited in thin area. Public _:,licy recommendations designed to meet the needs of elderly individuals include implementattt,n ¢_t a flexible retirement policy, implementation of preretireme_t training, assurance of adequate retirement income, and assurance of adequate access to medical care. Government policy now emphasizes, and is likely to continue to emphasize, the age, income, and medical care _treas of concern. Definitive conclusions regarding retirement health issues are discouraged by hinttations of the current research. Methodological problems and sorting out the effects of retirement from other life changes ha_e complicated the literature thus far. One table and 43 footnotes are included in the paper. WorMng Paper 5904-8.
Dc_;c'clptorr_9: Characteristics
of U.S. health care system, Poli-
cy/cha_ge_
re health care, Economic/commercial
influences.
352. iiea!th
and Retirement.
Issues.
Policy and Research
Robert Lee and Jane Kinsman. Urban Inst.. Washington, DC 20037 Admimstralion on Aging, Washington, Apr lg_78, 31 pp. .4v,,tJ,_tYity Urban
i,st.,
Washington,
353. Health and Taxes. An Assessment of the Medical Deduetion. DC. DC 20037.
Retirement i:qdiscussed m terms of its relationship to society, to the _di_idu:_l. and to health: policy and re.,,earch suggestions f_.,:tising o_ !his area are provided. The conventional wisdom ti_at _¢tm_cr_t !_,tsbad efft cts on health and well-being is based on s::ant e-.idence. Retirement may actually have beneficial effee__ ,.,- _he hc:,lth of some people. With regard to policy implica-
I- lcJO
Descriptor(s): Demographic features of population, Trends in health status, National economic conditions, Present legislation/ regulations, Policy initiatiw.'s.
Bridger M. Mitchell and Ronald J. Vogel. 1975, 13 pp. Availability: Southern Economic Jnl v41 n4 p660-672 Apr 75. The financing of health expenses as a medical deduction under the personal income tax is analyzed using 1970 Internal Revenue Service (IRS) statistics on itemized deductions. Previous studies have been conducted in aggregate terms, but this one classifies
Health Care i'ro_,,,,..,
data jointly by income bracket and size of deduction. In 1970, personal income tax deductions provided subsidies of $4.4 billion for personal health care services, in contrast to the $2.9 billion spent on medicaid that same year. These subsidies, in the form of deductions for the purchase of health insurance and for out-ofpocket medical expenses are disproportionately distributed to higher income taxpayers. Hence, the effect of Federal policy has been to spend more health care dollars on middle-income and upper-income taxpayers than on the poor. Analysis shows that family spending on health insurance clearly increases with income, allowing middle -income and upper-income taxpayers to make money by buying group health insurance rather than paying for their medical expenses directly. Apart from the separate deduction for one-half of health insurance premiums, the personal income tax operates to reimburse a family for medical expenses in much the same manner as a private health insurance policy. The Federal Treasury acts as the insurer of last resort, The 1970 data confirm that the probability of having unreimbursed medical expenses exceeding the deductible falls steadily with income, whether or not the family paid insurance prendurns. A modest increase in average subsidy per taxpayer occurs up to incomes of $15,000, but above that amount, the subsidy increases rapidly. Thus, despite its income related deductible, the Internal Revenue Service insurance plan has substantially larger benefits for high income taxpayers. Furthermore, analysis reveals that the tax subsidy provided under this system supplies only limited protection against catastrophic medical expenses, and the occurrence of catastrophic expenses is concentrated at lower incomes. Thirty-one footnotes and an appendix are provid-
caid, medicare, the maternal and child health program, and the comprehensive health centers are reviewed from 1965 to 1975. Recommendations are made for improving individual programs and for changing public policy in ways that would make comprehensive health care accessible to all. The initial chapter expounds the rationale for public health care for the poor, the elusive minimum standards of health care, the r_ons why these are issues of social concern, and the alternative approaches that pubfic policy could take in confronting the problem. Tne relationships of health, use of medical care, and income are then examined through trends in the differences between sociceconomic groups. The successes and problems of medicaid are analyzed historically, in terms of coverage and benefits; costs; the use of medical services by the poor; the Federal-State partnership in the distribution of medical benefits; financing; and screening, diagnosis and treatment practices. Undesirable cutbacks at the State level and proposals for positive reform conclude the discussion of medicaid. Analysis of the strengths and limitations of medicare follows a similar format, emphasizing benefits, expenditures, utilization patterns, racial and geographic inequities of care provision, and possibilities for reform. The maternal and child health program, comprised of a range of services, is evaluated as having met the health needs of many of the poor. Neighborhood health centers and cooperative clinics are discussed as new approaches to health care delivery. Footnotes and 50 text tables are suppfied. The appendix cxmtains a discussion of methodological problems with measuring the contribution of medical care to health. An index is provided.
ed"
Brookings
E_rh'er version of this paper appeared as Rand Repo_ R-1222OEO, prepared under a grant from the Office of Economic Opportunity,
Des_ptor(s): Medicare, Health care costs, Medicaid, National economic conditions, Participants in health care programs, Policy initiatives, Evaluations/outcome of health care programs, Demographic features of population, Demand/utili2ation of health care programs.
Descriptor(s): Participation in health care programs, Source of premium payment, Present legislation/regulations, Impact of third-party coverage.
$¢_es of Studies in Social Economics,
17th Volume.
355. Health Care. An American Crisis. 354. Health and the War on Poverty. A Tea-Year Appraisal. Karen Davis and Cathy Schoen. Robert Wood Johnson Foundation,
Lester A. Sobel. 1976, 189 pp. Avsilabih'ty: Facts on File, Inc., New York, NY 10019.
Princeton, NJ.
1978, 230 pp. Availability: Brookings Inst., Washington,
DC 20036.
This study summarizes the basic health and poverty issues and the public programs that have attempted to break the link between low income and poor health. The performance of medi-
The development of the U.S. health care "crisis" as it grew during the period ending in the mid-1970's is described. The "crisis" is defined in terms of exorbitant medical costs which continue to increase, inefficient and ineffective service delivery, inequitable distribution of quality care, incompetent providers, and limited or no health care insurance coverage for the unem-
1-161
ployed and the poor. The historic background that produced efforts to deal with the U.S. health care crisis is described under the topics of the Truman health program, the national health insurance (NHI) approach, Eisenhower health proposals, medical care for the elderly, Kennedy and the health care problem, and Johnson and the enactment of medicare. Also detailed are the efforts made to overcome faults found in Government programs, such as medicare and medicaid, as well as with the prirate health insurance and fee-for-service medical systems. The discussions consider the beginning of medicare, political developments, rising medical costs, program benefit limitations, State regulation, and health manpower problems. The increasing health care crisis and Government efforts to deal with it are traced through the Nixon Administration and into the Ford presidency, when controversy began to affect health agencies and programs. The malpractice dilemma is outlined in the coneluding discussion, as the doctors' revolt in response to rising malpractice insurance costs is described, along with State-byState action to deal with the problem. Graphic and tabular data and a subject index are provided. Data for the volume comes largely from the record compiled by "Facts on File" in its weekly coverage
of world events,
Descriptor(s): Economic/commercial influences, Publicly sponsored/mandated health plans, Publicly sponsored/mandated health plans, Participation in health care programs, Plan design/ program provisions (under health plans), Funding/financing of health care programs, Providers of health care services, Policy/ changes re health care, National health insurance (NHI).
British system of "choice by bureaucrats." The proposed changes to current medical and hospital insurance schemes would have the effect, over time, of reducing the built-in cost escalation without materially affecting access to medical care. The recommendations are aimed at increasing competition among suppliers of medical services, breaking the conflicts of interest faced by medical practitioners, and establishing an economically realistic basis for the delivery of hospital services. One of the greatest barriers to reforming the current system and one of the greatest causes of escalating costs is an unrealistic notion of what constitutes equitable access to health care. The concept that every citizen must have the highest quality of medical care available is deemed economically unrealistic. Universal "adequate" care is considered a more realistic basis for the development of a cost-effective health care system. Tabular data, notes, and 46 references are provided.
Descriptor(s): Demand/utilization of health care programs, Health care cost trends/p:rojections, Supply/availability of services, Competition/interaction among third-party payors, Impact of third-party coverage, Private health care plans, Publicly sponsored/mandated health plans, Plan design/program provisions (under health plans), Funding/financing of health care programs, Providers of health care services, Comparisons regarding foreign health poltieies, Outcome/evaluation of health administration.
357. Health Care Cost Containment. Challenge to Industry.
356. Health Care Business. International
Evidence on Private
Versus Public Health Care Systems. Ake Blomqvist. Fraser Inst., Vancouver, British Columbia. 1979, 185 pp. Availability: Fraser Inst., Vancouver, British Columbia, Canada
V6E 3M 1.
Based on analyses of the Canadian, U.S., British, and Swedish health care systems, recommendations are offered for improving the cost effectiveness of Canada's health care system. The study's primary conclusion, leading to a recommendation for a series of sweeping changes in Canada's system of medical insurance, is that in the process of ensuring equal access to medical services, the current Canadian system has become unacceptably inefficient and costly. The Government's response to rising medical costs has been to intervene increasingly in the health services market, thus gradually moving the Canadian system closer to the
1-162
Harry B. Wolfe, Judith D, Bentkover, Helen H. Schauffier and Ann Venable. Little (Arthur D.), Inc., Cambridge, MA 02140 Financial Executives Research Foundation, New York, NY. 1980, 183 pp. Availability: Financial Executives Research Foundation, New York, NY 10017.
This study examines the status of health care costs and the causes of their sharp increases in recent years. It presents examples of what various companies have done to help contain their own health care benefit costs and health care costs in the community. There is no single course of action that guarantees successful cost containment; each company must examine the array of possible actions to determine the most appropriate ones. A financial executive must analyze the f'mancial implications of proposed actions. Restructuring heal'_h insurance benefit plans to discourage inappropriate hospital utilization, building employee costsharing into benefit plans, and conducting utilization reviews are also employed. An increasing number of companies are self-
Health
Care Programs
insuring their employee health plans. Developing alternative health care delivery systems and focusing on prevention and health promotion programs are other cost containment possibilities. Many companies are beginning to develop health care costs information systems to help determine whether they are getting full value of health care premiums and to identify cost saving opportunities. Recognizing that community action to improve provision of health care or reduce the cost of health care services will also benefit corporations and employees, many companies encourage financial executives and other corporate staff to lend their service and talent to health care organizations in the community, such as through hospital board and planning agency membership. Finally, a chapter on cost containment activities documents actions by government and health care providers, Expected areas of future activity include establishment of hospital rate-setting programs by more States; further federally-sponsored experiments with reimbursement approaches designed to discourage unnecessary hospitalization, surgery, and ancillary service utilization; the promotion of preventive care, self-care, and noninvasive diagnostic techniques; the development and use of ambulatory alternatives to hospital care; the tightening of State certificate-of-need (CON) programs; reimbursement changes; and closer monitoring of providers under medicare and medicaid. Finally, national health insurance (NHI) cost containment impacts both for the nation and for individual companies are examined. A glossary, chapter references, and tabular data are provided. (Author abstract modified)
moting the objectives of Titles XIX and IV-A, respectively, of the Social Security Act. However, in the Georgia case, the plaintiffs contended that Federal regulations protecting human subjeets were applicable to the experiment at issue. While the precedent of past cases upholding the Secretary's authority to approve benefit-reducing experiments was not overturned in Georgia, the District Court held that the regulations affecting human subjects were applicable and, consequently, that such experiments must be reviewed prior to implementation by an institutional review board. If the experiment places human subjeets at risk, the regulations require that informed consent be obtained from participating subjects. The court's decision appears to mean that the regulations protecting human subjects apply to at least all similar projects. What remains unclear is whether the limits imposed by these regulations on future experimentation will result in needed protection of some 1ceneficiaries' rights or a missed opportunity to discover alternative health care financing strategies which might benefit all beneficiaries as a class. Eighteen reference notes are provided. (Author abstract modified)
Descriptor(s): Plan design/program provisions (under health plans), Voluntary initiatives, Cost containment efforts, Private
359. Health Care Cost Containment in West Germany,
health care plans, Policy initiatives.
Deborah A. Stone.
Descriptor(s): Cost containment efforts, Present leg_dation/ regulations, Plan design/program provisions (under health plans), Medicare, Medicaid.
German Marshall Fund of the United States, Washington, De. 1979, 22 pp. 358. Health Care Cost Containment Experiments. Policy, Individual RiOts, and the Law.
A vMlability: Jnl. of Health Politics, Policy and Law v4 n2 p176-199 Summer 1979.
Trudi W. Galblum.
The major difference between the West German
1978, 13 pp. Availability: Jnl. of Health Politics, Policy and Law v3 n3 p375-387 Fall 1978.
public health insurance in the United States lies in the collectivization of the West German system. Insured persons are required
In a climate of increasing pressure to contain health care costs, legislators and health services researchers have proposed experiments involving reductions in benefits currently authorized under the medicare and medicaid programs. This paper examines three court challenges to the conduct of such experiments in California, New York, and Georgia. The rulings on the California and New York cases were in favor of continuing the experiments on the grounds that the Secretary of Health, Education, and Welfare had judged the projects to be helpful in pro-
system and
to belong to a "sickness fund," or nonprofit quasi-public insurance company, and it is through these organizations that all patients have financial dealings with physicians and hospitals. Providers, in turn, also are organized and must negotiate, collectively with the sickness funds. As in most West European ¢ountries, there is a strict separation between office-based medicine and the hospital sector. The sickness funds pay hospitals a flat per diem rate for each patient; the rate is officially set by the responsible State agencies, but in practice is often the result of bargaining between the funds and the hospitals. Like the United States, the West German health care system has experienced a serious escalation of expenditures since about 1970. For a variety
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of reasons, many features of the national health insurance (NHI) program that might have provided restraints on costs were gradually eliminated. Most notably, some restrictions on the supply of physicians and hospital facilities were ended, as was an earlier system OffLxed budgeting for ambulatory care services. In addition, legislative and judicial decisions have continually expanded both the benefits and the standards of care that must be provided to publicly insured patients. In 1977, the Gow.'rnment passed a Health Care Cost Containment Act which ordered several measures to curb costs: prospectively negotiated ceilings on expenditures for physicians, services, dentists' servic.es, and prescription drugs; a stronger utilization review; composition of a unified fee schedule; small increases in cost sharing and limitations on insurance benefits; and some changes in financing. The reform eflbrts seem to have had a significant effect, though it is still too early to tell exactly what caused the declining growth rate of health expenditures, and whether the new trend will persist. Tabular data and 23 references are appended. 'Author abstract modified)
Descriptor(s): Cost containment efforts, Supply/availability of services, Comparisons regarding foreign health policies, Outcome/evaluation of health administration.
360. Health Care Cost Elements Planning Considerations. Edward
Affecting Legislative
and
L. McClendon.
1977, 6 pp. Availability: Topics in Health Care Financing Winter 1977.
v4 n2 p:57-62
To aid legislators and decisionmakers in planning cost containment mea_sures, this article outlines the elements and intricacies of health care costs. Total costs of the health care delivery system are influenced by quantity and quality of services, as well as by relative labor costs. The major cost areas are in turn influenced by combinations of factors such as system efficiency, accessibility of care. and research efforts. The ways in which major and modifying cost factors can interact with each other are almost unlimited. As a result, cash flows into the health care delivery system cannot be reduced on a long-term basis without serious negative consequences. Implementation of even limited cost control options requires more complex models for evaluating problems. Indeed, simplistic emphasis on single factors, such as surplus capacity in hospitals, has distorted the true efficiency relationships. Legislators must understand that surplus c.apacity is essential to accomodate catastrophes and seasonal peaks. Advantages and disadvantages of the duplication of CAT scanner,
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shared health care facilities, and extensive government regulations require careful consideration. However, until more sophisticated forecasting techniques have been developed, existing planning instruments must serve to test each alternative for problemsolving within tl_e framework of the total factors involved.
Descriptor(s): Cost/benefit analyses, Policy/changes care, Cost corttainment efforts, Inpatient facilities.
361. Health (_re
re health
Cost Increases.
Jack A. Meyer. American Enterprise Inst. for Public Policy Research, Washington, DC 20036 1979, 43 pp. Availability: American E_aterprise Inst. for Public Policy Research, Washington, I')C 20036.
This report reviews recent research into the causes of health care cost increases and analyzes the associated policy implications. Selections from the literature are evaluated, followed by an assessment of alternative policy proposals for reducing health care costs. Government proposals, as well as the policy recommendations of the surveyed authors, are assessed in terms of the extent to which they address, _Lnd promise to alter, the underlying causes of health care cosl: increases. The introduction outlines the dimensions of the basic: problem of health care cost escalation and notes the associated controversy over appropriate conceptual models. Subsequent sections discuss the components of rising expenditures, the role of market-oriented approaches, the efficacy of recent regulatory measures, and the potential of new regulatory proposals. The dominant force in perpetuating rising health care costs is deemed to be the widespread use of insurance as a means of absorbing direct patient costs and reimbursing providers. According to th e literature review, the causes of rising resource intensity are the growth of insurance, paying through premiums rather than at rime of use, tax subsidies for the purchase of insurance, and the collective bargaining drive for extensive coverage of rout:me services. Health maintenance organizations (HMO's) are the focus of discussion concerning market-oriented approaches. Certificate-of-need (CON) controls regulating capital expenditures by hospitals are evaluated as an example of government regulation. Proposed regulatory approaches are represented by hospital cost containment proposals and the administration's national health plan. Both are critiqued for failing to address the fandamental forces contributing to the upward spiral of health care costs. Notes to the text are supplied.
Health Care Programs
AEI Special Analysis
No. 79-3.
Descriptor(s): Policy initiatives, Health care costs, Economic/ commercial influences, Cost containment efforts, Impact of third-party coverage, Health care cost trends/projections,
362. Health Care Cost Inflation in the United States. Toward a Unified Theory of Cause and Control.
percent on larger bills must be coupled with a "'catastrophic illness" provision, sharply reducing patient payment once a given percentage of annual income has been spent. A program such as this, mandated by legislation, would increase administrative costs and bad debts for hospitals and would cause physicians difficulty in ascertaining whether the patient's expenditure requirement had been met. Descriptor(s): Health care costs, Supply/availability of services, National economic conditions, Deductible/coinsurance, Physiclans.
S. David Pomrinse. 1977, 6 pp. Availability: Mount Sinai Jnl. of Medicine v44 n5 p613-618 Sep/Oct 77.
363. Health Care Costs. An Analysis of Current Trends in Health Costs and Utilization. Mutual of Omaha Group Div., Omaha, NE 68110
This paper examines the history of inflation of the major elements of health care costs and demonstrates a common or sinfilar cause for each. In contradistinction to most fields, effective demand for health care services is determined primarily by the type and volume (supply) of available service and not so much by the sum of individuals' needs expressed by their decision to purchase health services. The history of the physicians shortage and the increase in specialization since the 1930's are reviewed, It is time to reexamine inducements to expand medical schools and to encourage creation of new ones with their attendant need for associated high-cost tertiary care hospitals. A not dissimilar history pertains to hospitals: the lack of capital during the Depression, World War II, and passage for the HiU-Burton Act in 1948, culminating in the 1975 National Health Planning and Development Act requiring planning approval for hospital construction. Nursing homes are also examples of a pattern of a perceived deficiency reacted to by Government without regard to how much the operation of the beds would cost. Overinvestment in manpower and in facilities is at the root of the inflation
Nov 1980, 47 pp. Availability: Mutual of Omaha Insurance Company, NE 68110.
of health care costs. But the medical care cost index is increasing at a rate far greater than the annual net increase in manpower or hospital beds. Third-party payment is the resource measured by the infaltion rate of money. The growth of third-party payment has emerged as a major force during the depression with the growth of Blue Cross into a national program. At the same time, people came to feel they had a fight to use their benefits, Aided by retrospective payment formulas for hospitals and usual and customary fees for physicians, change levels were effectively set by the sellers; the buyers could do little about it. Money was no object until the total amounts spent threatened profit margins of industries and forced priority decisions by State and local governments. To avoid serious economic damage from health service costs and to assure that needed care will not be relinquished, deductibles high enough to avoid the excessive cost of insuring small bills and coinsurance requirements of 25 to 33
(Mutual of Omaha, Group Div. abstract modified)
Omaha,
This publication features Mutual of Omaha's Group Division health care cost and utilization statistics for the first h_[" of 1980. Statistical data have been compiled by each State and region. In most cases, a comparison is made with the previous year's experience and with a new I l-year utilization average. An explanatory text precedes each statistical section. Included in this study are statistics on hospital utilization and health care cosl_, claims breakdowns by cause of disability, loss-of-time, medical care inflationary trends, and current hospital room and board costs. A special feature is the data on average semiprivate hospital room rates; over 400 major cities are included in the survey. Rates in force as of October 1980 have been compiled and formulated to establish city, State, and regional averages and represent the major metropolitan hospitals throughout the country. Besides the data tables, graphs and maps are also supplied.
Group Claim Research. Descriptor(s): Demand/utilization of health care programs, Health care cost trends/projections, Inpatient facilities, Health care/services, Commercial health insurance plans.
364. Health Care Costs. Private Initiatives for Containment. Stephen C. Caulfield and Pamela L. Haynes. Government Research Corp., Washington, DC 20036 1981, 147 pp. Availability: Government Research Corp., Washington,
DC
I-t65
20036.
Private initiatives designed to contain costs of health care ser-vices are discussed. The following areas are identified as con-. cerns of cost containment: managerial efficiency, prc_vider income, overuse of health care services, technology, demograph.. ics, and reimbursement mechanisms. Redesign of benefits is one of the private cost containment efforts discussed. The topic,; considered are (1) the degree to which there is a consensus abour_ what would constitute an acceptable and cost-effective benefit: package; (2) whether multiple-choice benefit plans can be designed to achieve cost-containment; (3) strategies for selling revi.sions and new benefits structures to emplo3ers, unions, and employees; and (4) whether there are new benefits being deve.loped that will result in systemwide savings. Another presentation examines efforts to exert some controls and limits on the supply- and structure of health care resources as a way" of containing costs and ensuring quality. Reimbursement systems and claims control are considered in the third presentation, with the following reimbursement systems being examined: negotiated voluntary prospective rate setting, an aggressive claims-processing system imposed on a number of existing fee-for-service marketplaces, the use of quality assurance as a vehicle to achieve cost controls through the Professional Standards Review Organization program, and the use of pooled data to influence the behavior of hospitals and physicians in a particular community. Other private cost containment efforts considered are labor, industry, and investor-owned delivery systems; voluntary efforts and coalitions in health planning; physicians' role in cost containment; and future directions t'or private cost containment efforts. References accompany each presentation. Footnotes are included. Descriptor(s): Cost containment efforts, Private healtk care plans, Inpatient facilitie.s, Plan design/program provisions (under health plans), Physicians, Claims administration, Methods of paymen; determination, Vcluntary inkiativ_s.
competition through alternative delivery systems and direct controls over prices and capacity. Because these efforts do nothing to correct the existing cost-increasing incentives, an alternative delivery system is suggested that would be based on the following principles of fair competition: (1) free choice for each consumer to enroll in any qualified health plan in the area, (2) fixed amount of financial help regardless of which health plan the consumer chooses, (3) a uniform set of rules applying to all health plans to assure that they provide good quality comprehensive care at reasonable cost, and (4) organization of physicians in competing economic units so that the premium each insurance plan charges reflects its ability to control cost. As a transition from the present controlled system to that 0f free competition, the Government should use its leverage of tax credits to enforce these principles m a few lost-cost measures. Each employer should be required to offer employees a choice of at least three distinct health plans as of the benefits program. All standards health plans qualifying for taxpart incentives should meet uniform in terms of basic minimum benefits, catastrophic expense protection, and continuity of coverage. The article expresses confidence that competition among doctors will occur under these rules.
Descriptor(s): Cost containment services, Competition/interaction Policy initiatives.
366. Health Care Dilemma
efforts, Supply/availability of among third-party payors,
and Corporate Debt Capacity.
John N. Simpson. 1978, 14 pp. Availability: Hospital and Health Services Administration p54-67 Summer 1978. The health-care industry's increasing involvement in corporate debt is examined as a factor in rising health-care costs, and alternatives for dealing wi;h this issue are discussed. As third
365. Health Care Costs. Why Regulation Fails, Why C,_mpetition Works, How to Get There From Here.
Alain C. Enthoven. 1979, 5 pp Availability: National
Jnl. vLt n21 p885-_89
26 May 7c
It is argued that Government regulations have been unable to contain soaring health care costs and that a system of fair competition among health plans would reduce those costs. The main direction of public policy in the 1970's has been to protect the dominant commercial insurance system from fair economic
1-166
parties or governmental agencies look at the health-care dilemma of growing demand for :_ervices and inflated costs of services, significant attention will be given the health-care industry's increasing involvement in debt. Even though the price of debt inflates the cost of health care, the major concern is determining a reasonable level of debt. Assuming a reasonable debt level can be identified, a method should be developed to hold debt at this level. This will require an outside agency or group to define and control the health industrk,_ debt involvement. Given the likelihood of debt control in the',near future, hospital administrators would be wise to minimize new debt obligations to allow for future flexibilities with this asset alternative. Prudence also calls for the development and expansion of a hospital's revenue
Health Care Programs
sources beyond the patient-care cost reimbursable sector. Cash flows from other revenue sources can serve as pay-ack mechanisms for debt, thereby increasing the corporate debt capacity of the institution. Responsible action by hospital administrators now concerning debt involvement can prevent government regulatory intervention in this area, which would tend to reduce hospital expenditure alternatives. Footnotes and one table are provided. (Author abstract modified)
Emergency Medical Services System. In addition, o,_c major problem in preventive health care is the lack of an adequate record and followup system. Training and education is also a major need in the health care network. In the future, projects using present technology can provide a health care network for the vast number of ambulatory patients in this country. Chapter references, figures, and an index are provided. Health and Medicine
Descriptor(s): Cost containment efforts, Facilities health care, Inpatient facilities, Funding/financing care programs,
providing of health
Series.
Descriptor(s): Health information/data systems, Providers of health care services, Outcome/evaluation of health administration, Supply/availability of services, Medical technology impacts, Cost containment efforts.
367. Health Care Dilemma. Problems of Technology in Health Care Delivery.
368. Health Care Financing Options for Colorado.
J. H. U. Brown.
Colorado State Dept. of Health, Denver, CO 80220
1978, 183 pp. Availability: Human
Sciences Press, New York, NY 10011.
Examining the existing health care system and the development of medical care, this book analyzes those systems of care that have a real impact on the future delivery of service. An overview of the health care system is presented and new techniques used in health care are examined. The book notes that operations research is just beginning to make an impact on the delivery of health care services and that much health care delivery failure can be attributed to managerial deficits in health care planning. To date, health care technology assessment has not been oriented towards the goals of the system; nor is there a system for development of technology in health services which provides a continuum from invention to testing to clinical use, although such a system has been designed. Moreover, an adequate data base from which to develop quality control criteria still does not exist, and appropriate health care services have not been identified in detail and standardized. Hence, regulations to control quality and quantity remain a mass of conflicting rules which need to be examined and coordinated. Another material improvement to the fragmentation, expense, and lack of expertise in the health care system could be realized by the development of a communications base. Several major communications systems linking health care services are described briefly, along with seven experimental projects, training projects, and satellite delivery of services to remote areas. Several experimental health services delivery systems are also discussed, including the Denver Department of Health and Hospitals (Colorado), the Space Technology Applied to Rural Papago Advanced Health Care project (Arizona), the Mount Sinai Telecommunications Project (Columbia, Missouri), the Automated Physician's Assistant, and the
National Center for Health Services Research, MD 20782 Nov 1979, 103 pp. AvMlability: Colorado 80220.
Hyattsville,
State Dept. of Health, Denver,
CO
Colorado's health-care financing options for the medic;ally indigent are considered through an assessment of Hawaii"s health insurance law, Minnesota's and Rhode Island's State catastrophic insurance, expanding the medicaid program to include the medically needy, and prepaid health services such as Oregon's Project Health and the Boston Community Health Plan (Massachnsetts). Financing medical care for the medically indigent is approaching a crisis in Colorado because (1) the number of hospitals participating in the medically indigent program is decreasing and (2) only 40 percent of Colorado's physicians accept medicaid patients because they view reimbursement as too low. One financial option being considered in order to deal with the problem is a mandatory State health insurance law similar to Hawaii's; Hawaii is the only State which mandates that employers provide health insurance for employees. A second option is the expansion of medicaid, which currently only covers certain targeted groups, to include the general category of the medically needy. A third option being considered (which is not mutually exclusive in relation to the other options) is the provision of catastrophic health insurance. Such programs in Minnesota and Rhode Island are discussed. Representatives of Oregon's Project Health and the Boston Community Health Plan describe their organization of local health services and discuss how health services can be cost-effectively financed locally. California's experience with its program for the medically needy and indigent is briefly discussed. Implications of each of the State programs discussed for Colorado are considered.
1-1_7
Proceedings
of a conference held September 24-25, 1979.
Descriptor(s): Supply/availability of services, Prepaid plans, Medicaid, Non-participants in health care programs, Eligibility requirements, Present legislation/regulations, Policy initiatives, Comparisons of health care programs, Funding/financing of health care programs.
Praeger Special Studies in U_S. Economic, Issues.
Social and Political
Descriptor(s): Impact of third-party coverage, Commercial health insurance plans, Premium determination/underwriting, Claims administration, IVlethods of payment determination, Voluntary initiatives, Outcome/evaluation of quality assurance.
370. Health Care in the American Economy. Number 3. 369. Health Care Guidance. Commercial Health Insurance and National
Health Policy.
Carol Klaperman Morrow. Milbank Memorial Fund, New York, NY. 1976, 140 pp. Availability: Praeger Publishers, New York, NY 10003
This study explores the influence of the commercial health insurance industry upon health care delivery. Health insurance is conceptualized as a guidance system that (1) collects and evaluates information about the cost and quantity of health care and (2) activates mechanisms to reward or penalize health care providers and patients who conform or deviate from the system's guidelines. This study sought to determine what types of information on the provider, the patient, and the care rendered are gathered by the insurance industry and to what ends. It also sought to ascertain what sanctions the insurer implements in order to effect regulatory goals and how willing insure_; are to act in a regulatory capacity. Data were drawn from Senate subcommittee records on the commercial health insurance industry as well as from surveys and interviews. Although insurance companies declined to furnish detailed statistics on their process claims investigation, seven insurance underwriters did respond to a questionnaire on insurer attitudes toward their guidance role. The study found that the insurance industry was developing technologically sophisticated information collection and evaluation processes and establishing charge and utilization guidelines, but was failing to follow through with effective sanctions to implement review decisions. The reluctance to interfere forcefully with professional patterns of services and charges stems from technological, economic, political, and ideological constraints. It is concluded that a mature health care guidance system can emerge only within the context of a national health care policy which taps the resources of the insurance industry to achieve standardized review and evaluation processes, predictable and effective controls, and balanced access to care and utilization, Tabular data, study instruments, a bibliography of about 100 references, and an index are provided,
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David H. Klein and John E Newman. 1980, 124 pp. Availability: Health Services Foundation,
Chicago, IL 60611.
Various aspects of health care costs are discussed in this collection of 17 papers. Economic forecasts on physician fees and expenditures and hospital costs are presented, followed by an examination of the difficul':ies involved in containing costs from the economic perspective. Using information gathered in a national survey conducted in 1975 and 1976, public opinions of health care are described along with their implications for cost containment efforts. Suggestions for containing costs are offered by representatives from management, labor unions, consumers, physicians, hospitals, and the Blue Cross and Blue Shield organizations. The final group of papers addresses various solutions for containing costs. The impact of the President's anti-inflation program on the health care sector is assessed. Based on personal experiences in Maryland and Massachusetts, two speakers contend that price controls are not effective in containing costs and can have adverse effects. An analysis of the impact of technology on costs emphasizes that increased use of technology should be debated on the basis of improved patient care and that shortterm savings could evolve into li_gher costs in the long-term. A former official of the Department of Health, Education, and Welfare reviews the effects of professional standards review organizations on hospital cost containment and their potential for the future. The final pal_._r analyzes the relationship between costs and quality control in hospitals. Several papers include tables and references. Proceedings of an annual conference sponsored by the Blue Cross and Blue Shield A_sociations, January 21-24, 1979, San Antonio, Texas. Descriptor(s): Cost containment efforts, Medical technology impacts, Present: legislatiort/regulations, Voluntary initiatives, Economic/commercial influences, Policy initiatives, Health care cost trends/projections, National economic conditions, Methods of payment determination, Outcome/evaluation of quality assurance.
Health Care Programs
371. Health Care in the 1980s. Who Provides. Who Plans. Who Pays.
Conference panelists' remarks are summarized with rci_:rence to the intent of the National Health Planning and Resources Development Act of 1974 and its effects on health care lawmakers,
1979, 98 pp. Availability: National League for Nursing, Inc., New York, NY 10023.
providers, consumers, and planning and regulatory agencies at the State and regional levels. The goals of the act are to facilitate the development of recommendations for a national health planning policy; to augment areawide and State planning for health services, manpower, and facilities; and to authorize financial assistance for the development of resources to further that pollcy. It adds two new titles to the Public Health Service Act, title XV, and title XVI, both of which revise existing health resource development programs. All panelists agreed that the act is an improvement over the former types of health care legislation. Some panelists questioned the adequacy of funding and thought the authorization levels should be carefully scrutinized. Others believed that the authorized figures are sufficient to get the program started. On the subject of Federal, State, or local control of the health systems agency program, one panelist mentioned that his State, as well as others, intends to requi:re health systems agency compliance to State standards. Others felt that the final power is in the hands of the Secretary of Health and Human Services, since the Federal Government has the final fight of approval and review. The checks and balances of the law, however, are generally believed by the panelists to provide for a decentralized operation. The panelists viewed the act as the last opportunity for the private sector to maintain a pluralistic systern in health care delivery; therefore, the stakes are: high in making the system work. The appendices provide goals for successful transition by existing agencies: strategies for coifing with challenges to continuity; national health priorities; funding authorization for the act; and the Department of Health, Education, and Welfare's implementation schedule for the act.
Presented in this collection are papers from a conference of nursing professionals in which prospective changes in the American health care system in the 1980's were considered. The introductory address identifies the dominant issues of health care for the decade as being affordable quality care; noninstitutionalization of long-term care; research and development of alternatives to long-term institutionalization, such as the home care and hospice approaches and the accountability controversy. Papers pertinent to nursing discuss nursing's role in planning for the future, issues and trends in the cost of nursing education, the future of community nursing, and the potential of primary nursing. The impact of new health professionals such as nurse practitioners and physician assistants is assessed, and manpower maldistribution is analyzed in terms of ameliorative efforts to increase provider supply and bring providers into shortage areas, A paper on hospital cost containment describes the political realities and current status of bills presently under consideration in Congress. In the paper evaluating the cost of technology, it is contended that technology has almost no causal responsibility for the rise in hospital costs. Rather, the increasing cost in nonlabor hospital expenditures per capita is deemed to follow from the structural defects in the hospital marketplace -- namely, the third party insurance mechanisms that generate incentives for patients to seek hospitalization and physician care instead of equally adequate and less expensive alternatives. Footnotes and tabular data are provided with individual articles. A bibliography contains 223 entries. Papers originally presented at the 1978 Conference of the Northeast Regional Assembly of Constituent Leagues for Nursing. Pub. No. 52-1755.
Based on remarks made at symposium on the implications of the National Health Planning and Resources Development Act of 1974, held in West Palm Beach, FL, May 1-3, 1975. Descriptor(s): Present legislation/regulations, Policy/changes re health care, Health care/services, Funding/financing of health care programs.
Descriptor(s): Nurses, Allied health professionals, Long term care facilities, Impact of third-party coverage, Characteristics of U.S. health care system. 373. Health Care Issues for Industry.
372. Health Care in Transition. Coopers and Lybrand Health Care Services Div., New York, NY 10020 1975, 28 pp. Availability: Coopers and Lybrand, New York, NY 10020.
Seymour Lusterman. Conference Board, Inc., New York, NY 10022 Alcoa Foundation, Pittsburgh, PA. Commonwealth Fund, New York, NY. Rockefeller Brothers Fund, New York, NY. 1974, 98 pp. Availability: Conference Board, Inc., New York, NY 10022.
I-lb9
This report presents the proceedings of a conference which considered the implications of problems relating to health care for business interests and roles. Business people were urged to participate in influencing constructive change in the health care system. A keynote address explored basic problems of the health care system and some implications for business policy. Health care costs were cited at an annual rate of over $100 billion and growing at a 12 percent compounded rate for the past 6 years, It was observed that the effect of national health insurance (NHI) on costs will depend on other measures taken to regulate, rationalize, and plan an industry that operates without "normal competitive controls and disciplines of a market economy." Other sessions addressed the issues facing management in determining the scope and character of the health care services they provide directly for employees, by arrangement with outside providers, or both. A central question asked was whether and how far companies should extend services beyond those required for health conditions traditionally viewed as occupationally related. One speech took issue with the advocacy of more regulation and control, and promoted a strengthening of market mechanisms through health maintenance organizations (HMOs). Around this theme four guidelines were suggested for business people: (1) that they actively encourage employees to join HMOs, (2) that they use their influence to put an end to investments in unneeded and inefficient health facilities, (3) that they encourage alternate health systems to compete with existing systems on the basis of price and benefits, and (4) that they support a NHI program so structured as to encourage competing alternate systems. Other issues discussed were business relationships with community health agencies, company organization for community health relations, roles for business in HMO development, and controlling hospital costs. Discussion comments and an appended luncheon address are included.
Strategies which hospital managers can use in an increasingly competitive and resource-regulated market are described. AIthough the hospital is the core institutional provider of health care, it will be in an increeLsingly vulnerable position within the health care market. This situation is caused by the increasing economic power of physicians, who determine how much the hospital is used; by advances in drug therapy which allow outpatient treatment of numerous disorders; by increasing use of health maintenance organizations, which can effectively reduce hospitalization rates of members to below the national average; and by a changing regulatory environment. Suggested strategies that hospital managers can use to confront this new environment are similar to those which corporations use for protecting an enterprise's position in a maturing market. These techniques include competing aggressively for physicians, diversifying out of acute inpatient care into a broader mix of medical services, developing captive distribution systems to control patient flow, and promoting the institution's services. Recruiting and retaining physicians are the most important marketing issues facing hospital managers. Because inpatient hospitalization costs have escalated drastically, the search for substitute methods of rendering care will intensify. Diversification efforts focus on outpatient care facilities, outpatient surgery, freestanding emergency rooms, health maintenance organizations, and screening programs. With regard to the third strategy, some hospitals have developed transportation services to bring in patients from within the entire State. Finally, promotional approaches that introduce new services or highlight specific existing services are seen as most useful. An e:daibit and 17 references are provided in the article.
Descriptor(s): Cost contaitmaent efforts, Hospital services, Inpatient facilities.
Proceedings of a conference held in New York, NY, on April23, 1974. Conference Board Report No. 637. 375. Health Care Policy _md Polities.
Does the Past Tell Us
Descrtptor(s): Cost containment efforts, Competition/interaction among third-party payors, Prepaid plans, Source of premi-
Anything About the Futu_re.
um payment, Voluntary initiatives, National health insurance (NHI), Outcome/evaluation of health administration.
Stephen M. Weiner. 1980, 11 pp. Availability: American Jnl. of Law and Medicine v5 n4 p331341 Winter 1980.
374. Health
Recent developments in the national health care delivery system are assessed in order to determine an appropriate direction for future national policy. The American health care delivery system and the attitude of the public toward the system have undergone considerable change during the past 2 decades. The belief held during the 1960's that adequate funds were available to broaden access to health services, to enhance their quality and availabili-
Care Market.
Jeff C. Goldsmith. 1980, 13 pp. Availability: Harvard Oct 80.
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Can Hospitals
Survive.
Business Review v58 n5 pl00-117. Sep/
Health Care Programs
ty, and to support medical innovation gave way during the 1970's to an awareness of limited resources, to skepticism about the motives and competence of established institutions, and to a conviction that the system's problems were too complex to be solved easily. Moreover, the system has become fragmented and highly competitive, the respect formerly accorded both professionals and institutions has deteriorated, and the Government's role in health care delivery is being challenged. It is suggested that the result may be a paralysis of policymaking in health planning, as exemplified by the failure of both public and private institutions to achieve the cost containment goals of the last decade, either through regulation or competition. In order to gain perspective on these problems and to determine the direetion of the health care delivery system for the 1980's, a national
mands on health services were fewer. The first section of articles examines the current inconsistencies and contradictions of health care policy in the United States, as well as health policy developments in other highly industrialized nations. Underlying forc_ for change are examined in the second section of articles, which deal with new patterns of mortality, morbidity, and disa. bility; changes in population structure; rising public expenditures; and the diminishing marginal benefit of high technology services. The concluding section discusses unresolved issues in the areas of control of health services, social justice, disease prevention and health education, primary health services, the limits of modern medicine, and national health insurance. References accompany each article. Tables and footnotes are included.
health debate should be held. Concepts the thatroletheof debate should care explore, include the role of consumers, hospitals, the proper function of regulation, and national health insurance. Debate participants' ultimate guiding principle should be compassion for people who have no choices within the health care delivery system. Institutional and self-interest must yield to that principle. (Author abstract modified)
Descriptor(s):
Developed Horwath's
377. Health Care. Regulation, Economics,
from a speech _'ven by the author at Laventhol and Twelt?h Annum Symposium on Health Care, in
Chicago, IL, on October 25, 1979. Descn'ptor(s): initiatives.
Demographic
features of population,
health status, Health care cost trends/projections, Cost containment efforts, Medical technology impacts, Providers of health care services, Policy/changes re health care.
Philip H. Abelson. American Association for the Advancement
Characteristics of U.S. health care system, Policy
Trends in
Ethics, Practice.
of Science,
Washington, DC 20005 AAAS/PUB-78/12 1978, 258 pp. A vMlability: American Association for the Advancement Science, Washington, DC 20005.
of
376. Health Care Policy in a Changing Environment. Roger
M. Battistella
and Thomas
1978, 390 pp. A vMlability: McCutchan
Publishing
G. Rundall. Corp., Berkeley, CA
94704. This collection of articles aims at helping consumers, nonhealth professionals, and students preparing for careers in personal health services administration and planning, acquire an understanding of the factors underlying the mounting signs of crisis in the U.S. health care system and the range of choices available for making health services more responsive to current and future needs. The overall view of the articles is that the instability now being experienced in the health sector is the consequence of changes in biomedical science, trends in demography, mortality, and morbidity; and the availability of material resources, which have exceeded the adaptive capabilities of systems of health services finance and organization established over a quarter of a century ago when medical technologies were simpler and de-
A compendium of 39 articles dealing with several aspects of health care in the United States is presented. Materials were originally published in the weeldy journal of the American Association for the Advancement of Science. Aspects of health maintenance which are addressed include regulation by various government agencies, increased costs, public education and preventive medicine methods for lowering costs while improving general well-being, improvements in diagnosis and therapeutics, and ethical considerations involved in the practice of medicine and medical research. Within these general subject categories, topics discussed focus on the quality of medical care, the development and regulation of new medications, evaluation of medical practices, health care economics, and Federal health spending. Also addressed are immunization against infectious disease, risk factor intervention for health maintenance, care of the aged, computer use in diagnosis, and prenatal diagnosis of genetic disorders. Ethical questions discussed include carcinogenie risk assessment, social imperatives of medical research, and clinical trials. An article on national health insurance suggests that any such plan, when first adopted, will haw: a role for
1-i71
both private and government insurance. In addition, the combined system should provide for the needs of low-income people through plans that cover others; should insure that the part of the plan operated by the government be built on the administrative structure of medicare but with changes in reimbursement to encourage more efficient delivery; should include direct capital and manpower controls; and should act as an aggressive buyer of health services rather than as an insurer. The compendium contains a subject index; reference notes are included for each article, and many provide tables and photographs, Material in this book originally appeared Jnl. of the American Association for Science. The articles were published over Aug. 27, 1976 to May 26, 1978. No. 7 Science Compendia.
in Science, the weekly the Advancement of a period ranging from in a Series of Special
Descriptor(s): Characteristics of U.S. health care system, Health care costs, Health care/services, Policy/changes re health care.
378. Health Care Reimbursement Tax-Exempt Providers.
Is Federal Taxation of
Hugh W. Long and J. B. Silvers. 1976, 16 pp. A vailabiliO:" Health Care Management Winter 1976.
Review vl nl p9-23
The economic impact of the Federal reimbursement system on private, voluntary, nonprofit or investor-owned hospitals is discussed in this article. Today's system, with its less-than-fullcharge limitations, causes tax-exempt health care providers to be as highly taxed as corporations or individuals in the highest brackets. The actual tax impact of the reimbursement system on an institution depends on the varying administration of the medicare program by different intermediaries, the extent to which State programs and private insurance plans such as Blue Cross pay less than full charges, and the proportion of total care delivered to consumers covered by cost-based or discount-fromcharges reimbursement contracts. Under parallel financial circumstances, the health care provider and the tax-paying corporation show equal bottom lines; the corporation pays a tax, and the health institution has a similar amount withheld by the Social Security Administration. Regardless of terms, this withholding still constitutes a tax. Once the system is recognized for what it is, health policy makers and regulators should adjust this "tax code" so that health managers are encouraged by economic incentives to develop a national plan. For example, by incorporating incentives parallel to the tax system, regulators could
1-172
encourage capital investment which would lower costs while maintaining quality, encourage certain types of treatment institutions such as outpatient facilities, and facilitate rural or innercity location of services. Eight tables and two references are provided.
Descriptor(s): Present legislation/regulations, Hospital services, Competition/interaction among third-party payors, Funding/ financing of health care programs, Inpatient facilities.
379. Health Care System in the United States.
Earl G. Creps, Lynn Goodnight, Trisha L. Linder and David P. Svaldi. 1977, 330 pp. Availability: National Texltbook Co., Skokie, IL 60076.
Analyses and approximately 1,500 pieces of evidence are presented for such areas as the quality of medical care, the rising costs of medical care, health care manpower, health maintenance organizations, national health insurance (NHI), malpractice, and drug regulation. The handbook is intended as a resource for those participating in the 1L977-1978 U.S. high school debates. The first chapter states and outlines issues of the debate propositions. The propositions are (1) that the Federal Government should guarantee comprehensive medical care for all citizens in the United States, (2) that the Federal Government should establish a national program of malpractice insurance for all health care professionals, and (3) that the Federal Government should establish a comprehensive program to regulate the health care system in the United States. Guidelines for research on the debate topics are provided. Subsequent chapters identify and discuss issues related to the debate topics and provide extensive resource listings that provide information on the issues reviewed. The section that discusses access to health care in terms of quality and quantity considers whether (1) facilities and services are adequate, (2) the geographical distribution of care is adequate, (3) cultural, economic, and educational barriers to care are minimized, and (4) access to competent medical care is adequate. Another section examines the costs and insurance coverage for health care services. Among the issues discussed are catastrophic medical care, preventive health care, and NH1. The chapter that explores regulation and responsibility in health care discusses physician quality, medical technology, drug regulation, and malpractice. The names and positions of influential persons in the health care field are listed, followed by a selected health care bibliography of about 170 references.
Health Care Programs
Descriptor(s): Health care cost trends/projections, Cost containment efforts, Supply/availability of services, Economic/cornmercia/ influences, Participation in health care programs,
381. Health Care Trends. Minneapolis/St. Highlights.
Prepaid plans, Pharmaceutical services, Providers of health care services, Present legislation/regulations, Policy initiatives, Na-
Linda Krane Ellwein.
tional health insurance (NHI).
380. Health Care Systems in World Perspective.
Milton I. Roemer. 1976, 289 pp. A vailability: University of Michigan,
Health Administration
Press, Ann Arbor, MI 48109.
Paul. Summary
Aug 1979, 17 pp. Availability: InterStudy, Excelsior, MN 55331. Data describing developments in the Minneapolis and St. Paul, Minn., health care system are presented, and the impact of health maintenance organizations (HMO's) is documented. National attention is focused on the Minneapolis and St. Paul health market because it is considered the best example of a competitive health system in the country. The HMO data given are a continuation of the study entitled "Do HMOs Stimulate Beneficial Competition" (InterStudy, 1978). Cost and use data for the total metropolitan population are presented for 1971 to 1978 in order to identify any systemwide changes which might
This collection of 30 papers is intended to provide perspectives on the variety of health care systems operating perspectives on the variety of health care systems operating throughout the world. It represents field work done by the author over the last 25 years under the sponsorship of such organizations as the Pan American Union, the U.S. Peace Corps, and the World Health Organization. Health systems in all kinds of countries -- industrialized, developing, capitalist, and socialist -- are considered. In addition, certain facets of health service, such as disease-specific campaigns, ambulatory care, and hospitals are examined across all types of countries. The volume begins with a background section intended to provide an overview of the world's health care systems along dimensions of time (development) and space, Part two analyzes problems and practices in selected Latin American, Asian, and African countries. Health care in industri-
be attributable to the development of alternative health plans. Tables offer Twin Cities HMO enrollment data for 1971 to 1979; HMO enrollment figures for Minneapolis and St. Paul; hospitalization data for Minneapolis and St. Paul HMO's; data on HMO Premiums for Twin Cities Standard Group Contract; and statistics describing distribution of HMO expenditures and admissions and patient days per 1,000 people. Selected hospital cost and utilization data for the area are presented for 1971 to 1979, and Minneapolis and St. Paul hospital utilization data are given by type of admission, hospital medicare beneficiaries, medicare indicators of hospital costs in Hennepin and Ramsey counties for 1972 to 1977, and annual percent change in consumer price indices for Minneapolis and St. Paul and U.S. city averages, 1975 to 1978. (Author abstract modified)
alized countries is then examined by viewing the systems in Western Europe, North Ameri6a, Australia, and the Soviet Union. The section on specific health problems presents various ways of handling manpower, facilities, and social insurance programs in diverse national settings. Examples of the topics examined include rural and occupational health services, work injury benefits, and general practitioner services under different social security and national health systems. The concluding section presents general interpretive papers on currently controversial issues, including regulation of health care systems, health con-
Descziptor(s): Demand/utilization of health care programs, Health care cost trends/projections, Competition/interaction among third-party payors, Prepaid plans.
sumerism, and coordinated health service as a national priority. The 116-item bibliography offers a listing of multinational and comparative studies of health services and another of national studies of health services arranged by country. Tabular data and endnotes accompany individual chapters.
Congressional Research Service, Washington, DC 20540 Apr 1980, 11 pp. Availability: Congressional Research Service, Major Issue System, Washington, DC 20540.
Descriptor(s): Comparisons regarding foreign health policies, Supply/availability of services, National economic conditions, Private health care plans, Publicly sponsored/mandated health plans, Health care/services, Facilities providing health care.
382. Health. Catastrophic
Health Insurance.
Jennifer O'Sullivan.
Background and policy analysis are discussed for Government involvement in catastrophic health insurance protection, and Federal legislative action is described. Increasing attention has been given to catastrophic health insurance for some or all of the population because health care costs associated with a major
1-17_
illness
or accident
could cause financial
ruin for all but tile
Under
Federal tax laws, businesses can write off as a business
wealthiest of families unless adequate insurance coverage is available. Proposals for making catastrophic health protection more uniformly available must address the following subjects: (1) definition of catastrophic, (2) scope of benefits, (3) linkage with existing coverage, (4) medicare, (5) medicaid, (6) the identification and enrollment of the currently uninsured population, (7) mandatory or voluntary insurer extention of catastrophic protection to specified target groups, (8) impact on employers, (9) financing, (10) cost control, and (11) administration. On June 20, 1979, the Senate Finance Committee began consideration of catastrophic health insurance legislation. The committee is currently making tentative decisions about the elements to be ineluded in a proposed program. As of its meeting on March 20, 1980, the committee had tentatively approved several elements of the employer-based portion of the program. Under this plan,
expense the cost of group medical insurance for employee_, while these same employees are not taxed on the value of this benefit. This has produced an absolute increase in the purchase of medical insurance and expanded insurance coverage of medical expenditures. With ease of access to expanded insurance coverage, the incentive for consumers to curtail expensive medical care has diminished. The reformation of tax laws to change the form of medical insurance policies and eventually people's behavior regarding health care would be preferable to Government health care regulation. Studies of Government regulation of other industries show that regulation tends to reduce competition that would keep prices relatively low, while placing policymaking in a regulatory body basically responsive to political realities more than consumer interests. Notes and references are provided.
all employers (except the self-employed and contribute State and local governments) would be required to provide and financially toward the cost of a catastrophic health insurance plan for all full-time employees and their dependents. Basic elements of Senate bills 350, 351,748, 760, 1590, and 1812 are described. Congressional activities and events related to deliberations on catastrophic health insurance are listed, along with other reference sources,
This article was presentat as part of the 1979 Annual Health Conference of the New Yc.rk Academy of Medicine held May 10 and 1L 1979.
Descriptor(s): Impact of third-party coverage, Economic/commercial influences, Healtl_ care costs, Policy/changes re health care.
Issue Brief No. IB79060.
Descriptor(s): initiatives.
Participation
in health
care programs,
Policy
384. Health Costs Can Be Reduced by Millions of Dollars if Federal Agencies Fully Carry Out GAO Recommendations. Comptroller 20548
383. Health Cost Problem. Is Regulation
Our Only Hope.
General of the United States, Washington,
Nov 1979, 206 pp. A vailability: General Accounting 20548.
Office, Washington,
DC
DC
Robert B. Helms. 1979, 12 pp. Availability: Bulletin of the New York Academy of Medicine v56 nl p26-37 Jan/Feb 80
Factors contributing to excessive health care costs are identified, and direct Government regulation of health care as the, means for dealing with this problem is analyzed. Although increases in health care workers' wages, the increasing use of high technoh> gies in health care, and the general impact of inflation have been cited as principal factors in high health care costs, medicare/ medicaid and various Federal tax subsidies that have distorted incentives in medical care markets are major sources of high health care costs. Medicare/medicaid has increased the scarcity of care to the larger populations not covered by the programs while increasing the amount of care demanded by covered individuals; both of these effects have stimulated price increases,
1-174
This report reviews all cost control recommendations
by the
General Accounting Office (GAO) on Government health programs. The recommendations were made between January 1, 1974, and December 31, 1978. The report discusses Federal programs which provide health care services through the Department of Defense (DOD), the Department of Health, Education, and Welfare (DHEW), and the Veterans Administration (VA) and spent about $7.4 billion in 1978. It presents examples of cost-saving GAO recommendations designed to prevent the construction or purchase of unneeded or oversized health facilities and equipment and to encourage Federal health delivery systems to share resources, when feasible. The report also describes Federal programs which pay for health care services for the aged, the disabled, the poor, and for Federal military and civilian personnel and their dependents. GAO cost-saving recommendations for these programs, which spent $54.2 billion
Health Care Prog_a.t_,
in 1979, were aimed at preventing provider overpayment and fraud and abuse, and at encouraging States and contractors to comply with Federal laws and regulations. Finally, cost-saving recommendations related to the grant and contract health programs of DHEW's Public Health Service (PHS) are presented to improve program efficiency and effectiveness. PHS expenditures were $7.9 billion for fiscal year 1980. Footnotes and tabular data are included. Appendices contain recommendations that were either partially or not implemented, cost-control recommendations which have been fully or substantially implemented, lists of recommendations made to agencies' heads which have not been fully implemented, and recommendations made to Con-
nance organizations is also included. Under the topic: of cost effectiveness, presentations discuss a case for more cost-effectiveness analyses and an economic analysis of the use of disposable commodities in hospitals. The concluding address ex_Lmines a study of consumption and household production in connection with the demand for dental care. Tabular data, footnotes, and references accompany individual articles.
gress which have not been implemented.
Descriptor(s): Demand/utilization of health care programs, Health information/data systems, Medical technology iimpacts,
Comptroller
Inpatient facilities, Funding/financing of health care programs, Health care costs, Private health care plans, Publicly sponsored/ mandated health plans, Health care/services, Facilities providing health care, Funding/financing of health care programs, Present legislation/regulations, National health insurance (NHI).
General's
Report
to the Congress HRD-80-6.
Descriptor(s): Cost containment efforts, Government employee plans, Medicare, Medicaid, Outcome/evaluation of quality assurance, Policy initiatives.
385. Health Economics and Health Care. Irreconcilable
Gap.
Contains Proceedings from a Health Ithaca College, Ithaca, NE.
Care Symposium
held at
386. Health Employment Requirements Under Alternate Health Insurance Schemes.
Frank W. Musgrave. Ithaca Coll., New York, NY. 1978, 166 pp. A vailability: University Press of America, Washington, 20023.
1979, 28 pp. Availability: Health Manpower
Literature
v3 nl p8-35 Jul 79.
DC
Addresses and discussions are presented from a symposium that sought to relate theories of health economics to the delivery of health care services. Various national health insurance proposals are outlined in one address, and barriers to and prospects for the
This study attempts to outline the objectives of national health insurance and to estimate the demand for health manpower under several hypothetical national health insurance schemes. The American health care system is dominated by physicians and by private non-profit and for-profit hospitals. However, since the mid-1960's, the Federal Government has taken an
passage of national health insurance legislation are discussed. In another presentation, the comparability of health care data is argued to be a prerequisite for precise research in health care. The development and nature of comprehensive health planning is considered in a panel discussion, and alternatives to the institutionalization of the elderly are described in an address. A case study in averaging in hospital reimbursement is presented for a 210-bed community hospital that is publicly owned and managed by a county. The New York State Department of Health is used as an example in describing the changing public image of departments of public health from that of health protectors to that of health regulators. The problems of medical ethics and hospital organization thrust upon the health care industry by new drugs and new diagnostic and treatment technologies are discussed in another presentation, followed by a review of the current role of the Federal Government in the health sector. A panel discussion of the problems and prospects of health mainte-
increasingly participatory role in the system through medicare and medicaid. The health care industry in general is characterized by a limited supply of physicians and licensure control of physician extenders. Consumers are unfamiliar with alternative sources of care so that physician suppliers can create their own demand. Finally, non-profit hospitals emphasize quality so that little effort is made to contain costs. Under these conditions, the goals of national health insurance proposals are to introduce universal coverage, prevent financial ruin from high medical bills, and improve access to health care in underserved areas. The type of health insurance plan adopted will determine: whether the level and mix of the manpower requirements created can be anticipated. Predictions of manpower requirements using simulation models suggest that an additional 1.6 million health care positions or a 44 percent increase from 1975 to 1985 will be needed to meet a balanced health insurance mix. Under the high assumption, (i.e., a national health insurance program with
1-175
no coinsurance) 2.5 million more jobs would be opened up, a 65 percent increase over the 10-year period. There are substantial variations in employment projections among the occupational categories, even under the same assumption. In general, however, even with comprehensive national health insurance with no coinsurance, the average increase in employment of hospitalrelated health personnel for the decade 1975-1985 will be lower
independent hospitals, and the complete reorganization of U.S. hospitals. Additional options include an increase in the number of HMO's, an expansion of paramedical aides and the development of primary care teams, and the use of computers and mass communication technologies to assume almost the total burden of diagnoses, testing, and prescription for health care centers and hospitals in the future. The article also examines the use of
than the annual rise for the previous decade. Thus, the rate of increase in health personnel employment, even for nurse, will decline. However, the introduction of any type of national health insurance could shift the structure of health care delivery in the direction of health maintenance organizations and hospital outpatient care. Such restructuring of health use could only he
telecommunications in medicine, including an experiment with satellite communications iin Alaska, and the growing emphasis on preventive medicine ard, holistic health. Photographs and a brief description of current and future biomedical advances are included.
reflected in a dynamic model. Even for the static analysis further verification of results is essential to match potential manpower supply to projected demand. Tables and 18 references are furnished.
Descriptor(s): Trends in health status, Supply/availability of services, Medical technology impacts, Health care/services, Providers of health care services.
Descriptor(s): National health insurance (NHI), Demand/utilization of health care programs, Supply/availability of services, Providers of health care services.
388. Health in the United States. Chartbook.
387. Health
in the Future. In the Pink or in the Red.
Robert Selim. 1979, 13 pp. A vailabil#y: Futurist vl 3 n5 p329,331-342
Oct 79.
This article discusses how satellites, computers, physician's assistants, health maintenance organizations (HMO's), hospital reorganizations, and many other changes could all improve illture health care. Noting that U.S. personal expenditures for medicine have gone from $20 billion per year in 1960 lo $124 billion today, the article examines some of the factors that contribute to these costs: medical research, the development and use of technology, the practice by doctors of ordering more tests than needed in order to ward off malpractice suits, and the use of health insurance policies that encourage hospital use. Additional health care issues assessed in the article include the growing shortage of doctors and the steadily declining number of general practitioners, growing doubts about modern medicine itself with its dependence on high technology, and the role of environmental causes of disease such as poverty and poor health habits. The problem of judging health care priorities, illustrated by current efforts to find a cure for cancer, is discussed as is the potentially dangerous effect of an overdependence by both doe.tors and patients on medical technology. The article also discusses such future options in health care as local hospitalization and hospital mergers, the sharing of hospital services for small
1-176
Andrea N. Kopstein and Steven R. Machlin. National Center for Health Statistics, Hyattsville, MD 20782 DHEW/PUB/PHS-80/1233 1980, 59 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-022-00686-3. This chartbook presents data on national trends and differentials in health status for the various population groups in the country. The data derive from several reports issued by the National Center for Health Statistics, Office of Health Research, Statistics, and Technology, and other statistical agencies of the Department of Health, Education and Welfare. The chartbook has a tripartite arrangement: health status, health services, and health care spending. Within these sections, charts illustrate the answers to a series of basic questions concerned with the national health care situation. For example, the initial question asks how our population is growing; the answer is presented by charting iates of birth, death, and natural increase between 1920 and 1977. Other questions concern life expectancy, infant mortality by race, and statistics on smoking by adults and teenagers. Questions about health services regard access to health care by various population and income groups, the use of hospitals, surgical procedures, nursing homes, mental facilities, and statistics on the number of physicians and hospital beds. Health care spending facts are presented in answer to questions relating to the gross national product, the causes of rising health care expenditures, sources of health care payments, and types of medical care expenditures. Much of the data is comparatively stated, and statistics are cited from selected years that range from 1950 to 1979. Illustrations and graphic material are provided.
Health Care Programs
Descriptor(s): Demographic features of population, Demand/ utilization of health care programs, Health care costs, Health
clasive negotiations. In Canada and France, centralized admmistration is favored. None of the models have had a chance to be
care cost trends/projections, Trends in health status,
fully operative. Nine references are provided aior_g with tables comparing dements of the different countries's coverage.
Supply/availability
of services,
Descriptor(s): Comparisons regarding foreign health policies, Cost containment efforts, Third-party payors. 389. Health Insurance and Cost-Containment Experience Abroad.
Policies. The
390. Health Insurance Bibliography. Uwe E. Reinhardt. Ford Foundation, New York, NY. 1980, 8 pp. A vailability: American Economic May 80.
National Clearinghouse for Alcohol Information, MD 20852 Review v70 n2 p149-156
Health insurance systems in three major industrial nations -Canada, France, and West Germany -- are described in order to
Rockville,
Alcohol, Drug Abuse, and Mental Health Administration, Washington, DC. 1980, 17 pp. AvMlabih'ty: National Inst., on Alcohol Abuse and Alcoholism, RockviUe, MD 20857.
provide a broader context for an assessment of the American system. Private health insurance coverage in the United States has grown extensively during the past several decades, but most developed nations now offer their citizens far more comprehen-
This bibliography is one of a series of subject area bibliographies produced by the National Clearinghouse for Alcohol Information, an information service of the National Institute on Alcohol Abuse and Alcoholism. The annotated work on health insurance
sive coverage and look upon the American health insurance system as an oddity. In Canada, France, and West Germany, virtually the entire population has comprehensive coverage for personal health care expenditures, and cost sharing on the part of patients is either very modest or absent entirely. Rapid growth in health care expenditures during the 1970's is shared by most other industrialized nations, and they have begun to attempt to curb growth through overt public intervention by pegging the growth of national health expenditures to the growth of the gross national product. However, whether society should allocate a constant proportion of its resource budget to health care is debatable. Health care providers in the United States and elsewhere typically profess support for the concept of the competitive market approach, although they seem skeptical of a market model, Universal health insurance is typically viewed as inherently undesirable but probably an unavoidable compromise. Most proposals for national health insurance have sought to minimize interference with the private markets, but the fusion of an ethically acceptable insurance program with free market principles
is divided into two parts: a quick reference list with selected citations representing the most significant materials, and a basic set of annotated bibliographic references divided by major subtopics relating to the alcohol and health insurancearea. Subtopics cover general materials, Federal and State activity, health maintenance organizations, industry and labor, and private sector or third party providers. Entries are arranged alphabetically by author. Most of the approximately 85 entries date from the mid-1970's.
turns out to be a complex task which has so far eluded pol!cymakers. In other countries policymakers despaired long ago of the feasibility of preserving classical market mechanisms for socialized commodities, and any commodity to which individuals.have a right regardless of income is a social commodity. The thrust in West Germany has been to develop new quasi-markets that fall somewhere between classical markets and centralized administrations. Decisionmaking gives way to collective bargaining among freestanding associations which guard the rights of weaker parties and provide compulsory arbitration for incon-
Evaluation.
Descriptor(s): Trends in health status, Mental health services, Private health care plans, Prepaid plans, Policy/changes re health care.
391. Health Insurance Coverage for Alcohol/Drug Addiction Treatment for Virginia State Employees. A Feasibility
Don Hardenbergh. National Inst. on Alcohol Abuse and Alcoholism, RockviUe, MD 20857 Alcohol, Drug Abuse, and Mental Health Administration, Washington, DC. Apt 1978, 52 pp. Availability: National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD 20857.
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In 1977, the Commonwealth of Virginia's General Assembly requested the State Department of Personnel and Training to develop an employee assistance program and to study the feasibility of including comprehensive substance abuse trealment benefits under health insurance coverage provided to State employees. This report represents the department's efforts and provides recommendations. The National Council on Alcoholism estimates that 5.3 percent of the nation's employed population have a drinking problem. This figure suggests that there arc over 4,000 Virginia State employees who have an alcohol problem. In terms of dollar losses, existing alcoholism and problems related to alcohol among State employees alone are estimated to co_,.tthe Commonwealth of Virginia about $I 1 million annually. A1coholism and drug addiction are medical illnesses, and should be treated like any other medical illness. With the establishment of a pilot employee assistance program for State employees working in the Richmond area, the Commonwealth has taken a r,ecessary step in providing complete health care services to its e.mployees. While the number of treatment facilities is not extensive at this point, adequate facilities (including out-of-State resources) appear to be available, and licensing and program standards are being developed to assure minimum levels of quality. Research based on similar pilot programs in California and Michigan indicates that a full range of substance abuse benefits can be purchased at relatively low cost. Blue Cross/Blue Shield of Virginia estimates that the recommended coverage will cost an additional 14 cents per individual and 36 cents per family each month The annual cost of providing this coverage to all State employees would be about $201,120. Long-term benefits to the Commonwealth appear substantial, and it is anticipated that resulting savings will nearly cover the additional cost of coverage. Appendices and 55 reference notes are provided i>: the report. (Author summary modified) Nattbnal Inst. on Alcohol Abuse and Alcoholism Health Insurance Resource Kit.
The purpose of this paper is to trace the devclopme,t of health insurance mechanisms to cover the costs of treatment for alcoholism in the United States. The paper describes early efforts aimed at identifying the nature and extent of health insurance coverage for alcoholism, traces the interests and accomplishments of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), ,describes the development of a model health insurance benefit package for treatment of alcoholism, and describes current or ongoing efforts in the development of this payment mechanism. Included in the paper are the results of surveys made of group health insurance coverage by 20 major industries in this country for a total worker population in excess of 1 million. The paper also mentions other surveys examining the development of insurance regulations by the various States which require in varying form that health insurance policies vendored within the State provide for health insurance coverage for alcoholism. The model health insurance benefit package is presented in terms of inpati,ent care benefits, intermediate care benefits, and outpatient ca_e benefits. The current efforts in health insurance coverage fbr alcoholism include the issue of standards for alcoholism treatment services as well as counselor certification, incentive contracts, experimental programs with health insurance companies, management training programs and health maintenance organizations. The necessary environment now exists for advancing effective third-party mechanisms for payment of alcoholism treatment services. Ten references are given. ( Author abstract modified)
National Inst. on Alcohol Abuse and Alcoholism Health Insurance Resource Kit, Overview of the Insurance Field. Paper presented at the National Alcoholism Forum in Milwaukee, Wisconsin.
State Ac__;vity.
Descriptor(3): Government employee plans, Mental health services, Plan design/program provisions (under healt_t plans), Trends in health status, Source of premium payment, Health care costs.
Descriptor(s): Prepaid plans, Impact of third-party coverage, Mental health services, Plan design/program provisions (under health plans), Mandated benefits.
393. Health Insurance Coverage of Veterans. Data Preview 4. 392. Health
Insurance
Coverage for Alcoholism,
1975. Walter R. Lawson.
Jerome B. Hallan and Barrie F. Montague. National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD 20857 Apr 1975, 22 pp. A vailabilitp:. National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD 20857.
1-178
National Center for Health Services Research, Hyattsville, MD 20782 Sep 1980, 12 pp. Availability: National Center for Health Services Research, Publications and Information Branch, Hyattsvillc, MD 20782.
Health Care Programs
This report focuses on the extent to which veterans have public or private health insurance coverage and whether they are similar to or different from other adult males in the population in this respect. Data for this study and related analyses were obtained in three separate, complementary stages which surveyed about 14,000 randomly selected households in the civilian noninstitutionalized population; each household was interviewed six times over an 18-month period during 1977 and 1978. Also surveyed were physicians and health care staff providing care to household members during 1977, and employers and insurance companies responsible for their insurance coverage. Approximately 27.3 milfion male veterans in the United States, andabout 2 out of 5 are eligible under Federal statute to receive care in or through Veterans Administration facilities. Overall, a slightly higher percentage of veterans than the rest of the adult male population (including the disabled) was found to have health insurance coverage. Approximately 75 percent of insured veterans had private health insurance, as compared with somewhat less than 65 percent of the rest of the adult male population, Coverage by public insurance mechanisms, including medicare and medicaid, was relatively infrequent among veterans. However, disabled veterans were much less likely than other veterans to have private health insurance and considerably more likely to be covered by such public mechanisms. Data do not provide comparisons of the type of services covered, and they do not address the question of whether veterans, regardless of coverage, used Veterans Administration services. Two footnotes and three tables are included. (Author abstract modified) NCHSR
National Health
Care Expenditures
Walter J. McNerney. 1976, 7 pp. Availability: Public Health Reports 76.
Descriptor(s): Medicare, Medicaid, Cost containment efforts, Private health care plans, Government employee plans, Health insurance industry, Competition/interaction payors.
among third-party
Study.
Descriptor(s): Demographic features of population, Publicly sponsored/mandated health plans, Participants in health care programs, Non-participants in health care programs, Private health care plans.
394. Health Insurance in the Medicare
Federal Employees Health Benefit Program. Cost containment initiatives now grouped under the concept of rationalization of the health system are also traced back to the pre-medicare years. Private-public relations are deemed central to the operation of medicaid and medicare. The evolution of this interrelationship is traced; Government assumes the role of setting goals and standards while in the private sector, the insurance industry's intermediary carriers retain the flexibility to deal with providers. These relative roles continue to evolve and undergo objective evaluation. The current problem facing the insurance industry concerns the immense burden of payment of fringe benefits by employers in the private as well as the public sector. In this context, the interdependency of funding mechanisms and other health actions, such as planning and utilization control, has become recognized. Responses to these needs are evident in areawide planning programs, utilization review and quality assessment, evaluation of effective payment methods, and consideration of alternative delivery systems. Future solutions seem likely to continue on the path of moderated pluralism and making productive use of the private industry as well as the public sector while minimizing the excesses and fragmentat3ion that have marred past performance.
Years.
v91 n4 p336-342 Jul/Aug
This assessment of health insurance in the medicare years begins with a review of the decades preceding the programs and describes group hospitalization of the 1930's and employee health insurance following World War II. Private and public sector relationships of the 1950's are illustrated through the Civilian Health and Medical Program of the Uniformed Services and the
395. Health Insurance in the United States. Implications for the United Kingdom. Paul R. Torrens. 1979, 5 pp. Availability: Lancet vl n8158 p27-31 5 Jan 80.
This article looks at the U.S. system of private health insurance in an effort to determine if making some form of private insurance available in Britain might not remedy Britian's lack of funds for innovative and modern health services. The development of health insurance in the United States is discussed, and particular attention is paid to Blue Cross, commercial policies, the Kaiser model, and medicare and medicaid. The results of these various forms of insurance have been mixed. On the positive side, the various insurance plans have protected people from the crushing f'mancial effects of illness. With 85 to 90 percent of the population covered, a sense of public confidence in protection exists. Most surveys of insured persons indicate that they have strongly positive feelings about access to medical and hospital care, although lack of a provider of care can be a problem.
1-179
The financial resources provided hospitals by such insurance have undoubtedly made U.S. hospitals among the best equipped and housed in the world. Health insurance has certaiJdy contributed to improvement in health, although it may rtot have been the primary cause. However, there are negative effects to be considered. Those in the 10 to 15 percent of the population who are uncovered, are usually also in the highest risk group, and have the greatest need for coverage. Further, health insurance has increased the utilization of high cost technology at the expense of simpler, nontechnological elements such as prew:ntire medicine and family practice, a particularly strong point of the British system. Private insurance has also increased the cost of health care by eliminating the incentive to watch costs and by encouragmg an enrepreneurial mentality among hospitals and doctors. In addition, the patient and family too easily disaptx,_ar in medical records, and are replaced by a long list of service items attached to a ledger number. Furthermore, health insurance has created a two-class health care system and resulted in a part of premiums being spent on administrative costs,
Descriptor(s): Private health care plans, Participation in health care programs, Comparisons regarding foreign health policies, Comparisons of health care programs, Publicly sponsored/mandated health plans, Impact of third-party coverage,
tween them. Third, the rapid growth in coverage has lc,_,alted in most employees being covered by some health insm an_c by the late 1960s. Finally, the economy has been a silent pa_t,er in shaping the industry's growth in recent years. For the industry as a whole, rising health care costs are being treated chiefly as a political and public relations problem. The possibihty of a national health insurance (NHI) is the most obvious pressure on the industry emanating fi;om the Federal level. A second pressure involves the antitrust consciousness. A third area of concern focuses on Federal promotion of Health maintenance organizations (HMO's). States exercise considerable authority over the industry through statute:_, regulations, and influence over the development of HMO's. Concerning pressure from policyholders, employers have traditionally avoided conflict with employees in the area of fringe benefits and even now often present the carrier a divided front on how aggressively to pursue cost containment. Response to these pressures may involve data mat_agement for a prospective NHI plan, generating a utilization control program, and wc,rking to develop acceptable standards of care. Six tables, 1 figure, and 33 references are included.
Descriptor(s): Health care costs, Economic/commercial influences, Health insurance industry, Private health care plan_. Plan design/program provisic,ns (under health plans), Funding/financing of health care programs, Present legislation/regulations.
396. Health Insurance Industry. Structural and Strategic Issues in an Uncertain Environment. 397. Health Insurance Diana Chapman Walsh, 1980, 15 pp. Avat;tabi/ity: Health Care Management Summer 1980.
Review v5 n3 p71-85
This article discusses the pressures on the health insurance
in-
dustry that emanate from the Federal and State Governments, policyholders, competitors, and from rising inflation, the private health insurance industry in the United States has three components. These include the nonprofit, tax exempt Blue Cross and Blue Shield prepayment plans; commercial health insurance, and about 400 plans insuring about 10 nfillion beneficiaries for hospital care and accounting for approximately $2.6 Oillion in premium or subscription revenue. These plans involve community-hased health programs, prepaid health plans, and benefit programs of employee health and welfare trusts. Out of the industry's 130-year history, four basic themes emerge. First, the group health insurance business received its most important boosts from outside the industry, frequently from the Gow:rnment. Second, the competition between the Blue Cross plans and commercial carriers has gradually eroded the distinctions be-
1-180
Plans. Promise and Performance.
Robert W. Hetherington, Carl E. Hopkins and Milton I. Roemer. California Univ., Los Angeles, CA 90024 Public Health Service, l_ockville, MD. California State Dept. oi"Public Health, Sacramento, CA. 1975, 341 pp. Availability: John Wiley and Sons, New York, NY 10016.
This book discusses a study, Patterns of Medical Care Organization (POMCO), which was begun in 1965 and completed in 1972. The study was designed to compare the performance of three major types of U.S. health insurance plans: commercial insurance company plans, which offer choice of physician and pay subscribers for some or all of their medical bills; providersponsored plans, which offer choice of physician and pay member physicians and hospiJals for some or all medical services used by the subscriber; and prepaid group-practice plans, one of the health maintenance organization (HMO) models. Two representatives of each type of plan were chosen from the Los Angeles metropolitan area. The six plans were compared on four effects:
Heahh
C;_rc l'J,,gfams
quantity of physician and hospital services used; quality of services provided in terms of range of technical services given;
399. Health Insurance. What Should be the Federal Role.
consumer expenses, including premiums paid and out-of-pocket expenses; and consumer satisfaction with financial coverage and medical care received. The research fieldwork consisted of interviews and questionnaires for relevant personnel and consumers, The study found that people in the six plans made a little over four visits to the doctor in thestudy year; that thegroup practice plan and the physician-sponsored plan delivered the lowest volume of services for those who received care, with the large group practice plan delivering the lowest; that the large group practice plan had the highest percent satisfied (71 percent) with financial coverage and the hospital-sponsored plan and the highest percent (25 percent) dissatisfied; and that hospital utilization rates differed markedly among the three plan types. Other findings and implications are also discussed. Tables, diagrams, footnotes, an index, and appendices of methodology and concepts and measures are provided,
Bill Brock, James C. Corman, Al Ullman and Caspar Weinberger. American Enterprise Inst. for Public Policy Research Center for Health Policy Research, Washington, DC 20036 1975, 42 pp. AvMlability: American Enterprise Inst. for Public Policy Research, Washington, DC 20036.
A
Wiley-lnterscience
Series.
Descriptor(s): Comparisons of health care programs, Demand/ utilization of health care programs, Commercial health insurance plans, Prepaid plans, Participants in health care programs, Service benefit plans,
398. Health Insurance. Public Programs. 1978-June, 1980 (A Bibliography With Abstracts).
This pamphlet contains the proceedings of one of a seri_ of the American Enterprise Institute's roundtable discussions an what the Federal role should be in health insurance. Department of Health, Education and Welfare (DHEW) Secretary Caspar W. Weinberger presents the Ford Administration's plan. Three members of Congress -- Senator Bill Brock of Tennessee, Representative AI Ullman of Oregon and Representative James C. Corman of California -- outline their particular proposals. Participants share a wide range of views on such matters as the probable costs of, the different programs and their impact on the Federal budget, alternative methods of financing, ways of controlling health care prices, and Federal versus local regulation of health care supply and defivery. Various kinds of cost controls are also discussed, including deductibles, fee regulation by State health commissions, per capita programs, competition among insurance companies, and improved insurance regulations. Problems of the high cost of physician malpractice insurance, consumer overutilization, and future administrative costs are also reviewed. (Author abstract modified) A Round Table held on January 22, 1975, at AEI, DC. Melvin R. Laird, Moderator.
Mary E. Young. National Technical Information Service, Springfield, VA 22161 Jun 1980, 191 pp. Availability: National Technical Information Service, Springfield, VA 22161, PB80-811367. This annotated bibliography presents references on the evaluation, use, administration, and financial management of Government health insurance programs. The bulk of the citations pertain to the medicaid and medicare programs. Reports are also included on the Medicaid Management Information System and the Civilian Health and Medical Program for Uniformed Services. This updated bibliography, whose search period covers 1978 through June 1980, contains 308 abstracts, t 17 of which are new entries to the previous edition. (NTIS abstract) Desc_4ptor(s): Publicly sponsored/mandated health plans, Medicare, Medicaid, Demand/utilization of health care programs, Health information/data systems, Evaluations/outcome of health care programs,
Washington,
Descriptor(s): Cost containment efforts, National health insurance (NHI), Policy/changes re health care.
400. Health Interview Survey and Minority
Health.
Eva J. Salber and Angell G. Beza. 1979, 8 pp. Availabih'ty: Medical Care v18 n3 p319-326 Mar 80. This article discusses the Health Interview Survey (HIS) which was conducted by the National Center for Health Statistics and analyzed its advantages and disadvantages when applied to the needs ofethnic minorities at the local level. Since1957, datahave been collected for the HIS by the Bureau of the Census through personal interviews conducted each week on a sample of households by a permanent, highly trained staff. Each year's
1-181
questionnaire contains basic core questions on disabilities, chronic conditions, and hospitalizations along with items on special topics. Race was classified as black, white, or other through 1975. In 1976 and 1977 race was ascertained for each household member, and in 1978 special questions on race and ethnicity permitted the classification of respondents into five categories -- black, Hispanic, native American, Asian, and white, HIS data are used to estimate costs of Federal programs, for general research, and to gauge the potential demand for medical services. In any national survey the numbers of minority persons sampled will be small and certain groups may be missed, such as migrant farm workers or young adult, black, urban males, Since most interviews are conducted during the day, households with single parents and working couples may be ignored. Many interviews are given by individuals who are not the head of the household and may not know details about the health of the absent person. Moreover some HIS questions may be misinterpreted or not understood by minorities. HIS also does not distinguish between differenct types of delivery systems used, an important indicator of health problems and care. Special supplemental studies need to be done where minority groups are concentrated since these people often need health and social services the most. Eighteen references are provided.
Federal programs for grarLt and loan supporl of ltMO's: lor 5 years at increased authorization levels; (2) end the dctnonbtration status of the HMO program and make it an ongoing program of Federal support; (3) exempt HMO's from certain requirements of the planning act which have proven impediments to rapid and widespread HMO development; (4) provide for Federal loans and loan guarantees to HMO's for constructing ambulatory care facilities; (5) provide specific authorization for a management training program for HMO administrators; and (6) specify disclosure requirements which, together with existing authorities, will help guarantee the integrity of federally qualifled HMOs. Testimony is provided from the director of the human resources division of the General Accounting 0trice (GAO) concerning GAO's current review of HMO programs. Other testimony is providext from a representative of the Departmerit of Health, Education, and Welfare, congressional officials with particular expertise in health care issues; representatives of private third-party payers, and spokespersons for existing HMO's. S. 2534 is presented, along with written statements from witnesses and additional informationt.
Adapted from a paper presented at a conference entitled "'Assessment of NCHS Activities Relating to Statistics on Minorities, "sponsored by the National Center for Health Statistics and the Office of Health Resources Opportunity, Silver Spzing, MD, February 4-7, 1979. Also See "'Household Health Interviews and
Descriptor(s):
Mino_ty
402. Health Maintenance Organization Planning Model to Evaluate an Alternative Health Care Delivery System for the
ttealth.
The NCHS
Desc-nptor(s): Demographic formation/data systems.
401. Health Maintenance 1978.
Perspective." features of population, Health in-
Organization
Act Amendmen__s of
Committee on Labor and Human Resources (U.S Senate) Subcommittee on Health and Scientific Research, Washington, DC 20510 Mar 1978, 237 pp. for the use of the Committee Availability: Printed and Human Resources.
on Labor
Testimony on 1978 amendments to the Health Maintenance Organization (HMO) Act is presented before the Senate Subcommittee on Health and Scientific Research. The amendments (S. 2534) would extend and strengthen current authorities sup.porting HMO's. Specifically, the amendments would (1) extend
1-182
95th Congress second session, S. 2534.
Prepaid phms, Present
Funding/financing
legislation/regulations,
of health care programs.
State of Georgia. Thomas Berton Morehart. 1976, 549 pp. A vailability: University Microfilms International, MI 48106.
Ann Arbor,
This study's primary purpose was to design and develop a computer simulation model of a health maintenance organization (HMO) and to use this model in the evaluation of the financial feasibility of a large-scale HMO meeting the requirements of the 1973 Health Maintenance Organization Act. The HMO was tested for its ability to provide a financially feasible alternative health care delivery system for the entire resident population of the State of Georgia. A large-scale computer simulation model was developed and programmed in FORTRAN. This model was used to simulate the use oflhe HMO system by percentage c_oss sections from 14 metropolitan area and county groupings within Georgia. The model produced 20-year financial operating results for enrollment populations in each of the 14 areas ranging in size from 5,000 to 30,000 enrollees. The financial operating results
Hcahh
Care l'i,J_ _,_m:,
included the costs of providing all of the basic and supplemental health services specified in the HMO Act and the dues, revenues and medicare reimbursements necessary to fund the costs. The results of the statewide HMO system were tested against measures of financial feasibility which considered the relationship of the HMO costs to (1) the ability of the enrollee population to pay for the dues required, (2) the costs of health care in the traditional health care delivery system, and (3) the combined health insurance and self-funding financing mechanisms traditionally used to purchase health care services. It was found that the main determinant of ability to pay was income. However, the income range within which the enrollee population could afford to pay was not immediately determinable, although analysis of the 1969 mean income of families for all of Georgia, based on the 1970 census, showed that the rates for the HMO would be in a range that could be afforded by the average individual and family unit. It was also found that the cost structure of the HMO would be quite similar to that of a traditional health care delivery system, Finally, the study determined that the HMO per capita rate would be competitive with the combined projected health insurance expenditure and the cost of self-funded medical care, since the HMO rate is 18.6 percent higher than the costs of funding the traditional approach in 1975 but projected to be 16.9 percent lower than the costs of the traditional funding in 1994. Thus, the financial feasibility of the large-scale HMO simulated model would appear to be affirmed. The study includes 129 tables, 11 figures, footnotes, a bibliography of about 180 items, and appendices of related material. (Author abstract modified) Submitted in partial fuiEllment gree of Doctor of Philosophy Georgia State Univ., 1976.
of the requirements for the dein Business Administration to
Descriptor(s): Prepaid plans, Health care cost trends/projections, Cost/benefit analyses, Health information/data systems, Comparisons of health care programs,
403. Health Maintenance Organizations. ning and Development.
and development; and critical issues related to the transition from HMO development to startup and ongoing management. The landmark Federal Health Maintenance Organization Act of 1973, together with current regulations and policy for the act's implementation, are treated in a major section, as well as within each functional subject area where the Federal program has significant implications. An epilogue provides a brief discussion of the potential effects of national health insurance oll HMO development. The book suggests that (1) reimbursement provisions of national health insurance should be flexible enough to accommodate the capitation payment arrangements furtdamental to HMO administrative organization and incentive-related achievements; (2) where there is the need to satisfy enrollee deductible and coinsurance provisions, HMO's, because of their deliberate deemphasis on placing a price on individual units of care, should be given special treatment; and (3) national health insurance reimbursement provisions must recognize the capital requirements of HMO's. The book maintains that there is urgent need for legislative relief from at least the more seriously detrimental provisions of the HMO Act of 1973, and that cornprehensive health planning legislation and policy must remain sufficiently flexible to recognize and encourage HMO development and other innovations in health care delivery. Significant Federal legislation and regulations, as well as planning (use and staffing) data, typical benefit schedules, and a list of regional Department of Health, Education, and Welfare offices, are appended. A bibliography is provided. Health Systems Management Series, Volume Z An updated rewritten version of a manual entitled, "Prepayment and Neighborhood Health Centers: Guidelines for the Planning of or Conversion to a Health Maintenance Organization." (Office of Economic Opportunity, June 1972). Descriptor(s): Prepaid plans, Health care/services, Plan design/ program provisions (under health plans), Funding/financing of health care programs, Present legislation/regnlations, National health insurance (NHI).
A Guide to Plan404. Health Maintenance Organizations
Roger W. Birnbaum. 1976, 219 pp. Availability: Spectrum Publications, Inc., Holliswood, 11423.
and Prepaid Group
Practices. A Bibliography. NY
This book provides a conceptual framework of the major features, advantages, and limitations of health maintenance organizations (HMO's); criteria for determining the feasibility of HMO development; principle functional activities of HMO planning
Joseph Lee Cook and Earleen H. Cook. Jul 1979, 35 pp. Availability: Vance Bibliographies, Monticello,
IL 618158.
This bibliography of recent literature on health maintenance organizations (HMO's) and prepaid group practices is addressed to hospitals, clinics, insurance companies, physicians, and other
1-183
groups interested in lowering or containing health costs. Over 400 works are cited from medical journals, magazines, and congressional reports. They include such topics as the feasibility of and resource allocation for HMO's, the effects of prepaid plans on rural health care, HMO legislation, consumer satisfaction with prepaid group practices, and contrasts in HMO and fee-forservice performances. Most of the material was published between 1973 and 1978. No annotations or price and availability information are provided, Public Administration
Series Bibliography
addition, the presence of an HMO in an area secr, l_.Io l,)_cr tile costs in the fee-for-service sector in that area as well. Su_c._ted policy alternatives include increased Federal funding aud techmcal support for HMO's, increased information dissemination to such areas as insurance or personnel offices of major employers, and the matching of HMO promotional efforts to specific types of HMO's. Regulations regarding HMO qualification could also be reconsidered. Footnotes and tabular data are given. Usual, customary, and reasonable reimbursement and fee schedules (UCR) and cost compari,,;ons are appended.
No. P-289. Paper presented at the Annual Meeting of the Atlantic
Descrtptor(s): Prepaid plans, Cost/benefit tainment efforts.
analyses, Cost con-
ic Society,
Washington,
Econom-
DC, October 10-13, 1979.
Descriptor(s): Cost containment efforts, Prepaid plans, Policy initiatives, Providers of health care services, Comparisons of health care programs. 405. Health Maintenance Organizations Cost Containment Policy.
as an Instrument for
Sinclair Coleman.
406. Health Maintenance Organizations
Rand Corp., Santa Monica, CA 90406 RAND/P-6431
Health Care Costs.
Can Help Control
Dec 1979, 34 pp. Availability: Rand Corp., Santa Monica, CA 90406.
Comptroller General of tJae United States, Washington, 20548
DC
May 1980, 75 pp. This paper considers the role of Health Maintenance Organizations (HMO's) in effecting economy in the U.S. health care system. There are now about 175 HMO's operating in the United
A vailabffity: General Accounting 20548.
States with a total enrollment of about 6.5 million members. Although all HMO's are paid on a capitation basis (or fixed fi_e per enrollee) they vary in three ways: (1) their method of payrnent to their physicians, (2) the amount of care covered by the capitation payment, and (3) the organization and delivery of services. The paper discusses problems in increasing HMO enrollment, such as premium costs and HMO legislation, and suggests cutting back HMO requirements or having more lenient phasing-in allowances. In summarizing cost comparisons between various types of HMO's and fee-for-service-settings, the paper states that HMO's generally have lower rates of hospital admissions and lower surgery rates. HMO's use more lower-cost paraprofessional medical manpower, show a lower average ra_e of drug prescriptions, and more often prescribe drugs generically rather than by brand name. Total costs for health care range from 10 to 40 percent lower in HMO's compared with other forms of health care delivery. However, HMO's that control their own hospital tend to show greater cost savings than prepaid groups that use an outside hospital. Both of these forms of HMO's tend to show greater cost savings than independent practice association (IPA) types of HMO's; however, IPA's with rigorous peer review do reduce costs relative to other IPA's. In
Advanced economic analysis was employed by the General Accounting Office (GAO) '_o study the performance of health maintenance organization_,; (HMO's) qualified to receive Federal assistance in order to determine if these organizations are performlng efficiently in the provision of health care services. Available data on 20 federally qualified HMO's were used to estimate multioutput, multi-input _tatistical cost functions. Among the factors expected to affect an HMO's cost of operation are size, output rates, level of input prices, case mix, organizational form, and time in operation. Specifically, this study was able to analyze whether HMO's could control overall health care costs by responding to relative input costs unaffected by third party payments and substituting among the services of their medical staffs, ambulatory health centers, and hospitals; by substituting capital for labor services; and by _'ealizing returns to scale in providing health care. However, limitations in data did not allow comparisons in quality of care or comparisons between comparable levels of care between HMO's and fee-for-service systems. It was found that federally qualified HMO's are responding to relative input costs and are substituting the services of medical staffs, ambulatory health centers, and hospitals. Because the costs of th_e services are not affected by third party payments, HMO's should
1-184
Office, Washington,
Health
DC
Care Prt,: ,._:_
be able to allocate these resources efficiently and help control overall health care costs. The HMO's analyzed range in size from 1,131 to 37,087 members, and if they continue to grow, the per unit cost of providing care will fall. However, it was not possible to determine how large an HMO must be to realize all economies of scale. With increased time in operation, HMO's are experiencing increases in the real cost of providing care, and deficits must be made up by increasing enrollments over time. Three appendices provide data and methodological information, and a bibliography of 43 entries is given. Two additional appendices contain prepublication comments on the GAO analysis by the Department of Health, Education, and Welfare.
for the deficit loan program and on regulations and policies for the ambulatory health care facility loan program; ensure adequate staffing for the Office of Health Maintenance Organization's loan branch; ensure that required reports from qualified HMO's are submitted more promptly; and assess the HMO office's ability to monitor compliance so that more staff could be added if needed. Other recommendations included giving priority to validating HMO report data, developing improved grant program guidance for regional offices, and publishing guidelines defining the requirements for qualified HMO's. Six appendices contain a list of qualified HMO's receiving Federal financial assistance under the HMO Act of 1973; HMO Act grants awarded during 1975 to 1979; a questionnaire; information on quarter-
Comptroller
ly cost, revenue, and membership experience of HMO's with either a good, fair or poor chance to achieve financial independence; and agency comments. Footnotes, and tabular data are given. (Author abstract modified)
General's Report
to the Congress, PAD-80-IZ
Descriptor(s): Cost/benefit analyses, Supply/availability of services, National economic conditions, Prepaid plans, Outcome/ evaluation of health administration, Cost containment efforts, Health care costs.
407. Health Maintenance Organizations. Federal Financing is Adequate But HEW Must Continue Improving Program Management.
Comptroller 20548
General of the United States, Washington,
May 1979, 100 pp. Availability: General Accounting 20548.
DC
Comptroller
General's Report
to the Congress HRD-79-72.
Descriptor(s): Prepaid plans, Policy initiatives, tion/regulations, Funding/financing of health Outcome/evaluation of health administration.
408. Health Maintenance Organizations.
Present legislacare programs,
Product Life Cycle
Approach. Office, Washington,
DC
M. Venkatesan, Mark M. Moriarty and Charles M. Sic'her. 1980, 10 pp. A vailabib'ty: Health Care Management Review v5 n2 p59-68
The 1978 amendments to the Health Maintenance Organization Act required the General Accounting Office (GAO) to determine whether Federal grants and loans are adequate to help develop new health maintenance organizations (HMO's) and expand existing ones, and to evaluate the effectiveness of the policies and procedures for administering these programs. The GAO found that viable, well-managed HMO's should need no more than $4 million -- the amount specified by law -- to cover operating losses and should be able to achieve financial in-
Spring 1980. Health maintenance organizations (HMO's)are entering a period of rapid growth which established marketing techniques have been shown to improve. Marketing specialists have found that certain persons tend to be earlier adopters of a new product or idea than others, and this group of early adopters has been found to be the most important group in the diffusion of the product. Research on HMO subscribers has concentrated on factors
dependence within 5 years after becoming qualified. The GAO also found that the Department of Health, Education, and Welfare's (DHEW) Office of Health Maintenance Organizations had improved its program administration but needed to expedite its efforts to issue formal policies and regulations, see that stalTmg shortages did not occur, and provide adequate guidance to regional personnel who help administer the grant program. The report recommended that the Secretary of DHEW establish a development strategy which would keep HMO's current costs per member month relatively stable; complete work on policies
which differentiate the HMO enrollees from those selecting traditional coverage. In order to better market HMO enrollment, research should concentrate on the characteristics of enrollees that mark them as early adopters. An adopter profile was developed from a case study and revealed that those persons choosing the HMO option tended tobe younger, had lived at their present addresses for shorter lengths of time, did not exhibit greater awareness or knowledge about HMOs, and did not seem to differ from nonadopters in terms of their prior health experience. The profile also showed that adopters considered the organizational
1-185
structure of the physician's practice, services located in relatively new buildings, and preventive health services important. The profile led to marketing recommendations geared to an early adopter target group composed of younger employees who had recently moved into the area and therefore had no regular physiclans. Multispecialty and preventive services located in modern new buildings and innovative technical and diagnostic services were emphasized. Approaches such as this one have successfully increased enrollments in a number of HMO's. Figures, tables and 10 references are provided.
active professionals, year-by-year separation rates for the existing supply, projected enrollments and graduates l'rtm_ U.S. schools (including student attrition) and, for physicians, a sharply reduced net inflow of foreign medical graduates. Individual sections describe the anti_zipated manpower supply and requirements situation for the major health professions: medicine, dentistry, optometry, podiatry, pharmacy, veterinary medicine, nursing, and allied health disciplines. Estimates are provided for the base year 1975 and for 1980, 1985, and 1990. Two equivalent 15-year periods (1960 to 1975 and 1975 to 1990) are used to make the projected changes more understandable and compati-
Descriptor(s): Supply/availability of services, Participants in health care programs,
ble with earlier periods. The article concludes that if current educational capacities and the health care system remain relatively unchanged, by 1990 the envisioned large increases in health manpower should bring requirements and supply for most health professions into a better balance than at any recent time in the Nation's history. N:me references and two tables are given.
409. Health Maintenance phy.
Organizations.
Prepaid
plans,
Selected BibliograDescriptor(s):
Supply/availability
of
services,
Physicians,
InterStudy, Excelsior, MN 55331 Jun 1979, 25 pp. A vailability: lnterStudy, Excelsior, MN 55331.
Nurses, Allied health professionals.
This bibliography cites materials from newspapers, magazines, professional journals, bulletins, graduate theses, and Government publications on health maintenance organizations (HMO's). The approximately 375 entries are dated from 1966 through 1979. Subjects covered include the concept and development of HMO's, business aspects of HMO's, marketing HMO's, and HMO performance. A legal section includes material on HMO's as legal entities, HMO malpractice experience, HMO legislation, and the legal aspects of HMO planning and development. Case studies are also cited.
411. Health Personnel. Meeting the Explosive Demand for Medical Care.
Descriptor(s):
Prepaid
plans,
410. Health Manpower for the Nation. A Look Ahead at the Supply and the Requirements.
Howard V. Stambler. 1978, 8 pp. Availability: Public Health Reports
v94 nl p3-10 Jan/Feb
79.
This article presents future projections of both the supply and requirements of health manpower for the Nation. The projections were developed by the Bureau of Health Manpower in preparing the 1978 report to the President on the status of health professions personnel and a report on the Nurse Training Act of 1975. The supply forecasts are based on estimates of currently
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Harold M. Goldstein and Morris A. Horowitz. Department of Labor, Washington, DC. Office of Research and Development. 1977, 128 pp. A vailability: Aspen Systems Corp., Rockville, MD 20850. The use of health-care facilities and employment in the industry in the Boston-Cambridge area (Massachusetts) are analyzed over a 5-year period (1968 to 1973), and results are compared with those from a similar national study. The study's principal purpose was to determine whether employment and job opportunities in the health-care industry decreased during the study period as a result of the decline in hospital occupancy rates. Traditionally, hospital occupancy rates have been used as the principal measure of hospital use. By this measure alone, hospital use during the period studied would have decreased; however, when more reliable measu_es of hospital use are considered, such as the number of admissions and the average length of stay, overall hospital use incr,eased during the period considered. Moreover, the decline in the occupancy rate during the 5-year period was concluded to be due to the disproportionate increase in the number of beds, which exceeded actual increased demand for health services. Study results indicate a trend in increased demand for all categories of health workers by inpatient facilities and an emphasis upon a :.'nore comprehensively trained health
Health Care Pr{_grams
worker mix in ambulatory facilities. Some reasons for this bright outlook for health-care employment are the current growth rate of inpatient, outpatient, and nursing and rest home facilities; the continued development and adoption of sophisticated healthcare technology; the continued trend toward specialization among health workers as a result of new technology; the expansion of the practice of defensive medicine; the continuous absorption of physician functions by allied health personnel; the increased demand for health services in general; and the expected passage of a national health insurance program. The appendices include the survey questionnaire, a list of occupations and descriptions, and definitions of levels of care for nursing and rest homes in Massachusetts. References and tabular data are provided.
Descriptor(s): Demand/utilization of health care programs, Inpatient facilities, Outpatient facilities, Intermediate care facilities, Supply/availability of services, Providers of health care services,
412. Health Plan. The Only Practical Solution to the Soaring Cost of Medical Care.
give better care at less cost. Government cannot reorganize the health care system by direct controls, but it can change the tax, medicare, and medicaid laws to create underlying incentives for change. It can create a system of fair economic competition in which consumers and providers of care, making decisions in an appropriately structured private market, would do the work of reorganization. The principles of such a system, multiple choice of plans and fixed-dollar subsidies, are the basis of the Consumer Choice Health Plan (CCHP), a national health in,,iurance proposal. Competition would not work quickly and it would not work perfectly. However, the principles of fair economic competition would at least point the health care system in the right direction, toward an organized system with built-in incentives for economy and consumer satisfaction. Nevertheless, vested interest in the status quo is strong. If employers in any of a dozen or more communities where strong alternative delivery systems already exist were to apply systematically the principles of fair multiple choice, they could create the kind of health plan competition already existing in Minneapolis and Hawaii. Notes, an index, tables, figures, and an appendix summarizing leading national health insurance proposals are provided. Portions of this book are reprinted in New England Jnl. of Medicine, March 23, 1978, March 30, 1978, June 1, 1978; National Jnl. May 26, 1979; Harvard Business Review Jan/Feb 1979.
Aiain C. Enthoven. Henry J. Kaiser Family Foundation, Palo Alto, CA. 1980, 196 pp. Availability: Addison-Wesley Publishing Company, Reading, MA 01867.
Examining factors that have led to sprialing health care costs, the author blames the fee-for-service principle and "free choice of doctor" allowed under most insurance plans, tax laws that put the control of health insurance into the hands of employers, and the misperception that cutting costs would mean lowering quality. A health plan is recommended that entails fundamental reform whose most important principles are multiple choice and fixed-dollar subsidies to families enrolling in the health plan of their choice. Many factors contribute to the increased cost of health care, but the main cause of unnecessary and unjustified increases is the complex of perverse incentives inherent in the piecework system. In this system, doctors are paid for providing more and more costly services whether or not the care is beneficial. Furthermore, hospitals are paid on the basis of either their costs or charges based upon their costs. Some argue that the remedy for the ineffectiveness of government regulation is to provide more rigorous controls, but more bureaucratic controls imposed upon an inherently irrational system are not needed, Rather, a fundamental reform of the financing and delivery system itself is needed that rewards providers for finding ways to
Descriptor(s): Cost containment efforts, Economics of thirdparty payors, Policy initiatives, Publicly sponsored/mandated health plans, Present legislation/regulations, Competidon/interaction among third-party payors, Private health care plans.
413. Health Planning and Regulation. A Manual for State Legislators.
Ron Schmid and Richard E. Merritt. National Conference of State Legislatures, Bureau of Health Planning and Resources Hyattsville, MD. 1978, 137 pp. A vailabilt'ty: National Conference ver, CO 80202.
Denver, CO 80202 Development,
of State Legislatures,
Den-
The purposes of health planning, identification of State responsibilities under the Federal National Health Planning and Resources Development Act, an examination of issues which States face in implementing this legislation, and a review of State experiences with health planning are considered in this manual for State legislators, staff, and others concerned with health plan-
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ning and regulation as a method of controlling health care costs, The 1975 National Health Planning and Resources Developmerit Act requires that each State establish and administer a certificate-of-need program meeting Federal requirements. This is a method for preventing the construction or other development of health care facilities and services when they are unnecessary and inappropriate. Papers dealing with certificate-of-need issues examine a regulatory scheme, the linkages between certificare-of-need and rate regulation, and the role of health planning in cost containment legislation. New opportunities for the public to shape the Nation's institutional health care services are also discussed. State experiences with a certificate-of-need scheme are discussed for Maryland, Wisconsin, New Jersey, and Massachusetts. State experiences with rate setting for hospitals are examined for Maryland, Connecticut, Massachusetts, and Washington. The National Conference of State Legislatures' policy statement of health planning/certificate-of-need is also presented.
Descriptor(s): Cost containment efforts, Facilities providing health care, Funding/financing of health care programs, Present legislation/regulations.
health planning and regulation had little influence on 10_.=_ ti_at have been implicated in rising hospital costs. Moreover, current knowledge about the effects of planning and regulation on health care costs is too narrow a base for firm policy decisions. A frequent criticism of planning and regulation has been its fragmented and piecemeal approach, and evaluating the impacts of diffused programs is no longer an adequate or even feasible strategy. Furthermore, the practice of concentrating on particular components of health zare expenditures fails to take account of the organic nature of the health care cost problem. Although important, the lowering of capital investments or per diem costs and lengths of hospital stays are not ultimate objectives Rather, planning and regulation should be assessed in terms of how they affect, independently and jointly, the types of services that are available to and used by defined populations and the total costs they entail. Seventy-four references are provided.
Descriptor(s): Cost containment efforts, Impact of third-party coverage, Methods of pai_ment determination, Present legislation/regulations, Inpatier_t facilities.
415. Health Planning as a Regulatory of its History and Current Uses.
Strategy. A Discussion
414. Health Planning and Regulation Effects on Hospital Costs.
Thomas W. Bice. 1980, 25 pp. A vnildbilify: Annual Review of Public Health vl p137-161 i980.
Louis Tannen. 1980, 18 pp. Availability.. International Jnl. of Health Sciences vl0 nl p115-132 1980.
This paper discusses hospital cost containment efforts in the areas of health planning and regulation. Health planning legislation is reviewed: the Hospital Survey and Construction Act of 1946 (Public Law 79-725, known as the Hill-Burton program), the Partnership for Health Act of 1966 (Public Law 89-749), and the National Health Planning and Resources Development Act of 1974 (Public Law 93-64). This last statute and subsequently issued administrative regulations define the objectives of health planning more precisely than has been done before, assign specific functions to each of .the agencies involved, specify the types of plans that agencies must produce, and establish means for
Traditionally, government, industry, and insurance companies have had minimal direct control over the evolution of the health system. However, third-party payers, driven by escalating costs, have become the major fo_mebehind the health planning system. As planning structures begin to serve those who control their use, they lose their visionary thrust and become instruments of regulation and cost control. Classic definitions of planning refer to it as the rational use o["knowledge in making decisions concerning future action, directed at some vision of the "good life." Such visions portray planning as an objective science, performed by rational human beings who are not influenced by interest groups or ideological bias¢_. The pretense of a rational, scientific determination and evaluation of alternatives masks the true
promulgation of national guidelines and standards. Moreover, planning agencies have been thrust directly into the business of cost containment in their roles of reviewing and approving uses of Federal subsidies and in implementing capital expenditures and service controls. Next, the regulations are reviewed: capital expenditures and service controls, utilization review, and rate controls. Available evidence suggests that, as of the early 1970's,
orientation of planning decisions. All Health Services Agencies must be guided by cost control and are given little discretion to act in areas of occupatior_al, environmental, and public health, much less issues about qu_dity of care. They are generally limited to tinkering with existing ,,;ervices rather than given the initianvc to foster new and innovative programs. Planning can maach health resources supply with demand, the usual practice today,
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tfealth
Care tq,,_i,,,_,,
but health planning can also determine health needs and resource requirements according to the health status of the population regardless of resources. This second type of planning extends health planning into areas such as occupational health, environmental pollution, and social conditions. However, the emphasis in health planning remains cost containment and only marginally health status. Planning is not a neutral force, but the images of public participation, scientific evaluation, and consumer control will be used to legitimize cost-cutting strategies, Progressive concerns about people's health within these structures constantly struggles against the tide of cost containment, When used effectively as a forum for the discussion of health concerns, planning agencies can raise issues and seek to redress problems but only by understanding and exposing the bias of these planning agencies can they be used effectively. Forty-seven footnotes are provided,
Descriptor(s): Cost containment efforts, Present legislation/ regulations, Outcome/evaluation of quality assurance, Economics of third-party payors, Economic/commercial influences.
416. Health Planning in the United States. Issues in Guideline Development.
Institute of Medicine Committee on Health Planning Goals and Standards, Washington, DC 20418 IOM/PUB-80/01 Health Resources Administration, Hyattsville, MD. Mar 1980, 113 pp. A vm/abi/ity: National Academy of Sciences, Institute of Medicine, Washington, DC 20418.
This report
presents findings of a study commissioned
by the
Health Resources Administration (HRA) of the Department of Health, Education, and Welfare. HRA asked the Institute of Medicine to examine the process by which national health planning guidelines, defined in the National Health Planning and Development Act (Public Law 93-641) as health planning goals and resources standards, might be developed and to make recommendations for improving the process. The report presents background information on the history of health planning, the planning program as it operates under Public Law 93-641, and subsequent legislative changes. Also discussed are major health policy issues that intersect with or influence health planning. In addition, the national guidelines are described, and what is known, in general, about national planning goals and standards is discussed. The report concludes that the current health planning program has substantial potential for helping to achieve important
social goals through local planning for improved local
health care systems. It recommends that the limitations of health systems agencies (HSAs) in reducing health care costs Ix- recognized and that the planning agencies bejudged according to such broad measures as improvement of access, quality, and equity. Moreover, properly formulated national health planning guidelines, including normative resources standards, can be used to set targets and to measure progress toward a more equitable but not necessarily uniform distribution of health resources. An overall system of priorities for developing national guidelines is essential. An agenda for development must take into account the needs and interests of planning agencies, consumers, providers, payers, and key participants in the health system. The entire process of guidelines development, from agenda development through evaluation and revision, should be organized in consultation with the National Council on Health Planning and Development to ensure broad public participation and selection of a broadly representative set of perspectives and interests as appropriate to each problem. Wherever possible, information based on solid research must be used as the foundation for planning decisions. Footnotes, reference notes, appendices giving a statement and national guidelines for health planning, and a bibliography of approximately 160 references are supplied.
Descriptor(s): Present legislation/regulations, Economic/commercial influences.
417. Health Promotion Programs
Policy initiatives,
in Occupational
Settings.
Julius B. Richmond. Public Health Service, Washington, DC. Office of Health Information, Health Promotion and Physical Fitness and Sports Medicine. 1980, 59 pp. • AvMlabih'ty: Public Health Reports v95 n2 p99-157 Mar/Apt 80.
This collection of background papers for the National Conference on Health Promotion Programs in Occupational Settings reflects current approaches to effective and cost-beneficial health promotion. The first article presents data linking occupational stress to illness and introduces stress management procedures such as assertiveness training and biofeedback. A second study recommends exercise programs in industrial settings which might be financed by the facility itself, the employee health or medical program, labor unions, or membership fees. Health risk appraisal is presented as a method for describing a person's chances of becoming ill or dying from selected diseases, and the current state arid future development of the method are sketched. The next paper develops a nutritional
education
pro-
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gram tbr weight reduction that is attuned to diet-related cardiovascular risk factors; the program could easily be put into practice in company cafeterias. Next, current literature regarding the control of alcohol and drug abuse through industrysponsored programs and projects is reviewed. Several methods by which occupational programs can influence third-party payments have been suggested. They involve convincing carriers to voluntarily provide coverage for alcohol and drug abuse services to employers, encouraging major purchasers of health insurance to demand such coverage, and encouraging the enactment of mandated health insurance coverage for alcohol and drug abusing employees by State legislation. Current occupational smoking control programs are discussed, and hypertension programs
system depends largely on the extent to which there is a coJ_cusus among analysts who have studied health care with regard to defects and cures. Analysts agree that the physician determines between 75 and 80 percent of all health expenditures, that nlost hospitals have no incentive to limit their expenditures, and that physicians are able to determine their income by establishing the number and nature of their services. It is predicted that national health insurance will not be passed and implemented in any of its more expensive versions, that the development of new medical technology will continue, and that the Government will focus on providing some form of insurance against catastrophic illness and providing dental care for low-income youngsters.
in occupational settings focusing on either the detection or prevention/treatment of hypertension are characterized. Chapter references are supplied,
Descriptor(s): Characteristics of U.S. health care system, Economic/commercial influences, Cost containment efforts, Policy/ changes re health care.
Descriptor(s): Preventive services, Voluntary initiatives, Mental health services, Policy initiatives, Third-party payors. 419. Health Services and Health Hazards. The Employee's Need to Know. 418. Health Reform. The Outlook for the 1980s.
Eli Ginzberg. 1978, 16 pp. AvailabB_ty: Inquiry
v15 n4 p311-326
Dec 78.
Health care reform is considered in historical, analytical, evaluative, and prescriptive terms in this essay. With regard to efforts at health reform during the past 3 decades, four principal lessons may be extracted. First, money is a potent factor for ehangxng the structure of the health care system, but even large expenditures often fail to accomplish important goals. Second, reallocation of assets from affluent to underserved areas is difficult, Third, increases in the supply of health professionals does not necessarily assure access to quality services for members of the population. Finally, the marked reduction of morbidity and mortality rates remains difficult despite increased research efforts, Considering these background principles, the Carter Administration's proposed framework for health care reform is now set forth. The United States should move as quickly as possible to provide comprehensive health care coverage for all. Enhanced coverage must be accomplished without large new expenditures, relying primarily on the savings from increased efficiency. The major sources of increased efficiency are to be found in greater reliance on prevention, ambulatory care, and prepaid services, Plan implementation is to be accomplished without changing the freedom of the individual to choose and private insurance cornpanics to participate. The extent to which the Carter Administration and Congress can agree about desirable changes in the
l-lg0
Richard H. Egdahl and Diana Chapman Walsh. Boston Univ. Health Policy Inst., Boston, MA 02215 1978, 184 pp. Availability: Springer-Verlag, New York, NY 10010. Based on interdisciplinary working conferences convened by the Boston University Center for Industry and Health Care, this volume raises issues concerning the consumer's right and need to know about health se_wices and health hazards, the costs of generating information, and management's responsibility to provide such information. All of these issues are set against a backdrop of changing societal norms and expectations. The volume traces the central theme -- the employee's expanding intbrmational needs -- through three successive topics in health: physiclan advertising, health maintenance organization (HMO) marketing, and information about health hazards. Background papers elaborate on speciific informational issues relating to the cost and quality of eyeglasses, prepaid dental programs, workplace health hazards, the regulation of professionals in New York, and the publicizinl_; of health care reforms. In addition, the effects on employees and the health care industry of new reporting and disclosure requiJ:ements for employee benefit plans established by the Employee Retirement Income Security Act are discussed. Although complex issues remain to be solved, it appears that information on the medical profession is becoming increasingly available, more employees are being offered the option of joining an HMO in lieu of traditional health insurance coverage, and standards are being set for occupational heahh hazards. Chapter notes and a few tables and graphs are included. The names of conference participants are appended.
Health Care PrograHt._
Springer Series on Industry
and Health
Care, No. 4.
Descriptor(s): Present legislation/regulations, tives, Prepaid plans, Workers compensation,
Voluntary initiaHealth insurance
industry.
420. Health Services, Power Centers, and Decision-Making Mechanisms. Eli Ginzberg. 1977, 11 pp. Availability: Daedalus
v106 nl p203-213 Winter
1977.
The principal reform elements in American health care rest with the slow internal reform of the medical profession itself. Consumers will have marginal influence on restructuring the health care system in the face of the vigilant self-interest of the principal producer groups. Solutions to the problems of improved access, quality, and responsiveness to the consumer, and to additional services and lower costs, depend upon the self-discipline and responsibility of the purveyors of health services, not the consumers and not Congress. Labor intensive service industries are expensive, and cost constraint is not a realistic goal. Demographic factors determine services which are available, and no amount of money will substantially alter the distribution of people, traditions, facilities, and money, all of which determine the type of services available in an area. Furthermore, labor intensive industries are difficult to manage, and increases in personnel do not necessarily lead to increased productivity. It is likely that restrictive budgets will lead to increasingly intense struggles over the division of the medical dollar. The goals for health care are too ambitious. Power is likely to remain diffused among a few centers, with consumers having little leverage against organized professional and political interests. Effective transformation of the health care system depends upon local groups, but at present, neighborhoods and cities have few decisionmaking mechanisms for structural and operational change.
1979, 102 pp. A vailabih'ty: National Academy of Sciences, Office of Publications, Washington, DC 20418. The current status of health services research in the United States is discussed in this study conducted by an Institute of Medicine committee. Issues addressed include the definition of health services research the establishment of research priorities, contributors to the field, tbe organization of health ser¢ices research within the Federal Government, and the role of the National Center for Health Services Research. Information in this report was gathered from literature reviews, hearings, reviews of documents, interviews, and deliberations of the committee. Direct information about the utility of health services research is limited to the Federal Government. The committee found that several departments and agencies of the Government sponsor health services research, principally as an adjunct to tbeir programmatic missions. The committee recommended that administrative procedures be established within the Government to coordinate the setting of departmental and agency health services research priorities, agendas, and projects. Agencies should be designated to assume responsibility for studies that will fill gaps in knowledge. A significant portion of all monies invested in the research area should support extramural research initiated by investigators. The National Center for Health Services Research should be maintained, and the center should conduct and sponsor synthesizing research efforts. The Department of Health, Education, and Welfare should provide the cenLter with resources required to perform identified functions. Six figures, eight tables, and references are included in the report. (Author abstract modified)
Descriptor(s): initiatives.
Characteristics
of U.S. health care system, Policy
422. Health Status and Use of Medical Services.
Evidence on
the Poor, the Black, and the Rural Elderly. Desca)_tor(s): Characteristics of U.S. health care system, Economic/commercial influences, Voluntary initiatives, Providers of health care services.
Lynn Paringer, James Bluck, Judith Feder and John Holahan. Urban Inst., Washington, DC 20037 UI-1215/14
421. Health Services Research. Institute of Medicine Div. of Health Care Services, Washington, DC 20418 IOM/PUB-78-06. Executive Office of the President, Washington, Science and Technology Policy.
DC. Office of
Administration on Aging, Washington, DC. Ford Foundation, New York, NY. Jan 1979, 111 pp. Availability: Urban Inst._ Washington, DC 20037. This monograph is one of a series developed for the Department of Health, Education, and Welfare's Administration on Aging.
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The purpose of the series is to bring together information on health policies affecting the elderly for use by policymakers, researchers, and the general public. This work focuses on whether certain subgroups of the elderly, (the black, the poor, and rural residents) are particulary prone to illness and, if so, whether they receive medical care appropriate to their needs. As a group, older Americans experience more health problems and use more health services than any other. In addition, not only is the proportion of the population that is aged increasing, but within the over-65 age category, the proportion aged over 75 is increasing. Therefore, it is important to identify those target groups whose health needs are greatest. Economic and demographic characteristics of the elderly are considered first. Evidence available on the relationship between these demographic and economic characteristics and health status is examined. Finally, the utilization of medical care is addressed. In general, findings support the idea that the elderly are not a homogeneous group with respect to health status. Furthermore, factors such as income and race are significantly correlated with health status. The extent of the relationship depends partly on the measures employed. Measures of health status such as chronic conditions, activity restrictions, and disability are negatively related to income. Blacks exhibit significantly lower health status than whites. Urban or rural residency is not associated with significant differences in health status. Blacks, the lowincome elderly, and residents of rural areas use less medical care relative to other groups than is commensurate with their health status. Current programs have therefore not fully provided for equity of access in the use of medical care by the elderly Sixtytwo tables and 56 footnotes are included.
Health
Policy and the Elderly Series.
Dcscrtpto_"(s): Demographic initiatives, Demand/utilization in health .status.
This volume is the first of a four-volume annotated blbli_5;raphy with more than 1,300 pages. The bibliography draws t_gcther the literature relevant to e_timating the process and parameters associated on health statu% health care utilization, and outcome. This first volume covers health status and its relationship to medical care use, including health status distribution as classifled by health status measure; the relative seriousness of specific symptoms, diseases, or fun ctional levels; medical care use related to health status; and medi,zal care outcomes. Studies cited in the complete bibliography report data analyses undertaken between 1950 and 1976, The framework stems from a systems model of the health care system that follows patients from a perceived desire for health care to the seeking of care, treatment, and outcome with the patient deciding at each stage whether to proceed. Within each section, the entries are arranged by type of population studied. National samples appear first, followed by local samples, low-income samples, ethnic minority samples, maternity samples, infants and children, college students, the aged, the disabled, and finally populations outside the United States. For each entry, the location, characteristics, and size of the sample are identified, if known, as well as the date, and in some cases the method and purposes, of the study. Types of data are specified, but usually the results and conclusions arc not. Pricing and availability information are not given. (Author abstract modified)
NCHSR
Research Repot _.Series.
Descriptor(s).. Demand/tLtilization of health care programs, Health information/data _;ystems, Health care cost trends/projections, Third-party pay,_rs, Preventive services, Funding/financing of health care programs, Trends in health status, Participants in health cars programs.
features of population, Policy of health care programs, Trends 424. Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliography of Empirical Studies. Volume 2.
423. Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliography of Empiricsd Studies. Volume 1.
Linnea C. Freeburg, Judith R. Lave, Lester B. Lave arLd Samuel Leinhardt. National Center for Health Services Research, Hyattsv:ille, MD 20782 DFI EW/PUB/PHS-80/3263 Nov 1979, 408 pp. A _aNabJlity: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782.
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Linnea C. Freeburg, Judil:h R. Lave, Lester B. Lave and Samuel Leinhardt. National Center for Heallh Services Research, Hyattsville, MD 20782 DHEW/PUB/PHS-80/3263 Nov 1979, 297 pp. Availability: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782.
This is the second of a four-volume annotated bibliography of more than 1,300 pages which draws together the literature on
Health C,_rc Pr,)g_,,l_l_
health status, health care utilization, and outcome. This volume focuses on the relationship of medical care utilization to factors other than health status, such as demographic and socioeconomic variables; readiness to seek care and delay in seeking care; attitudinal, psychological, and sociocultural variables; and information about disease or health care. Studies cited in the complete bibliography report data analyses undertaken between 1950 and 1976. The framework stems from a systems model of the health care system, which follows patients from a perceived desire for health care to the seeking of care, treatment, and outcome, with • the patient deciding at each stage whether to proceed. Within each section, the entries are arranged by type of population studied, with national samples appearing first, then local sampies, then low-income samples, ethnic minority samples, maternity samples, infants and children, college students, the aged, the disabled, and finally populations outside the United States. For each entry, the location, characteristics, and size of the sample are identified, if known, as well as the date of the study, and in
to care, the cost of medical care, and preventive care. Studies in the complete bibliography report data analyses undertaken between 1950 and 1976. The framework stems from a systems model of the health care system that follows patients from a perceived desire for health care to the seeking of care, treatment, and outcome, with the patient deciding at each stage whether to proceed. Within each section, the entries are arranged by type of population studied. National samples appear first, followed by local samples, low-income samples, ethnic minority .samples, maternity samples, infants and children, college students, the aged, the disabled, and finally populations outside the United States. For each entry, the location, characteristics, and size of the sample are identified, if known, as well as the date of the study, and in some cases the method and purposes of the study. Types of data axe specified, but usually the results and conclusions are not. Pricing and availability information are not given. (Author abstract modified)
some cases the but method andthe purposes the conclusions study. Types are of data are specified, usually results ofand not. Pricing and availability information are not given. (Author abstract modified)
NCHSR
NCHSR
programs, Trends in health status, Impact of third-party coverage, Preventive services, Participants in health care'programs.
Research
Report
Series.
Desciqptor(s): Demographic features of population, Demand/ utilization of health care programs, Trends in health status, Health information/data systems, National economic conditions, Participants in health care programs.
425. Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliography of Empirical Studies. Volume 3. Linnea C. Freeburg, Judith R. Lave, Lester B. Lave and Samuel Leinhardt. National Center for Health Services Research, HyattsviUe, MD 20782 DHEW/PUB/PBS-80/3263 Nov 1979, 301 pp. Availability: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782. This is the third of a four-volume annotated bibliography of more than 1,300 pages which draws together the literature on health status, health care utilization, and outcome. This volume focuses on the relationship of medical care utilization to factors other than health status, such as health insurance or means of payment, sources of medical care, factors affecting accessibility
Research Report
Series.
Descdptor(s): Demand/utilization of health care programs, Health information/data systems, Comparisons of health care
426. Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliography of Empirical Studies. Voimne 4. Linnea C. Freeburg, Judith R. Lave, Lester B. Lave and Samuel Leinhardt. National Center for Health Services Research, Hyattsville, MD 20782 DHEW/PUB/PHS-80/3263 Nov 1979, 341 pp. A vailabib'ty: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782..
This volume is the fourth of a four-volume
annotated
bibliogra-
phy of more than 1,300 pages which draws together the literature on health status, health care utilization, and outcome. This volume covers patient flow within the medical care system, with emphasis on the relationships among different health services; visit characteristics; and patient dispositions. Studies cited in the complete bibliography report data analyses undertaken between 1950 and 1976. The framework stems from a systems model of the health care system which follows patients from a perceived desire for health care to the seeking of care, treatment, and outcome, with the patient deciding at each stage whether to
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proceed. Within each section, the entries are arranged by type of population studied. National samples appear first, followed by local samples, low-income samples, ethnic minority samples, maternity samples, infants and children, college students, the aged, the disabled, and finally populations outside the United States. For each entry, the location, characteristics, and size of the sample are identified, if known, as well as the date, and in some cases the method and purposes, of the study. Types of data are specified, but usually the results and conclusions are not. This final volume also includes an evaluation of data validity and reliability .'iswell as a five-part list of references. The first of these appendices covers literature reviews and bibliographies. The next two appendices list studies examining two or more alternative measures of health status, either as related to each other or as correlates of medical care use. The last two appendices index studies relating medical care use to sociodemographic and attitudinal variables using more specific headings than those provided in the main body of the bibliography. Pricing and availability information are not given. (Author abstract modified) NCHSR
Research
Report Series.
Outpatient rice.
Status, and Utilization
of
Services for Members of a Prepaid Group Prae-
Donald K. Freeborn, Clyde R. Pope, Maradee A. Davis and John P. Mullooly. National Center for Health Services Research and Development, Rockville, MD. 1976, 14 pp. Availability: Medical Care v15 n2 p115-128 Feb 77. When evaluating the effectiveness of medical care programs, An important concern is whether receipt of care is based upon health care needs or upon socioeconomic status. This study describes the relation between health status and socioeconomic status and attempts to determine which has the greater effect on ambulatory care use. The study setting was an operating HMO servinq a cross-sectional membership of nearly 200,000 persons. Outpatient utilization data were derived from the medical records of a 5 percent sample of health plan members for 1969 and 1970.
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Presented at the 102nd Annual Meeting of the American Public Health Association, New Orleans, LA, October 20-24, 1974.
Desc_ptor(s): Economic/commercial influences, Prepaid plans, Demand/utilization of health care programs, Participants in health care programs, Preventive services, Demographic tures of population, Trends in health status.
Descriptor(s): Demand/utilization of health care programs, Trenda in health status, Health information/data systems, Health care/services, Facilities providing health care, Evaluations/outcome of health care programs, Participants in health care programs.
427. Health Status, Socioeconomic
Social, economic, situational, and attitudinal data were provided by 2,603 respondents in a household interview survey. Since a population's perceived health status may reflect health need, information from the survey provided measures of health status that ranged from specific symptoms and complaints to a general measure of perceived health status. Although the findings vaned somewhat according to which variables were considered, they generally showed health status to correlate more highly than socioeconomic factors with the utilization of services in this medical care system. An exception was the use of preventive services which was not significantly related to health status measures but rather, for women, to education and, to a lesser extent, income. Six tables and 18 references are given. (Author abstract modified)
428. Health, United States,
fea-
1980.
National Center for Health Statistics, Hyattsville, MD 20782 Public Health Service Office of Health Research, Statistics, and Technology, Hyattsville, MD 20782 DHHS/PUB/PHS-81 / 1232 Oct 1980, 470 pp. Availability: Health Care Financing Administration, ORDS Publications, Baltimore, MD 21235.
This fifth annual report on the health status of the United States presents statistics on recent trends in health care and detailed discussion of selected current health issues. The report also contains Prevention Profile, a national profile of disease prevention that is submitted to Congress every 3 years by the Secretary of Health and Human Servi_. The first part of the report includes several analytic articles and a section of 78 detailed tables organized around 4 major themes: health status and determinants, use of health resources, health care resources, and health care expenditures. Report data show that, among other things, the period between 1964 and 1978 saw a marked trend toward equality in the volume of physician visits between the poor and nonpoor, although the poor continued to use fewer dental services. The Nation's mean length of a hospital stay decreased from 8.5 to 7.4 days from 1968 to 1978, a trend most prevalent in the West. The supply of physicians increased by 25 percent from 1970 to 1979,
Health ('are
Programs
and the increase is expected to continue at an even faster rate between 1979 and 1990. In addition, health care expenditures continued a rapid rise, reaching $212.2 billion in 1979 -- an increase of 12.5 percent over that for 1978. The expenditure for hospital care accounted for the greatest part of the health care dollar, although nursing home care is increasing as a proportion of health care cost. Physician services, drugs, and dentist services are decreasing as a proportion. Third-party payment for medical care services increased from 48 percent to 80 percent during the period 1966 to 1977. The second part of the report, the Prevention Profile, covers these issues: reduction of illness and ¢conomic burdens through prevention; successes, failures, and gaps in prevention and control; and major national objectives for reduction and prevention to be attained by 1990. Chapter references and footnotes are included,
Descriptor(s): Demographic features of population, Inpatient facilities, Allied health professionals, Demand/utilization of health care programs, Outpatient facilities, Health care cost trends/projectious, Intermediate care facilities, Supply/availability of services, Long term care facilities, National economic conditions, Limitations on coverage, Health insurance industry, Physicians, Economics of third-party payors, Nurses.
429. Health. What Is It Worth. Measures of Health Benefits.
Selma J. Mushkin and David W. Dunlop. National Center for Health Services Research, HyattsviUe, MD. Milbank Memorial Fund, New York, NY. 1979, 372 pp. Availability: Pergamon Press, Elmsford, NY 10523.
This volume is derived from the proceedings of a conference on functional health status and biomedical research and technology, held in response to the current public skepticism and legislative scrutiny of medical care provision and of biomedical research benefits. The purpose was to discuss the latest concepts and methods for determining health policy priorities and resource allocation to biomedical research and to measurement of the population's health status. Scholars from the fields of economics, psychology, sociology, biostatistics, and public health contributed methodological and conceptual developments from their disciplines in the effort to clarify how health progress should be measured and how the benefits of health programs should be valued. The opening paper gives measures of functional health change preference over those based on the occurrence
of death and submits a taxonomy to facilitate use of the health status index for specific resource allocation. Another paper describes a patient assessment procedure for use in long-term care facilities. A series of papers deals with various conceptual and operational aspects of valuing health benefits. Theoretical approaches, such as the application of investment concepts to health program calculations, are reviewed; new approaches, such as quantification based on individual consumer preference rather than on gains or costs to society as a whole, are assessed. The problem of social returns to biomedical investments is addressed by a critique of the human capital and the consumer surplus approaches to measuring the value of benefits. A methodology emphasizing the cost of risk concept for measuring the benefits of cancer prevention programs is introduced. Papers on health resource allocations discuss funding of research in cancer, heart disease, and child development in relation to the rationale of political decisionmaking. Tabular data, footnotes, and references are provided with individual chapters. A bibliography of over 250 citations and an index are provided.
Pergamon Policy Studies. Derived from a series of pa_rs presented at a two-day conference at Georgetown University, Washington, DC, September 1977. Descriptor(s): Medical technology impacts, Cost/benefit analyses, Outcome/evaluation of quality assurance, Trends in health status.
430. HIAA Reviews State Cost Control Regulation. 1980, 3 pp. Availability: Jul 80.
Employee Benefit Plan Review v35 nl p24,26,95
This article describes a report published by the Health Insurance Association of America (HIAA) that advocates strong support of mandated State prospective budget and rate approval programs. Much of HIAA support is based on figures derived from the American Hospital Association's Annual Statistical Surveys, 1969 through 1978. The report assesses the New York experience, which is often cited as a major criticism of regulation. A study by the Hospital Association of the State of New York showed that up to 25 percent of the average hospital bill was directly attributable to the cost of complying with loeal, State, and Federal regulations. HIAA contended, however, that the New York system imposed arbitrary formulistic limits and incentives to maximize reimbursement by extending the length of hospital stay. The HIAA report analyzes cost containment programs in Maryland, Connecticut, Massachusetts, Washington,
1-195
Rhode Island, and Indiana. The report indicated savings of more than $124 million a year in Maryland and lowered rates of escalation in net patient revenues (NPR) for Connecticut, Mas L sachusetts, Washington, and Rhode Island. A statistical chart is included.
Descriptor(s): Cost containment efforts, Inpatient facilities, Present legislation/regulations.
432. Historical Development of the California Pilot Program to Provide Health Insurance Coverage for Alcoholism.
Jerome B. Hallan, HaroJd D. Holder and Martha J. Stuckcr. H-2, Inc., Raleigh, NC 27607 National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD. Nov 1975, 75 pp. Availability: National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD ::0857.
431. High Cost of Hospitals and What to Do About ][t. Martin S. Feldstein.
The article identifies insurance as a key ingredient in the rise of hospital costs and suggests the major risk approach as artalternative to comprehensive national health insurance. It is argued that health insurance, by lowering the net cost the patient pays at the time of service, has induced hospitals to provide much more expensive and sophisticated care. The high cost of hospital care, in turn, induces families to buy more complete insurance, and the growth of insurance induces the hospital to produce more expensive care. The challenge to any comprehensive national insurance system is to find new methods of financing health care which take these facts into account. Any system of financing health care should be judged by the following six criteria: it should prevent deprivation of care; it should prevent financial hardship; it should keep costs down; it should avoid large tax increases; it should be easily administered; and it should be generally acceptable. After showing that a universal, comprehensive health insurance, which is akin to an extension of medicare to the entire population, does not meet the proposed criteria, the major-risk approach is explained. Every family would receive a comprehensive major risk insurance: pc,iicy with an annual direct expense limit (i.e., a limit on out-of-pocket payments that increases with family income). A $500 directexpense limit means that the family is responsible for up to $500 of out-of-pocket medical expenses per year no matter how large the total annual bill. For example, the direct-expense limit might amount to 10 percent of the family income between $4,000 and $15,000 and $1,500 for incomes above that level. Because relatively few families have such large expenditures in any year major risk insurance need not be a costly program. A few footnotes are given,
This report is the first in a series sponsored by the National Institute on Alcohol Abase and Alcoholism designed to document and evaluate various aspects of the California Pilot Program. Specifically, the historical development of the program through its first year of operation is presented. Information was collected through structured interviews with legislative, administrative, and program representatives of the State, and through a review of relevant documents, notes, reports, and data gathered during August 1975. The legislative history of tile bill authoriZing the program extended over a period of approximately 9 months during 1973. The program resulting from this legitlation underwrote the costs of extending health insurance coverage for alcoholism care to State and certain pubhc eraployees and their familiel. Following enactment of the authorizing legislation, the Office of Alcohol Program Management was faced with the task of identifying the target population for the program and negotiating with the participating carriers. Negotiations with each of the carriers resulted in formal administrative agreements tbcusing on specified benefits, reimbursable costs, and length of participation in the program. In the months following program initiation in July 1974, several problems emerged. The total number of people initially using the program was less than anticipated. Low program use was attributed to lack of awareness of the program's existence, unfamiliarity of'service providers with the program, poor referrals by supervisory personnel, and denial of the problem by potential clients. In response to these problems, plans are underway in the State to train employee supervisors in the identification of problem drinkers. Further, the program is now being explained to providers, and informational brochures are being prepared for distribution to employees. California officials recommend that similar pilot programs should last no less than 3 years and that information dissemination be closely supervised. Tables, footnotes, and appendices containing interview forms and backgroud information are included. (Author abstract modified)
Dc_cr_otor(s): Cost containment efforts, Inpatient t'acilities, Funding/financing of health care programs, Impact of thirdparty coverage, Hospital services, Policy initiatives.
National Institute on Alcohol Insurance Resource Kit.
1977, 15 pp. Availability: Public Interest 48 p40-54 Summer 1977.
1-190
Abuse
and Alcoholism,
Health
ltcalth
Care Pr_)gramb
Desc_ptor(s): Government employee plans, Mental health services, Plan design/program provisions (under health plans), Source of premium payment, Policy initiatives.
433. History and Organization of Pretreatment Dental Utilization
Review, a
Review System.
Susan Reisine and Howard L. Bailit. National Center for Health Services Research, Hyattsville, MD. 1980, 9 pp. Availability: Public Health Reports, v95 n3 p282-290 May/ Jun 80. Within the next 5 to 10 years, the majority of Americans are likely to have access to private or publically financed dental insurance, and it is certain to be a component of the proposed national health insurance (NHI)plan. Pretreatment review, also known as precertifieation, prior authorization, and predeterminauon of benefits, is the major method presently operating in this country for monitoring the cost and quality of ambulatory dental care. Dentists are asked to submit treatment plans for all treatments exceeding a certain dollar amount, usually $150. The third party payer certifies eligibility, dental consultants determine if services are necessary and appropriate, and patient and provider are informed of the level of reimbursement. The problems with pretreatment review stem from competing goals within carrier organizations. Eighty percent of the dental claims submitted consist of completed services that do not meet the dollar requirements for pretreatment review. All claims, however, are scruffnized for patient eligibility, contractual limitations, and size of fees. Of all the claims processed, 5 percent (some may be under $150) reveal problems. The methods for resolving conflicts are described in detail, but nonetheless, pretreatment review programs lack legal definitions of quality and lack the means for dealing with dentists who abuse the system. The resolution of these problems will require the development of formal relationships among the carriers, the profession, and public regulatory agencies such as professional standards review organizations, Even under an NHI plan, there will be considerable demand for fa_t claims processing by both patients and providers, along with pressure on review agencies to be cost effective, with little support for increasing expenses to improve quality. Sixty-eight footnotes are provided; three figures show the pretreatment review process. Descriptor(s): Cost containment efforts, Dental services, Demand/utilization of health care programs, Methods of payment determination, Plan design/program provisions (under health plans).
434. HMO Enrollment Decision. A Transactions and Literature Review.
Analysis
Ralph Ullman. Pennsylvania Univ. National Health Care Management Center, Philadelphia, PA 19104 National Center for Health Services Research, Hyattsville, MD Jan 1979, 34 pp. Availability.. Pennsylvania Univ., National Health Care Management Center, Philadelphia, PA 19104. Available literature on health maintenance organizations (HMOs) is reviewed and analyzed to explain why enrollments have remained low. The literature shows that all HMOs serve a voluntarily enrolled population but can be classified into two major models. In a prepaid group practice (PGP), services are provided by a physician group under a contractual relationship with the prepayment organization. Physicians in an individual practice association (IPA) maintain their regular practice location and patient load but accept enrolled patients from the prepayment organization. Brief summaries of 11 studies on HMOs are followed by discussions of their findings which locus on transactional considerations that influence the choice of HMO enrollment. Areas examined include protection against unanticipated medical bills, prepayment arrangement% availability of specialists, atmosphere, doctor-patient relationship, centralization of services, and preventive health claims. Also assessed are the innovative nature of the HMO, cost considerations, and the effect of persons who benefit from HMOs by misrepresenting their medical condition. Research evidence indicates that a community's newest residents are most likely to enroll in an HMO, particularly the PGP type. The preventive and prepayment aspects of the HMO do not often sell the contract to the consumer, who placed greater value on trusted medieal personnel and reimbursement competitive with private physicians' fees. The reluctance of consumers to discontinue established patterns of health care appears as a significant deterrent to the PGP, the dominant HMO form. Consumers should have the opportunity to choose an HMO, and the Government should not hamper their development through bu_rdensome regulations or exemption from a national health insurance plan. Footnotes and about 80 references are provided. Descriptor(s): Demand/utilization of health care programs, Participants in health care programs, Prepaid plans.
435. HMOs and the Politics of Health System Reform. Joseph L. Falkson. 1980, 219 pp.
1-1_7
A vailabilit): 60611.
American
Hospital Association,
Chicago, I]_
436. HMOs From the Management
Perspective.
Ruth H. Stack. American Management l'his book describes the evolution of the Federal Government's
i979, 49 pp.
commitment to prepaid health care in the United States in the 1970's. The book presents a factual account of the emergence of the health maintenance strategy and the health maintenance organization (HMO) program as centerpieces of national health 'policy in the 1970's, describes congressional and health insurance interest groups' attempts to shape a health mainteltance policy in their own images, and offers insights into future direcdons for HMO policies by placing them in the broader framework of national health policy. Legislative struggles to implement a national health policy that encouraged the development and expansion of HMOs are discussed in extensive detail, as well as obstacles that limit health system reform. The book notes that in 1929 there were only 2 prepaid health plans :ia the United States. By 1970, 39 prepaid plans had developed with a total enrolhnent of 3.6 million people. Federal intervention through legislation supported HMO development, and the humber of HMOs grew from 39 to 217, with enrollment doubling to 7.9 million persons. However, although Federal intervention has facilitated HMO growth in some ways, it has inhibited it in others. Congressional insistence on shaping the emerging universe of HMO's to a set of rigid specifications, coupled with persistent executive branch difficulties in administering so cornplex a program has had some adverse effects on growth. Moreover, due to the economic situation in 1979, HMOs and other cost containment measures have replaced national health insurmice (NHI) as the central elements of health system reform. The book concludes that HMOs remain viable instruments of reform
A vailabffity: NY 10020.American
because the3 are unambiguous in purpose, amenable to concrete plans for implementation, and arouse less opposition than other reforms. Moreover, HMO's offer health systems the opportunity to shape their own futures, rather than bringing the Federal Government into open conflict with health system components. Thus, HMO:_ are alternative models of health care organization that meet two basic requirements for reform in a pluralistic democracy: :',1)they work and (2) private health care interests find them increasingly acceptable. By 1988, if present Federal policies and likely private sector responses hold firm, there will probably be over 440 operating HMOs offering health services to over 19 mdlion people in the United States. Footnotes and an index are included.
AHA
1-198
Prepaid plans, Present re health care.
Management
New York, NY I(YO20 Associations,
New York,
The Health Maintenance Organization (HMO) Act of 1973 as amended in 1976 and 1978 and its effect on employers are highlighted, and aspects of offering the HMO option to employees are reviewed. Furthermore, the future of HMO's is discussed. An HMO is an organized system of health care that ensures the delivery of comprehensive, continuous, coordinated health-care services to a voluntarily enrolled group of persons under a prepayment plan. The prepe:yment mechanism compels HMO's to set their budgets in advan,ze and operate within them. For this reason, they must give health care that is efficient as well as appropriate. The Federal HMO Act of 1973 established grant and loan programs to assist developing HMO's and provided a mandatory dual-choice option for employees (a requirement that some employers offer a qual:LfiedHMO to their employees). The 1976 amendments to the HMO Act limited the benefits required for Federal qualification, gave HMO's a 5-year period in which to achieve financial stability before offering open enrollment, and also gave them time to become well established before offering community-rated premiums. The 1978 amendments extended the funding authorization for HMO, including provision for a special construction loan. A checklist of issues to be considered in the company policy is provided in this brief, followed by a discussion of the criteria a company should use in evaluating an HMO. The criteria include the accessibility of health care services and their availability, acceptability, appropriateness, and accountability. The brief also considers the mechanics of a cornpany's negotiation with an ][-IMO and the implementation and administration of the HMO option for employees. A glossary and nine references are provided. AMA
Management
BrielTn_:
Descriptor(s).. Prepaid plan,;, Plan design/program provisions (under health plans), Source of premium payment, Present legislation/regulations, Outcome/evaluation of health administration.
437. Home Health Care Selwices. Tighter Fiscal Controls Needed.
Catal_,g No. 1183.
Descriptor(s?: Policy/changes
As:;ociations,
legislation/regulations,
Comptroller General of the United 20548 May 1979, 57 pp.
States, Washington,
Health
DC
Care Programs
Availability: National Technical Information Service, Springfield, VA 22161, HRP-0030018. Medicare's cost reimbursement procedures for home health care services and recommendations for improvements are discussed. As of June 30, 1978, 2,612 agencies were certified by medicare to deliver certain authorized home health care services. To review cost reimbursement procedures, detailed audit work was conducted at 11 home health agencies (8 in Florida and 3 in Louisiana). It was found that home health care costs varied greatly, particularly with regard to management and clerical costs, agency staffing, and cost limits. Questionable costs were claimed by agencies; some were undocumented or unrelated to
about $287 per month for every $120 spent by agencies. However, older people greatly impaired who are living alone have a greater chance of being institutionalized. The President's August 1977 welfare reform package includes a proposal for creating 200,000 public service jobs for providing home care for the elderly; the Social Security Administration agrees this proposal will save money by reducing institutionalization-related costs. Most of the problems noted by the General Accounting Office have been alleviated by better implementation of various 1972 Amendments to the Social Security Act and better provider understanding of medicare's home health care requirements. However, physicians are still unaware of the types of services provided by home health agencies, and States' different require-
patient care and others pertained to office space, patient solicitation costs, and salaries and fringe benefits. Program abuses were found that involved the establishment of home health agencies, The Department of Health, Education, and Welfare generally agreed with the recommendations of the General Accounting Office and stated that actions were planned or underway to deal with the problems noted. Home health agencies, in commenting on questionable costs, indicated that they were not violating medicare program regulations. Additional information on the
ments under medicaid will cause some confusion. Due to the number of agencies involved and other factors, home health care and other home services available to the elderly under medicare and medicaid are not being coordinated properly. Finally, it is recommended that the Department of Health, Education, and Welfare should have intermediaries and carriers publicize the use of home care and provide information about it to physicians. It should also identify State medicaid programs which do not tremt eligibles equally and correct the situation, and it should
review of home health agencies is appended. (NTIS abstract)
develop a comprehensive national home health policy for consideration by Congress. Tables and appendices of related information are included.
Comptroller
General's
Report
to the Congress, HRD-79-1Z
Des¢_qptor(s): Medicare, Home health services, Reimbursement, Comparisons of health care programs.
Comptroller
General's Report
to the Congress, HRD-78-19.
Descriptor(s): Demand/utilization of health care programs, Cost/benefit analyses, Supply/availability of services, Medicare, Home health services, Long term care facilities, Policy initiatives. 438. Home Health. The Need for a National Policy to Better Provide for the Elderly.
Comptroller 20548
General of the United States, Washington,
Dec 1977, 67 pp. Availability: General Accounting Washington, DC 20013.
DC 439. Homemaker Services. Essential Option for the Elderly.
Office, Distribution
Section,
This publication compares the costs of home and institutional care for the elderly, discusses the costs of liberalizing home health benefits under Social Security, and makes recommendations germane to this liberalization. Until older people become greatly impaired, the cost for home services, including the large portion provided by families and friends, is less than the cost of institutionalization. As impairment increases, the costs or values of home services and the proportion of family-provided care increase. At the greatly impaired level where breakeven point in cost is reached, families and friends are providing over 70 percent of the value of services. Thus, families and friends provide
Anne R. Somers and Florence M. Moore. Robert Wood Johnson Foundation, Princeton, 1976, 6 pp. Availability: 76.
NJ.
Public Health Reports v9 n4 p354-359 Jul/Aug
This article advocates development of homemaker services as a less extensive and more acceptable alternative to institutionalization of only partially incapacitated elderly who would prefer assistance in their own homes to commitment to a nursing home. In-home nursing services are also desirable to facilitate earlier hospital release, thus alleviating overutilization. In addition, part-time homemaker-home health aide services are needed by the disabled and by families with small children when the mother
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is incapacitated. The number of agencies providing homemaker services is growing, but not fast enough in relation to need. Currently in the United States there is only 1 homemaker for every 5,000 persons -- far below the ratio of other industrialized nations such as Norway, Sweden, or the United Kingdom. Addressing the need in the United States for such services requires recognition of the necessary tasks and qualifications of homemakers, the need for standards and accreditation, the costs and financing, and the benefit of establishing a national policy. The services of homemakers, which include both personal care and household tasks, should be seen as one aspect of a broad speetrum of other in-home services like medical care, nursing, physical therapy, social work, nutrition, and paraprofessional or volunteer services in the form of telephone reassurance, visiting, transportation, and meals-on-wheels. Cost estimates of homemaker services are usually done in comparison with institutional nursing home care. The issue becomes clouded if patients in need of 24-hour-a-day service are confused with the appropriate elients of homemaker service -- those requiring only intermittent assistance. The reluctance of third-party payers, especially medicare, to reimburse for homemaker services is the most visible obstacle to program expansion. Other drawbacks are the priority of acute illness, the potential for abuse of in-home services, and the difficulties of monitoring them. Agreement on the definition, standards, recordkeeping, and Federal program benefits for home health services would advance their development. Also
dying through elimination of isolation from family, friends, and a caring environment, as well as through provision of sophisticated management of severe pain and other debilitating symptoms. Hospice principles can be applied to many settings, including unique palliative care facilities, general hospitals, specialized hospitals, nursing homes, day care institutions, homes, and others. Good care must adhere to an explicit set of standards, must be patient-centered, must give the patient the opportunity to discuss death and dying, and must facilitate access to family and friends. In addition, it should use a team approach, must be financially available to everyone, and must allow the patient the right to die at home if that is the patient's wish. Guidelines for hospice program development are presented, based on the hospice concept's development in England and its adaptation at the New Haven Hospice. Responsibilities of each hospice team member (physicians, nurses, social workers, chaplains, psychiatrists, volunteers, and research and public relations staff) are outlined. The limited experience of existing American hospices provides a basis for guidance on establishing a steering committee, initial research, pilot funds and funding, legal questions, team building, and related issues. Additional chapters examine financial aspects of hospices and the concept of home care for the dying. Reference, notes and suggested reading lists are included. Appendices lis_;materials used in orienting volunteers and give an official definition of hospice.
needed are voluntary coverage by private insurance companies, a realistically formulated package of home health benefits in the eventual national health insurance program, and employment and training programs for homemakers. An illustration and 12 references are given.
Descriptor(s):
Descriptor(s): Home health services, Allied health professionals, Policy initiatives.
441. Hospice Movement in the United States.
Hospital services, Home health services, Facilities
providing health care.
Richard L. Vicker.
440. Hospice. Creating New Models of Care for the Terminally Ill.
1979, 31 pp. Availability: Long Terror Care and Health Services Administration Quarterly v3 n4 p253-283 Winter (Dec) 1979.
The hospice provides a climate of warmth, caring, and love for Parker Rossman.
dying (usually cancer) :patients and their families. Support is
1977, 238 pp. A vailabih'ty: Follett Publishing Company, Chicago, IL 60607.
given to all family members, and the patients' pain and collateral symptoms associated with terminal illness are controlled. Hospices in the United States are organized in several ways, includhag those that are primarily home health care organizations and those that operate as units in skilled nursing facilities. Models described are The Connecticut Hospice, Inc., in New Haven, Conn., and Hillhaven Hospice in Tucson, Ariz. In 1977, the National Hospice Organization was created to provide national leadership to the growing hospice movement. A study conducted by the U.S. General Accounting Office in 1978 identified 59 organizations that eonshtered themselves to be providing at least
Based on the experience of the hospice in New Haven, Conn., as well as similar English and Canadian programs, this book is addressed to persons concerned with establishing hospice type institutions or programs in their own communities. The book is also intended for families of the terminally ill, clergy, social workers, health professionals, and community social service leaders. Hospice programs seek to provide humane care for the
1-200
Health Care Programs
1 service which employed the hospice philosophy. In addition, 73 hospice programs were being developed in a manner similar to the 59 operating organizations. Third-party payers, such as medicare and medicaid, Blue Cross and Blue Shield, commercial insurance companies, and various Federal and State agencies in the United States health care system, now cover the vast majority of all health care spending. Unfortunately, the personnel who make up the hospice team are not adequately covered by medical insurance. Hospices are reimbursed for some of their medical services, but many other hospice services are not covered. Thirdparty payers are primarily concerned about lack of established standards for evaluation, separate development of hospices which may hamper efficient integration and use of health care resources, the need for cost control, and the appropriateness of health insurance coverage for bereavement visits and other support services for family members of hospice patients. A total of 101 references are provided.
vey conducted to determine the extent to which private insurance companies have knowledge of hospices and have: benefit coverage for their services. Other issues analyzed are right-to-die legislation, legal definitions of death, a study of U.S. and Canadian hospices, and barriers to the development of the hospice movement. The concluding chapter offers recommendations for improving hospices and removing barriers to their furtber development. Appended are a listing of hospices and organizations that deal with issues of dying terminal illness and deaths, the questionnaire used in the insurance company survey, material on the California Natural Death Act, and materials used in other reported surveys. References, a glossary, an index and a bibliography of approximately 310 references are provided.
Descriptor(s): Intermediate care facilities, Funding/financing of health care programs, Policy initiatives, Long term care facilities.
Descriptor(s): Third-party payors, Home health services, Intermediate care facilities, Exclusions from coverage. 443. Hospital Backlog. Patients With No Place 'to Go.
442. Hospice. Prescription for Terminal Care.
Kenneth P. Cohen. 1979, 302 pp. Availability: Aspen Systems Corp.,
Rockville,
Malcolm M. Manber. 1980, 7 pp. AvMlnbility: Medical World News v21 n8 p63-65,69,70,77,81 14 Apr 80. MD 20850.
Issues and concepts related to the development, operation, expansion, and improvement of hospices are discussed. The goals of a hospice are to use specialized medical and psychological therapy to ease the physical and psychological discomfort of terminally ill patients and their families. The hospice movement has developed because of the general lack of specialized care for the terminally ill in traditional hospital and long-term care facilities. Following a description of the origins of the hospice concept and movement, the unique factors affecting the terminally ill patient are identified and discussed as a basis for showing why the specialized services of the hospice are required to help produce maximum comfort and stimulate positive experiences for the terminally ill. Various attitudes toward death are considered under the topics of the conspiracy of silence, fear of death, cultural beliefs, theological views, and health professionals' views. Also discussed are the stages of dying, social death, and grief and bereavement. Hospice models, are considered, as are appropriate treatment, and elements of a hospice program. Attention is given to symptom control in discussions of the four types of pain, pain control through drugs, and relief of secondary symptoms. The consideration of issues of reimbursement for hospice services includes an examination of the results of a sur-
The major factors creating the backlog of patients ready to be released from acute care hospitals, but unable to find placements in nursing homes or other sites of appropriate care, are (1) low levels of reimbursement for medicaid and medicare pal_ients and (2) a shortage of nursing home beds in some areas. Compounding the problems of backlogged patients is the lack of' information about long-term care options, fragmented o:r skimpy services in communities, widely varying eligibility requirements, and the tendency of professionals to recommend nursing home placement because they do not have the expertise or the time to mange for community care. Each day of a prolonged stay in an acute-care bed means a loss of health care system dollars for unnecessary hospitalization and inappropriate level of care. A recent 5-county survey in New Jersey found an average, daily backlog of 237 patients, a waste of $35,500 a day, or $13 million a year. There are several alternatives for alleviating this situation. Physicians should begin to plan for a patient's discharge from the day of entry and notify hospital social service departments, and hospitals should work more closely with nursing homes. Some hospitals have converted entire floors to sections for long-term care, but results are mixed. Another approach is the swing-bed concept which permits hospitals to designate any bed for either acute care or skilled nursing care as the need arises. Experimental use of swing beds began in Utah 1973 and later
1-201
was established in Texas, South Dakota, and Iowa. Besides relieving pressure of backlogged patients, swing beds allov¢ rural hospitals to increase occupancy and hence reduce costs. However, acute hospitals-care usually have no communal dining :rooms and only limited facilities for physical therapy, rehabilitation programs, and other activities common to well-run nursing homes. The proper matching of patient and bed in a triage or channeling system is another approach now being tested. It involves either preadmission screening and evaluation of nursing home applicants to match needs and services or the coordination
nent question is; whether capital expenditure controls _'_fl depress the costs of health care. Twenty-two foot note_ arc pJovided. (Author summary modified)
Descriptor(s): Cost containment ance (NHI), Inpatient facilities.
efforts, National
health insur-
_f at-home care for the elderly as an alternative to nursing homes. The "cash assistance program" encourages famihes to ,zare for elderly relatives at home, and the foster home plaz_ puts
445. Hospital
the elderly into private homes with payment for _hrough the cash assistance program. More realistic ment levels, a drastic change in the functioning ihomes, and a national policy for long-term care are effectively combat the patient backlog. Specific foster grams are described, and photographs are provided.
Harris (Louis) and Associates, Inc., New York, NY 10111 Hospital Affiliates International, Inc., Nashville, TN. Apr 1978, 108 pp. Availability: Hospital Affiliates International, Inc., Nashville, TN 37205.
their care reimburseof' nursing required to home pro-
Descriptor(s): Home health services, Intermediate care facilities, iong term care facilities, Supply/availability of services, Inpa:dent facilities, Publicly sponsored/mandated health plans,
444. Hospital Capital Expenditure and Expected Results.
Jeffrey E. Jarrett. [979, 7 pp. .4 vailability: University p20-26 Sep 79.
Controls. Their D_ired
of Michigan
Business Review v32 n5
A likely result of national health insurance legislation is that health finan,zing will be closely related to health planning. Coupied with this description of the rationale for hospital capital expenditure controls is a study of several models of hospital behavior to find the expected changes in the prices and costs of health care services controls. the Although capital expenditure controls associated are designedwith to diminish rise in the cost of inpatient
care, the models indicate
that such controls
will
z_ctually incxease the price of inpatient care, increase physician income, and tend to induce the substitution of outpatient for inpatient care. Hence, additional beneficiaries of capital expenditure controls are the providers of less expensive ambulatory care. Future empirical research measuring the effectiveness of cost containment legislation should study the relationship between such controls and medical care costs. Merely relating such controls with the magnitude of hospital capital investment will not determine the effectiveness of such legislation. Indeed, the perti-
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Care in America.
This survey tapped public opinions, attitudes, and concerns about hospital care and possible national health plans. The study assessed satisfaction with _che hospital experience and determined acceptable health service tradeoffs in the face of cost containment efforts. Personal interviews were conducted in February and March of 1978 with a national cross section of 1,503 adults aged 18 and over. In addition, representative samplings of leadership groups for doctors, hospital administrators, hospital trustees, health insurance company executives, and congressmen serving on health-related committees were interviewed. Results indicate that health care providers are widely respected, but the public is nevertheless concerned about the costs and availability of health care. Although the public does believe that hospital costs are too high, it wants more money to be spent at the expense of welfare and defense. Furthermore, the public believes that the health care system is out of control and needs changing, but it does not want complete Government control. Majorities of the public and all the leadership groups, including 75 percent of the Congressional samph:, oppose a Federal cap on hospital revenues. The public also opposses reducing numbers of hospital beds in communities, supports use of more paramedics and trained doctors' assistants, and favors the present insurance system alone or with some modification. The five leadership groups expect hospitals will continue to buy more sophisticated equipment, drawing on improved technology and computers; they also expect to see an increase in outpatient facilities and ambulatory care and a slowdown in the building of new hospitals. The appendix provided gives details of the sample design and methodology; survey data are presented.
Descriptor(s): Characteristics of U.S. health care system, Health care costs, Hospital services, Inpatient facilities, Policy/changes re health care, Providers of health care services.
Health Care Programs
446. Hospital George
Collective
Bargaining.
Structure and Process.
Availability: Printed for the use of the Committee and Human Resources.
on Labor
W. Bohlander.
1980, 21 pp. Availability: Employee mer 1980.
Relations Law Jnl. v6 nl p41-61 Sum-
Based primarily on interviews with labor and management negotiators in voluntary hospitals in New York State, this paper discusses the role of third-party payers and State regulatory agencies in labor management negotiations. The following economic features strongly influenced bargaining in the hospitals studied: the predominent position of private insurers, medicaid, and medicare in generating hospital revenues; a reimbursement system which is based on costs rather than a standard rate; a high labor-cost ratio; and pressures for cost control which frequently center on labor expenses. This study tested the proposition that bargaining in voluntary hospitals is a multilateral process because of the informal power exercised by third party payers based on their abilities to regulate hospital revenues. New York State was selected because it has an agqressive union movement and was the first State to enact restraints on inflationary health care costs. A total of 42 labor and management spokesmen for all bargaining units were interviewed in 15 hospitals representing a variety of sizes, locations, and organizational arrangements. All bargaining parties recognized the pervasive influence of third party payers and identified the upward adjustment of luted reimbursement rates as a focal point of negotiations. An analysis of negotiating strategies details how the reimbursement attitude of third party payers affects the wage bargaining tactics of both management and labor. The impact of third party payers is graphically illustrated in the 1976 hospital negotiations in New York, which resulted in wage increased below former years and below settlements reached nationally. Payer representatives refused to participate in these negotiations, but exerted their influence through public pronouncements. The political aspects of hospital labor relations are examined, as are the implications of New York's experiences for other States. State and Federal efforts to control health costs, combined with growing hospital unionization, will encourage increased multilaterial Twenty footnotes are provided, Descriptor(s):
Impact of third-party
ties, Cost containment
coverage,
efforts, Providers
bargaining.
Inpatient
facili-
of health care services,
447. Hospital Cost Containment Act of 1979. Committee on Labor and Human Resources, CLI.S. Senate) Subcommittee on Health and Scientific Research, Washington, DC 20515 1979, 817 pp.
This document contains the proceedings from the Senate subcommittee hearing on Senate Bill 570, the Hospital Cost Containment Act of 1979. This legislation proposes to e,stablish voluntary limits on the annual increases in total hospital expenses and to provide for mandatory limits on the annual increases in hospital inpatient revenues to the extent that voluntary limits are not effective. Views of both the advocates and opponents of the legislation are included. Testimony of representatives from government agencies, the administration, State governments, organizations of both health care providers and insurers, and hospital associations is given. A transcript of the public debate on hospital cost containment is also included. Participants were from the Department of Health, Education, and Welfare; academic institutions; the Federation of American Hospitals; the Federal Trade Commission; and the subcommittee on Health and Scientific Research. Related materials and statements and tabular data are appended.
Descriptor(s): Health care costs, Hospital services, Present legislation/regulations, Policy initiatives, Cost containmenlL efforts.
448. Hospital Cost Containment Programs. A Policy Analysis.
Edward F. X. Hughes, David P. Baron, David A. Dittman, Bernard S. Friedman and Beaufort B. Longest. Northwestern Univ., Center for Health Services and Policy Research, Evanston, IL 60201 1978, 153 pp. Availability: Ballinger Publishing Company, Cambridge, MA 02138. This study evaluates two pending health care cost containment proposals: the Carter administration's Hospital Cost Containment Act of 1977 and Senator Talmadge's Medicare-Medicaid Administration Reform Act. Based on an assessment of these proposals, a hospital cost containment program is recommended which would supplement the limits of these bills and expand their strengths. The proposal det'mes both short-term and longterm objectives for creating an effective cost containment program, including the long-term resolution of the fundamental causes of the hospital cost inflation problem. The recommendations recognize the complexity and magnitude of the problems of health care inflation and incorporate a critical examination of current mechanisms and procedures which have been applied in an attempt to stem the rate of inflation. Since the primary dimen-
1-203
sions of the hospital cost inflation problem are the rapid increase in service intensity, inefficiency at the industry level, and the inability and/or unwillingness of providers to make explicit costqualifying tradeoffs, the recommended program is designed to induce both hospital decisionmakers and local and State plannets to focus on these problems. It incorporates national controls on both revenue and capital expenditures as well as constraints under which deeisionmakers are to exercise their judgment and authority. These two forms of control are to be parallel in design and in administration so that more effective planning can take place. The parallel between the revenue limitation and the capital expenditure control features of the proposed program would permit coordination at the local level, so that authorized capital
the third section, articles report hospital experiences with the Economic Stabilization Program, hospital rate setting, prospcctive reimbursement systems, a State cost control commission, certificate-of-need legislation, and professional standards review organizations. Essays addr,_sing methodological issues of hospital cost containment analyze the techniques of cost measurement, marginal cost estimates, and cost function analyses. The topics outlining future needs discuss the research requirements of policymaking and the policy coordination required, given the choice of policy alternatives and combinations. Individual chapters contain tabular data, footnotes, and references. An index is also supplied.
expenditures for expanded services be matched by allowedin increases in revenue to cover the could operating costs incurred using those services. Tabular data, chapter notes, and art index are supplied. The appendix contains the American Hospital Association Index of Hospital Input Prices (1974 to 1975), a policy analysis of the expanded Talmadge Proposal, and the Rogers and Rostenkowski Amendments to HR 6567. (Author abstract modified)
Published for the Milbank Memorial Fund in cooperation the National Center for Health Services Research.
Originally submitted in a national competition to the N_tionM Center for Health Services Research, July L 197Z Descdptor(s): Policy initiatives, Economic/commercial ences, Inpatient facilities, Cost containment efforts.
with
Descriptor(s).. Health care cost trends/projections, Cost/benefit analyses, Cost containment efforts, Medical technology impacts, Present legislation/regnlations, Voluntary initiatives, Policy initiatives, Outcome/evaluation of quality assurance, Outcome/ evaluation of health administration, Comparisons regarding foreign health policies, Inpat:tent facilities, Physicians, payment determination.
Methods of
influ450. Hospital Cost Control in Maryland. Nell Solomon and Harold A. Cohen.
449. Hospital Policy.
Cost Containment.
Selected Notes for Future
Michael Zubkoff, Ira E. Raskin and Ruth S. Hanft. 1978, 656 pp. Availability: Prodist, Div. of Neale Watson Academic cations, Inc., New York, NY 10010.
Availability:
Forum v2 n5 p12-19 1978.
The structure, responsibilit:ies, and accomplishments of the State of Maryland's Health Service Cost Review Commission are Publi-
This volume on hospital cost containment divides the subject into five sections: an overview of perspectives and chapters on decisionmaking at the institutional level; Federal, State, and local experiences; methodological issues in cost containment procedures; and future outlooks. Articles within each section are authored by recognized experts. The overview is comprised of essays that consider cost containment from the viewpoints of national health policy, international comparisons, the American Hospital Association, consumer interests, and the administra.tion's most recent legislative proposals. Institutional decision.making focuses on physician involvement in hospital decisionmaking, the administrator's role in cost containment, and the relationship of medical technology to hospital costs. In
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1978, 8 pp.
highlighted. The commission is composed of seven persons appointed by the Governor for 4-year terms. Members can succeed themselves once, and only three members can be associated with a hospital or related institution. Members work with a full-time staff of 27, attend meetings twice each month, and are allowed an annual budget of about $600,000. The commission has two responsibilities. The first is to ensure that the financial condition of Maryland hospitals is open to public inspection. To accomplish this, the commission publishes annual reports and maintains open files. The seconcl responsibility is to review hospital rates to ensure that a hospital's costs are reasonably related to its services, that a hospital's, aggregate rates are reasonably related to its aggregate costs, ancl that no undue discrimination exists between purchasers and chLsses of purchasers. The commission was the first among State or Federal agencies to e_tablish both a planning agency and an appropriateness _,:,qew ,_gency prior to a Federal statute. Once the commission approves a hospital's
Health Care Prog_amb
budget, the commission will increase it without a public hearing only because of inflation, price variances, changes in patient mix, changes in volume, changes in payer mix, or unusual costs. The organization emphasizes that the major cost problems of hospitals are excessive use, unnecessary tests, unnecessary services, and unnecessary lengths of stay. Largely as a result of commission efforts, costs per admission in Maryland rose 8.6 percent in 1977 compared to the national average of 13.9 percent. Only two other jurisdictions had a lower rate of escalation during that
tlined above. Hospital cost-containment considerations include both voluntary and regulatory controls. The regulation of insurance companies may be the major cost-containment factor. The insurance regulators in all States have been willing to limit premium hikes, and these constraints have been passed on to the hospitals by the insurance intermediaries in the form of tighter controls on payments. Tabular data and 27 references are appended. (Author abstract modified)
period.
Descriptor(s): Supply/availability of services, Impact of thirdparty coverage, Deductible/coiusurance, Reimbursement, Source of premium payment, Outcome/evaluation of health administration, Competition/interaction among third-party payors, Hospital services.
Four tables are included.
Descriptor(s): Cost containment efforts, Funding/financing of health care programs, regulations, Inpatient facilities,
Hospital services, Present legislation/
451. Hospital Cost Inflation and Health Insurance. A Cornplex Market Model.
452. Hospital Inflation. A Diagnosis Laurence
Philip Jacobs, Alan D. Banerschmidt and Richard W. Furst. 1978, 8 pp. Availability: Inquiry v15 n3 p217-224 Sep 78.
This paper presents an analysis of a complex hospital care market which incorporates the behavior of the various groups in the system, including the market mechanism, consumers as insurees, the doctor and the consumer-patient, hospitals, and the nonprofit intermediaries. To apply this hypothetical model of an endless inflationary spiral to real market conditions, the paper examines the effects of competition among insurance intermediaries and the introduction of government financing programs such as medicare and medicaid. Competition among insurees, when hospitalization costs are given, will amount to fuller coverage and lower administrative expenses. For example, the recent trend in hospital insurance has beech toward more full-service contracts and wider coverage and lower administrative expenses and profits. Medicare and medicaid contribute to cost inflation by underreimbursing the hospitals, leaving them to recover losses by increasing prices to self-paying patients and increasing reimbursment from private insurance companies. The effect of this dual pricing system might be to reduce demand of uninsured populations; however, as shown previously, it instead encourages additional insurance coverage as a protection against the increased expected loss. In addition, the favorable tax treatment given to employers who deduct premiums as business expenses lowers the premium cost, which employers consider as compensation. The employee thus receives insurance coverage at a lower premium rate which acts as an inducement to obtain insurance, Alternative self-care routes, and an increase in cost-sharing arrangements might contain the cost/pass-through mechanism ou-
and Prescription.
S. Seidman.
1979, 7 pp. Availabib'ty:
Challenge
v22 n3 p17-23 Jul/Aug
79.
The Kennedy health insurance plan virtually eliminates patient cost sharing for all medical care, placing the entire responsibility for efficiency on government regulation. The regulator in the medical situation, unlike the regulator in the marketplace, must try to contain the cost of a free service rather than try to prevent monopoly prices for a paid service. Anymarket will fail ifa third party pays virtually 100 percent of the costs for consumers. Concern for equity does not prohibit consumer cost sharhlg, that is, the payment of a fraction of the hospital bill by the patient. Cost sharing could be administered through a medical tax credit schedule on the 1040 income tax return. The househotd's deductible, coiusurance rate, and ceiling could vary according to income and could apply equally to all medical care, including outpatient, office, and home care, now often excluded from current insurance coverage. Cost sharing in this manner would increase as the household's income increased, unlike the present medical deduction which goes up as the income goes up. Eligibility would not depend upon whether an itemized return were submitted, and households with low income could file the return solely to obtain the medical tax credit. However, the success of this system depends upon several conditions. First, households must have access to medical loans until tax returns are filed and processed. After the tax return is processed, the Internal Revehue Service (IRS) would use the tax credit to repay the lender, who would then bill the patient for the remainder. Secondly, current tax subsidies in the form of payroll premium contributions should end. The IRS would base its credit solely on the household's out-of-pocket expenses, ignoring private insurance
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payments. This would prevent the purchase of private insurance to avoid cost sharing. Private insurers could shift their business to the administration of medical loans. Under a medical tax credit plan such as this, each household would be free to select the medical provider it preferred, allowing fair competition between HMOs and fee-for-service providers. For the first time, the incentive for consumer cost consciousness would be cornbined with confidentiality and access to needed medical care without financial hardship, Descriptor(s):
Plan design/program
provisions
(under
health
plans), Funding/financing of health care programs, Policy initiatives, Economic/commercial influences.
453. Hospital
Production.
Charles E. Anderson. 1979, 5 pp. AvailabHity: American May 79.
Descriptor(s): Cost containment efforts, Inpatient facilities, Methods of payment determination, Policy initiatives, Outcome/evaluation of quality assurance, Competition/interaction among third-party payor,...
Can Costs Be Contained.
454. Hospital Rate Setting. This Way to Salvation. Economic
Review v69 n2 p293.-297
The cost and output effects of two types of regulatory sU_actures imposed on hospitals are discussed. One system, referred to as a limited competition hospital industry, moderates industry cost levels by reimbursing hospitals on the basis of average industry costs and the classification of firms. Consequent production arid investment decisions are determined by market forces. The second system, referred to as a fully planned hospital industry, modex ates industry cost levels according to guidelines specified by need and community preference criteria. In this arrangement, oligopolistic firms deliver medical care in a system largely shaped by the joint decisions of the medical care professions and planning agencies, rather than wholly by market forces. The policy instruments at the disposal of planning agencies in this framework are rate-setting and certificate-of-need review procedures. Neither of these systems fully satisfies the social demands for a hospital industry that moderates hospital costs while delivering acceptable services. A limited competition industry permits increasing hospital costs in the long term and in spite of reimbursement constraints, if administrators expand expenditures to the levels of reimbursement schedules without significantly increasing output or if physicians perceive hospital resources as zero-priced inputs. Fully planned hospital industries fail in that they virtually negate market forces. The requirement of joint agreement among health authorities and planning agencies regarding industry expansion and control severely limits the effective market decisions of administrators. Appropriate modifications of either of these systems should allow markets to play a viable role in determining socially acceptable ranges of
1-200
prices and costs for hospital services. Bestowing project veto powers on planning bodies in the limited competition industry would curtail inappropri_,te administration and provide incenfives for stronger cooperation between physicians and administrators. Deemphasizing need criteria and centralizing planning activities in the fully planned hospital industry would return discretionary powers to hospital administrators in investment matters while maintaining physician interest in efficient hospital management. Graphic data and seven references are provided. (Author abstract modified)
Katharine G. Bauer. 1977, 42 pp. A vailability: Milbank Memorial Fund Quarterly/Health Society v55 nl p117-158 Winter 1977.
and
This paper explores the nature of rate-setting and the impetus behind the movement, State and regional experiences with the practice, and major issues that implementation has raised. Hospital rate-setting is a ne_ type of regulatory activity which is rapidly spreading in the United States. Between 1970 and 1975 the number of rate-setting programs grew from 2 to 27. Most of these programs are administered by Blue Cross plans or State governments; the FederalGovernment'sinvolvement in hospital rate-setting has been minimal. The current trend toward prospeetive rate-setting rests on the premise that a major reason for the recent rise in hospital costs was the adoption by medicare and medicaid of retroactive cost-based reimbursement. Hospital leadership saw rate-setting as a possible answer to the problem of cost shifting by major £hird party payers. Proponents of ratesetting, including Blue Cross, insurance commissioners, taxpayers, State governments, and hospitals, often had different expecrations of what rate-setting programs should accomplish. These diverse objectives involved curbing the rate of increase in the unit price of services, curbing the rate of increase in overall expenditures for hospitalization, and curbing the shifts of legitimate hospital costs from one type of payer to another. However, the methods employed to accomplish any one of these objectives can well block attainment of the others. In general, State and regional experience during the 1970's indicates that hospital rate-setring is an ineffective cosl containment technique. Most State rate-setting executives feel severely limited by budget con-
Health
Care Programs
straints. Moreover, even though State legislatures grant formal authority to rate-setting bodies, political constraints exist on the amount of power these bodies can actually exercise. Other problems arise with regard to specific cost containment objectives, methods of determining rates, budget reviews, and interhospital comparisons. Although rate-setting programs appear to be learning from their initial experiences and are continually improving their methodologies, expectations of cost containment through rate-setting should be modest. Federal policymakers were wise not to have prematurely accepted this route to cost containment. Several tables, 7 footnotes, and 50 references are provided. Descriptor(s): Cost containment efforts, Inpatient facilities, Methods of payment determination, Present legislation/regulations.
rate review, the Indiana system of hospital cost tztmttoi i_ described. Under this system of controlled charges, ho_pit,ds are allowed to set rates correlated with reasonable costs in terms of individual institutional needs. An overall view of prospective rates is presented in the concluding discussion.
Edited Proceedings of the March 2L 1978 Seminar, Regulation through State Rate Review.
Hospital
Descriptor(s): Cost containment efforts, Inpatient fhcilities, Methods of payment determination, Present legislation/regulations, Competition/interaction among third-party payors.
456. Hospital Reimbursement by Diagnosis Related Groups. Preliminary Bibliography. 455. Hospital Regulation Through State Rate Review. Mandated Interference or a Noble Intrusion.
Alton Ochsner Medical Foundation, New Orleans, LA. Louisiana Hospital Association, New Orleans, LA. 1978, 105 pp. Availability: Teachem, Inc., Chicago, IL 60611.
Papers dealing with the pros and cons of hospital regulation through State rate review are presented. Factors influencing the consideration or adoption of State rate review for hospitals are discussed in the opening presentation, followed by an analysis of the New York State experience in hospital rate review from the regulator's perspective. New York has a prospective reimbursement system, which is acknowledged to be a short-term effort to constrain the cost of hospital services. Another paper considers the New York experience from the hospital's viewpoint. This address concludes that the reimbursement system for an industry such as hospitals cannot cap income at group average levels over the tong-term. The work of Maryland's Health Services Cost Review Commission is assessed in another paper. Under the Maryland system, all payers pay all covered hospitals on the basis of commission-approved prospective rates. A consequence of the commission system is believed to be Maryland's ability to keep its rise in hospital costs below the national average. The cooperation between the commission, hospitals, and third-party payers in helping to make the system work is described in another paper. The American Hospital Association's position on hospital rate regulation is presented in one of the addresses. Recognizing that some form of regulation at the Federal and State levels is inevitable, The American Hospital Association presents guidelines for such legislation. Following the presentation of a panel discussion of hospital regulation through State
Health Research and Educational Trust of New Jersey, Princeton, NJ 08540 Jul 1980, 9 pp. A vnilability: Health Research and Educational Trust of New Jersey, Princeton, NJ 08540.
This bibliography includes approximately 1130entries which deal with issues relating to hospital reimbursement for medical services. It was prepared as a part of an overall evaluation of the Diagnosis Related Group based hospital reimbursement program being conducted by the Health Research and Educational Trust of New Jersey. Entries date primarily from the mid- 1970's through 1980. The majority of the works are articles published in professional journals, such as "Inquiry," "The Journal of Law and Economics," and "Medical Record News." The works are arranged in alphabetical order according to the author's last name. Author, title, publication source, volume number, date, and page numbers are specified.
Descriptor(s): Hospital payment determination.
services,
457. Hospital Serf-Insurance Benefits.
Reimbursement,
Program.
Douglas D. Gregory. 1979, 11 pp. Availability: Health Care Management Spring 1979.
Methods
of
Employee Medical
Review v4 n2 p15-25
1-2(_/
Methods used by the Henry Ford Hospital in Detroit, Mich., to analyze the benefits and disadvantages of a self-insurance plan are detailed. The type of plan discussed is an Administrattve Services Only contract, in which the claims processing service of a private insurance carrier are leased for external claims only. Advantages of self-insurance are outlined, such as cost savings in several areas; flexibility to vary copayments, deductibles, and benefits; and prompt reimbursement ofclaims. Problems include unwillingness of other health care providers to accept the hospital's insurance card, high claims processing costs if sophisticated systems are not used, and short-term claims risks incurred by the hospital. A cost model is described which can predict the cost of basic self-insurance from past claims data on major medical, prescription drug, and dental costs. The following key variables are identified as factors in the costs of self-insured employee health benefits: average percent of medical charges reimbursed by the claims processor, average percent of medical charges reimbursed, and the average percent of medical and hospital charges incurred for internal services provided by the hospital, Even if a self-insurance plan seems less costly, a hospital should weigh sensitivities and risks before making a decision, The sensitivities of self-insurance cost to medical reimbursement rates and internal claims processing costs are analyzed to demonstrate these procedures. Methods to analyze risk during the first year of self-insurance when employee use and claims costs are uncertain are presented. Insurers' responses to a high use year are also considered. The costs of employee health care could probably be reduced significantly by hospitals joining together in a cooperative self-insurance program. The Henry Ford Hospital did not adopt a self-insurance program, but its assessment helped the administration to challenge the traditional insurer and bargain for competitive rates. Graphs, tabular data, and 11 references are included.
Descriptor(s): underwriting,
Cost/benefit analyses, Claims administration.
Premium
determination/
based physicians are includeA. The primary data source was physician surveys sponsored by the Health Care Financing Administration in 1977 and 1978. Findings support past research showing that radiology is the most lucrative HBP specialty, followed by pathology and anesthesiology; hospital-based practice tends to be considerably more lucrative than office-based practice. The future of HBP's vis-a-vis regulatory activities and other exogenous influences is uncertain, but some further changes seem imminent. In particular, passage of the Talmadge bill or similar legislation may mean the end of percentage forms of compensation. Such legislation would not make percentage compensation illegal but would probably remove most of its remaining advantages, pushing even more HBP's into fee-forservice or salaried compensation. To the extent that some HBP's and hospitals have been influenced to switch from percentage to fee-for-service arrangements, the transaction costs of billing and collecting for HBP department services have probably increased. However, the greater ease in monitoring HBP service charges and use which accompanies the change in compensation arrangements may be sufficient to justify the added costs. Tabular data, footnotes, and 43 references are provided.
Descriptor(s):
Health care costs, Inpatient
Policy initiatives.
459. Hospital-Based Costs.
Versus Free-Standing
Primary Care
Marsha Gold. Bureau of Health Planning and Resources Development, Hyattsville, MD. National Center for Health ',Services Research, Hyattsville, MD. 1978, 20 pp. Availability: Ambulatory 79.
458. Hospital-Based
facilities, Physicians,
Care Management
v2 nl pl-20 Feb
Physicians. Current Issues and Descrip-
tive Evidence.
According to the literature, primary care delivered in the traditionai outpatient department will be more expenisve than that
Bruce Steinwald.
provided in the free-standing setting. Although hospitals are becoming increasingly involved in the delivery of primary care, few articles provide data on the actual costs per outpatient visit.
1980, 13 pp. Health Care Financing Review v2 n l p63-75 Availability: Summer 1980.
Issues and trends concerning hospital-based physicians (HBP's) are discussed, and evidence is presented on practice characteristics, compensation methods, and incomes of anesthesiologists, pathologists, and radiologists; some comparisons with office-
1-208
At present, cost figures on hospital-based primary care come almost exclusively from third party reports, reports which often lump teaching programs, social services, and autopsy costs into outpatient costs. Until measurements of costs and the influence of setting on primary care can be clarified, the problems of evaluation are likely to remain unsolved. Costs, while important, represent only one consideration in determining how much to
Health Care Programs
develop or extend hospital-based primary care. Other issues such as access, consumer preference, provider preference, training requirements, and quality of care are also important factors, Hospital-based primary care probably treats a sicker group of patients than do free-standing care units, yet the effect of case mix differences on costs is rarely considered in the literature, Furthermore, research treats both hospital-based and free-standing primary care settings as internally homogeneous even though these forms vary widely in organization. These mixtures of costs in research design make it difficult to demonstrate that improved management and reorganization reduces outpatient costs. There is a general lack of evidence that lower costs will result from
cies and inconsistencies in the group practice literature itself. Although little empirical evidence exists which critically assesses the group practice ambulatory care hospital setting, the literature provides some insight into the conceptual issues involved and into the experience of specific hospitals. The review of literature is organized as follows: hospital-sponsored group practice development and operations, including hospital goals and community needs, group practice operational design issues, patient care services and systems, f'mancing of hospital-sponsored ambulatory care, and results of group practice in the hospital; and broader group practice literature, covering such issues as attracting patients, physician recruitment, economic and other consid-
larger sized practices. The available literature provides sufficient justification for concern about the influence of hospital setting on the intensity of care delivered, although intensity of care and quality of care are not necessarily associated. One table and 84 references are provided.
erations, and prepaid group practice. Two tables, showing issues discussed in the hospital-sponsored group practice literature and an agenda for further research, and 116 references are provided.
Descriptor(s): ic/commercial
Outpatient facilities, Inpatient facilities, Econominfluences.
460. Hospital-Sponsored Primary Care Group Practices. A Developing Modality of Care.
Stephen J. Williams, Stephen M. Shortell, William L. Dowling and Nicole Urban. Robert Wood Johnson Foundation, Princeton, NJ. 1978, 12 pp. Availability: Health and Medical Care Services Review vl n5/6 pl,3-13 Sep/Dec 78.
The past 25 years has seen a dramatic increase in the role of hospitals in ambulatory care; this paper reviews the literature on hospital-sponsored medical group practices which have developed in response to this demand. Many traditional hospital groups have provided specialized services, but the development of primary care groups is now a rapidly growing modality. This review has been directed primarily toward the literature that addresses hospital-sponsored group practice directly and consists almost entirely of reports from individual facilities concerning their efforts and discussions of the problems involved in establishing such groups. Furthermore, the literature on group practice is primarily directed to fee-for-service groups independent of the hospital, with some on group practice prepaid plans, There are notable differences in the hospital versus nonhospital settings, including sponsorship, physician reimbursement, and issues of competition. The extent to which the general group practice literature is transferrable to the hospital setting remains largely to be determined, besides the fact that there are deficien-
Descriptor(s): Demand/utilization of health care programs, Supply/availability of services, Outpatient facilities, Evaluations/outeome of health care programs.
461. Household Health Interviews and Minority Health. The NCHS Perspective.
Dorothy P. Rice, Thomas F. Drury and Robert H. Mugge. 1979, 9 pp. Availability: Medical Care v18 n3 p327-335 Mar 80.
Responding to a paper by Salber and Beza on the iml:dications of the Health Interview Survey (HIS) on the usefidness of minority health statistics, this article contends that a comprehensive information system on minority health needs special national and local surveys. As part of its Civil Rights Implementation Plan, the National Center for Health Statistics (2qCHS) has tried to develop statistical programs that collect data on minorities and are more accessible to minority users. Salber and Beza criticized the Center's HIS program as being biased against minorities because of wordings of questions, surveying methods, and sample design. Other areas of concern were variations in interpretations of illness among minorities and the small number of minority cases in the HIS sample. Methods to evaiuate the effects of cultural bias in the HIS are suggested, such as comparing it with the Health and Nutrition Examination Survey and combining several years of data. However, much useful information for policy decisions, planning, and evaluations would require special national surveys of selected populations as well as in-depth studies of minorities in their social contexts. For exampie, NCHS is planning a survey among Hispanics and is cooperating with the National Medical Care Utilization and Expenditure Survey to develop a data base on recipients of medi-
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caid. NCHS is also involved in promoting the development of local health statistics through the Cooperative Health Statistics System. Special surveys still have to overcome problems faced by national surveys in identifying minorities and creating instruments which accurately measure their health problems. A table and 52 references are provided,
studies, serving on provider and insurer boards, and supporting efforts to improve the effectiveness of health care delivery. Tabular data, 76 references, and lists of HSA's by location, capital expenditure controls by State, and status of hospital rate review programs by State are appended. A guide to selected references and resources is also provided. (Author abstract modified)
Also See "'Health Interview
National Health Care Strategy Series.
Survey and Minority
Desc_qptor(s): Health information/data features of population,
Health. "
systems, Demographic
462. How Business Can Improve Health Planning and Regulation. Linda K. Stokes and John C. Rosala. InterStudy, Excelsior, MN 55331 National Chamber Foundation, Washington, 1978, 48 pp. Availability" National Chamber Foundation, 20062.
DC. Washington,
DC
In addition to working toward better contained costs within their own benefits programs, businesses can help control overall health care costs by involvement in public or private health planning and regulation. Regulations such as employment-related laws, tax laws, and laws protecting public safety and health affect the health care sector just as they do any corporate entity, However, the health care industry must also comply with additional specific health care regulations, such as Federal and State drug laws and licensure, accreditation, and medical practice acts. These regulations often add substantially to costs. Cost-oriented health regulations include capital expenditure reviews, utilization reviews, and reimbursement controls. Due to their uncoordinated introduction and implementation, these measures have yet to demonstrate their overall cost-effectiveness. As the planning and regulation processes evolve they can facilitate the development and operation of a competitive health care system, create a heavily regulated public health care utility, or combine elements of both approaches. To become involved in health planning, business should first identify the status of current and pending health planning and regulations; consider the extent of their current involvement in both public and private sector efforts; and determine whether new or additional initiatives would be appropriate and beneficial. Participation in public health planning agencies, such as Health Systems Agencies (HSA's) at the local level, in statewide Health Coordinating Councils, and in legislative debates over future health care system regulation is important. Private health planning activities involve initiating
1-21 _
Descriptor(s): Cost containment efforts, Competition/interaction among third-party pay0rs, Voluntary initiatives, Source of premium payment.
463. How Business Can Promote Good Health for Employees and Their Families.
Keith W. Sehnert and John K. Tillotson. InterStudy, Excelsior, MN 55331 National Chamber Foundation, Washington, 1978, 38 pp. Availability: National Chamber Foundation, 20062.
DC. Washington,
DC
Health promotion is gaining in popularity due to rapidly rising health care costs and to cortcern that health status in general is not improving. The health promotion programs that business might undertake focus on educating consumers to adopt more healthful lifestyles and to become more prudent buyers of health care services. Business must make two major perceptual and economic shifts: from a passive role in health care involvement and from support of expensive treatment-oriented programs. Establishment of an adequate company health data base may be the first step in conducting a meaningful evaluation of health promotion programs. These programs can be developed using in-house professional personnel, outside consultants, or a combination of both. Efforts will be enhanced by considering the roles of insurers, government, physicians, hospitals, and health maintenance organizations and other alternative delivery services. Among the programs are physical fitness, smoking cessation, alcohol/chemical abuse, nutrition and weight control, medical self-care, and stress management. A firm can select appropriate health promotion programs based on an assessment of the needs and capabilities of the company, the employees, and the community. Expectations for such programs should be realistic; evaluating them can be difficult. Two evaluation parameters can help measure effectiveness: outcome measures, which may give an indication of program success but are difficult to quantify; and cost-benefit measures, which can be converted more readily into dollar amounts. Often these measures will
Health Care Pl-o_r.,Jtis
reflect the effectiveness of a company's total health promotion package; an individual program's contribution may be difficult, if not impossible, to determine. Selected case reports of corporate health promotion programs, 56 footnotes, 20 references, and a list of 8 resources are appended. Tabular data are provided,
National Health
Care Strategy Series.
Descriptor(s): Cost containment efforts, Prepaid plans, Voluntary initiatives, Competition/interaction among third-party payOrs.
National
Health
Desclqptor(s):
Care Strategy Series. Cost containment
efforts, Preventive
services,
Voluntary initiatives, Impact of third-party coverage.
464. How Business Can Stimulate a System.
CompetitiveHealth
Gerald B. Meier and Mary M. Hunter. InterStudy, Excelsior, MN 55331 National Chamber Foundation, Washington, 1978, 46 pp. Availability: National Chamber Foundation,
465. How Business Can Use Specific Techniques to Control Health Care Costs.
Care
1978, 31 pp. A vailability: National Chamber Foundation, 20062.
DC. Washington,
John K. Tillotson and John C. Rosala. InterStudy, Excelsior, MN 55331 National Chamber Foundation, Washington,
DC
20062. This analysis discusses how business can stimulate competition to produce long-term cost containment in the health care system, The proliferation of alternative health care delivery systems (ADS's) can create the needed competition. Although many types of ADS's could effectively contain costs and stimulate competition, most ADS's are health maintenance organizations (HMO's). Successful HMO operation depends on responsible physician involvement in the total HMO operation, including its financing. HMO's and other ADS's contain costs by substituting less expensive modes of care (office visits) for the more expensive (hospitalization) wherever possible; prevention as well as treatment is stressed. Since HMO's rely less on costly, rapidly inflating care, their premiums tend to rise more slowly than traditional health insurance premiums. Competition for enrollees between ADS's and traditional health insurers and providers and among ADS's themselves can result in better controlled health care costs in an entire community. Businesses now pay a large proportion of total personal health care costs and are obligated under certain Federal and State laws to offer HMO's under certain conditions. Therefore, companies should support ADS's through employee and community education. Physicians, hospitals, insurers, and others should be encouraged to organize or expand ADS's. Management, marketing systems, and financial resources should be used to help new and developing ADS's succeed. Finally, a company should examine the feasibility of developing an ADS, either alone or in cooperation with other businesses. Tabular data, 66 footnotes, a list of currently operating HMO's (as of August, 1978), a review of HMO's and Federal and State governments, and selected references and resources are appended.
DC. Washington,
DC
Cost-containment programs fall into three categories. Lowering costs through administrative control involves claims review to identify health care costs a firm is not obligated to pay. Coordination of benefits and subrogation (the substitution of one creditor for another) eliminate duplicate claims payments. Serf-insurance, though not feasible for many fLrms, cam bring returns on dollars otherwise paid out as premiums. Broadening benefits to alter utilization of services involves alternative delivcry systems. Consumer cost-sharing through copayments and deductibles transfers a portion of risk and cost to employees to encourage more prudent use of health care services. Hospital utilization review, which can be performed before, during, or after hospitalization, is designed to encourage providers -- mainly by peer pressure -- to use the hospital efficiently. Second surgical opinion programs can potentially reduce the incidence of unnecessary elective surgery. Readmission testing programs may shorten hospital stays through outpatient, presurgical testing. For selected procedures, ambulatory surgery can be an alternative to inpatient surgery. Home health care, as either an addition or alternative to inpatient care for some types of rehabilitation or maintenance, can save hospital coslLs while providing a valuable service. Controlling charges requires volume purchasing of drugs and medical appliances (giasses, hearing aids, etc.); several types of health screening programs can be used to negotiate lower unit prices. Prenegotiated fees with physicians, though likely to meet with provider resistance, have obvious potential for controlling costs. Tabular data, 59 footnotes, examples of companies and unions using selected costcontainment mechanisms, and selected references and resources are appended.
National
Health Care Strategy
Se_qes.
1-211
Descriptor(s): Cost containment efforts, Diagnostic services, Deductible/coinsurance, Pharmaceutical services, Voluntary initiatives, Claims administration, Premium determination/underwriting, Medical/surgical services, Home health services.
National Health Care"Strategy Descriptor(s):
Cost containment
.5'elms efforts, Volu_t:try
i_,tiati_cs.
467. How Cheap is a Life. Daniel M. Berman. 466. How Business Interacts With the Health Care System_
Paul M. Ellwood, Walter McClure and John C. Rosala. InterStudy, Excelsior, MN 55331 National Chamber Foundation, Washington, DC. 1978, 36 pp. A vai!abih'ty: National Chamber Foundation, Washington, 20002.
1978, 21 pp. Availability: International Jnl. of Health Services v8 n! p7999 1978.
Business cost containment strategy is based on six key actions: reviewing the company situation, evaluating the community health care system, implementing cost-containment measures, introducing health promotion programs, and reorienting health planning and regulation. This report expands upon the first two elements and includes a special guide to health care for the smaller business. Several areas need to be explored when assessing a company's status: adequacy of information, utilization
This article on workmen",; compensation argues that the owners of capital in the United States have successfully transferred most of the costs of industrial casualties onto the working class and the public. Tills has beert accomplished by the creation of the privately owned worker's compensation insurance system and the corporate-dominated safety establishment. "rhis compensation-safety establishment has been able to take over most of the Federal apparatus created by the Occupational Safety and Health Act (OSHA) of 1970. The article argues that although millions of workers have benefitted from worker's compensation, particularly those with rcLedical expenses and acute, temporary disabilities, the system h_Lsbeen a failure for workers. Workers suffering permanent disability from "nonschedule" back, head, and multiple injuries, for which benefits can vary, have onJy a small part of their income losses replaced by worker's compensation. In addition, the worse the disability is, the smaller is the
rates, employee responsibility, and company costs. Adequate demographic data for the covered population should be maintained (including information on dependents), geographic distribution identified, and utilization experience determined, Cost-consciousness can be encouraged through cost-sharing, multiple choice benefit options, and health promotion programs,
proportion paid. In ma_y States, death benefits for workers' survivors total only two to four times the annual median wage. The afficle also discusses evidence that occupational disease is ignored by the compensation system and examines compensation's irrelevance to the betterment of working conditions. It also describes intermittent refbrm efforts made to reform the situa-
Health-related expenses should be calculated and used as the basis of cost projections. Community characteristics, such as
tion, including those made by the Carter administration to eliminate OSHA's enforcement function. Footnotes, 5 tables, and 101
population growth rate and composition, payment methods, and status of health care systems, should be considered. The conduct
references are given. (Author
of an evaluation of health promotion programs and alternative delivery systems (ADS) requires technical assistance from health
Descriptor(s): Workers ,:ompensation, Impact of third-party coverage, Plan design/program provisions (under health plans), Limitations on coverage, Exclusions from coverage.
DC
service agencies (HSA's) and others. These include local Blue Cross and Blue Shield plans and medical societies. Survey results may provide the basis for further action. Company strategy should involve cost-containment and the promotion of competition. For example, a firm might establish in-house medical programs for employees, offer ADS plans, and investigate corporate sponsorship of health maintenance organizations (HMO's) and other ADS. Healthful lifestyles and prudent use of health care services should be encouraged. Finally, a company can participate in pl,amiug and regulation through membership in planning forums and on policymaking boards. Tabular data, footnotes and selected references and resources are appended.
1-212
abstract
modified)
468. How Interested Groups Have Responded to a Proposal for Economic Competition in Health Services. Alain C. Enthoven. 1980, 7 pp. A vailability: American 15_zonomic Review v70 n2 p 142-148 May 80.
Health Cafc P__elam_
This paper provides a brief explanation of the Consumer Choice Health Plan, (CCHP) a proposal for comprehensive national health insurance based upon fair economic competition, and the reaction of various interest groups to elements of the plan. The interest groups discussed are organized labor, business, the medical profession, hospitals, the commercial health insurance industry, and Blue Cross-Blue Shield. Traditionally, labor has fought for comprehensive benefits Although it finds CCHP's proposals
469. How Much Can Business Expect to Earn From Smoking Cessation.
fo competition and incentive for efficiency unpalatable. Labor's Support for the Kennedy plan, however, indicates some moderation of past positions. Business has not held a comparably unified view. For the most part, employers generally approve of fair economic competition but have not applied these principles to their own purchases of health care services. Most employers still consider traditional insured fee-for-service health care the norm and feel that offering choices increases administrative work and interferes with insurance arrangements. How business will respond to procompetitive legislation is not yet known. The medical profession has historically opposed economic competition, although most doctors dislike the prospect of detailed bureaucratic controls even more than the prospect of economic competition, about which the American Medical Association's leadership and physicians in general are ambivalent. In contrast, hospital leaders have to some extent favored State rate regulation in the belief that they could dominate the regulatory agencies, Clearly, the hospital industry leaders recognize that the Government will be forced to control costs with either detailed Federal controls or true economic competition. The commercial health insurance industry is opposed to proposals to create economic competition in health services, although a few companies, most notably SAFECO, have developed health maintenance organizations. The industry generally favors public utility regulation of hospitals, endorses extension of controls, and views State regulation as an opportunity to secure equality among payers. Unlike the commercial insurance industry, Blue Cross-Blue Shield is participating in alternative delivery systems and preparing to succeed in a competitive system. No references are given,
This article aids companies in determining a rational policy in the area of employee smoking cessation by reviewing the costs of smoking to business. The data are aggregate and average and not individually predictive. A summary of the various costs of smoking figures, indicates that the average one-pack-plus per day smoker may, be costing the employer about $624 per year in extra expenses. Present studies indicate that more than half of these costs may, at least in part, be recaptured in the mediumrun to short-run by smoking cessation efforts at the work place. Insurance expenses, as influenced by smoking, depend on the coverages offered by the company to employees. Generally, the literature in regard to the health insurance costs associated with smoking is clear cut. Based on calculations of the incidence of neoplasms, circulatory diseases, and respitatory disorders, the adult smoker accounts for $204 of annual excess medical care costs as compared to nonsmokers. The indirect costs of morbidity and premature mortality, apart from insurable costs, average two times these direct medical costs. In addition, fire accident costs due to smoking average $10 per year per smoker. Costs to business for employee smoking include those incurred as a result of absenteeism. Smokers report a 33 to 45 percent rate of excess absenteeism as compared to nonsmokers. Direct productivity losses are caused by such factors as time lost due to smoking rituals, extra cleaning costs, damage to equipment and furniture, errors and inefficiency, and measured lower attentiveness. Taking all these aspects into consideration, potential short-nln benefits to the employer to support smoking cessation efforts may total $345 per year per quitter. Seven tables and 17 references are included in the paper.
Marvin M. Kristein. Nov 1980, 19 pp. A vMlability: American Health Foundation, Brook, NY 11790.
SUNY,
Stony
Presented at the National Interageney Council on Smoldng and Health's National Conference, "$moldng and the Workplace," January 9, 1980, New York, ArE. Paper presented at the Ninety-Second Annual M_ting of the American Economic Association in Atlanta, GA, December 2830, 1979.
Descriptor(s): Health insurance industry, Impact of third-party coverage, Policy initiatives, Prepaid plans, Commercial health insurance plans, Service benefit plans, Inpatient facilities, Inpatient facilities, Competition/interaction among third-party payors.
Descriptor(s): Trends in health status, Voluntary initiatives, Private health care plans, Cost containment efforts, Preventive services, Source of premium payment.
470. How Much Will U.S. Medicine Change in the Decade Ahead. Eli Ginzberg. 1978, 48 pp.
1-213
Availability: Oct 78.
Annals of Internal Medicine v89 n4 10441-588
Since 1965, health care services have been increasingly used by low-income families, largely as a consequence of infusion of more funds into the health care system. The number of persons employed in health care has gone up, along with an expanded governmental role. Present government concerns are focused on cost and the relation of pubfic attitudes toward a system of nation health insurance (NHI). In the near future, medical ser-
a year in advance; budget review and rate regulation; and experimental programs such as New Jersey's reimbursement on a caseby-case basis. Federal cost-containment programs include the Carter administration proposal to place a ceiling on hospital revenue increases, and the Talmadge plan which would limit reimbursements to any hospital to a total no more than 20 percent above the average. The article concludes that hospital revenues will continue to be controlled and hospital spending scrutinized for cost-effectiveness. Charts are included.
vices are not likely to be expanded, and various costly services may be contracted. The number of physicians will go up, but the fraction in solo practice will decline. Patterns of physician maldistribution are not likely to be changed substantially. Costs will continue to increase, and government and other third party payers will strive to control them. A comprehensive form of NHI
Descriptor(s): Cost containment efforts, Impact coverage, Inpatient facilities, Policy initiatives.
will not come soon, and the public will become increasingly aware of the limits to which health care can improve their lives. Footnotes and 25 references are provided. (Author abstract modified)
472. How to Improve Health and Contain Costs.
Descriptor(s): Health care cost trends/projections, Supply/ availability of services, National health insurance (NHI), Demand/utilization of health care programs,
InterStudy, Excelsior, MN 55331 National Chamber Foundation, Washington,
of third-party
DC.
Jan 1979, 40 pp. Availability: Chamber of Commerce of the U.S., Data Processing Dept., Washington, DC 20062. This booklet is based on a comprehensive study of health and business that resulted in a national health care strategy. The
471. How Things Work in the Real World of Hospital Finance,
Merian Kirchner. 1977, 11 pp. Availabilit.v: Medical Economics v55 n3 p218224,229,230,232,237 6 Feb 78. This analysis of hospital finance argues that the third-party reimbursement system has created the escalating hospital costs which have risen an average of 14.7 percent each year since 1966. Medicare, medicaid, and other public programs now pay about 55 percent: of all hospital charges; Blue Cross pays about 18 percent and commercial carriers 17 percent. In addition, because most hospital revenue comes from bulk reimbursements provided for by contract, hospitals are paid for the expenditures they have incurred. As a result, third-party payments have provided a powerful incentive for still more spending and no incentive at all for economy. Further, health insurance plans have historically skewed the health care delivery system toward hospitals by reimbursing for diagnostic procedures and minor surgery on an inpatient basis only. New reimbursement mechanisms include prospective reimbursement, in which hospitals reach agreement with Federal and private health insurers on an operating budget
1-214
strategy is presented in a series of five reports on business involvement with health of which this guide to the series, or health action kit, is a part. The first chapter examines why business, community groups, and concerned citizens should be involved in improving health and containing costs; it is intended asa framework for developing speeclhes and background articles. The second chapter describes a step-by-step process to help concerned individuals in a company, chamber of commerce, or community group organize a successful health care action program that will also improve the quality of health care services. The process is outlined for both an internal company program and a community-wide program. Case studies in the third chapter highlight the success of private action in improving health care cost containment. The final chapter contains summaries of each of the suggested strategy reports and action plans. These reports discuss how business can interact with the health care system, use specific techniques to control health care costs, stimulate a competitive health care system, promote good health for employees and their families, and improve health planning and regulation. These reports differ from similar efforts because they contain step-bystep, how-to plans that translate theoretical recommendations into practical solutions. In several cases, guides are provided for establishing worksheets arkd other tools to investigate and solve these problems. Tabular data and a list of action plans for a national health care strategy are appended.
Health Care Programs
National
Health
Care Strategy
Series.
Desc_ptor(s): Preventive services, Cost containment efforts, Voluntary initiatives, Comparisons of health care programs,
473. Idea Whose Time Has Come. [,as
A theory of demand for preventive medical services is developed from a model of an expected-utility-maximizing consumer. Preventive medical care is said to alter the probabilities of illness as well as the final health outcome in sick states. The ,value of
Health Insurance.
A. F. Ehrbar. 1977, 7 pp. A vailability: Medical Economics v54 n24 p183,184,186,188,193, 195,196 14 Nov 77. Less, rather than more, health insurance is needed in order to meet the problem of rising health care costs. Such costs have resulted not only from the growth in the over-65 age group and the increase in living standards, but from rising hospital prices which are nearly four times their 1950 level. Because hospitals are paid on the basis of their costs, they have no true incentive to restrain them. In addition, one study has shown a strong, positive correlation between the extent of coverage and the price of hospital care. Further, after medicare and medicaid were established, hospital prices increased from 4.4 percent annually to 10.7 percent, and physicians' fees from 1.3 percent to nearly 3 percent in constant dollars. The present inflation-propelling system is not a natural product of the marketplace and, for most people, insurance for ordinary medical expenses is not a good buy. Blue Cross, which sets the pattern for coverage, has been able to dominate the market because of exemption from Federal income and State taxes and lower hospital charges for Blue Cross subscribers. Moreover, the Federal Government's employerpaid health benefits are exempt from income and payroll taxes. To end the waste in medical care, the tax subsidy that encourages employers and employees to buy first-dollar insurance coverage should be eliminated. In addition, Blue Cross's competitive advantage should be eliminated, and competition among doctors and hospitals should be encouraged. Finally, Government aid could be used to help individuals meet catastrophic medical expenses, and a system of risk-pooling could be implemented to help lower the costs of individual and small-group policies. Descriptor(s):
Cost containment
efforts, Supply/availability
services, Service benefit plans, Inpatient facilities, initiatives, Policy initiatives,
Charles E. Phelps. Rand Corp., Santa Monica, CA 90406 Department of Health, Education, and Welfare, Washington,
preventive medical care depends upon pure health gains (which directly increase utility), work-loss-time avoided, and out-ofpocket medical expenses avoided. Studies cited from the literature show that many commonly accepted screening procedures have no observable payoff in health status or medical expenses saved. In stark contrast, personal behavioral decisions, such as smoking and dietary patterns, appear to have dramatic effects on health and mortality. Public policy appears to be better directed toward inducement of such health-producing behavior than inducement of further medical-preventive procedures. Tables, figures, footnotes, and 43 references are included. (Author abstract) Paper originMly presented at the National Bureau of F_vonomic Research Conference on "The Economics of Physician and Patient Behavior."
Descriptor(s): Impact of third-party coverage, Trends in health status, Medical technology impacts, Policy initiatives, Preventire services.
475. Impact of a Change in Regulations perimental Program.
on Costs in an Ex-
Neville Doherty and Gary Crakes. National Center for Health Services Research, Hyattsville, MD. 1979, 4 pp. Avnilability: Inquiry v16 n2 p154-157 Summer 1979.
of
Voluntary
474. Illness Prevention and Medical Insurance.
DC. 1978, 25 pp. Avallabih'ty: Jnl. of Human Resources v13 p183-207 Supplement 1978.
A federally supported program, Triage, provides for the assessment of health and social needs and the prescription, organization, delivery, and financing of appropriate services for medicare-eligible elderly in a seven-town region of central Connecticut. This study of Triage was conducted to determine change in the costs incurred during the period when new Department of Health, Education, and Welfare regulations required consent form signatures for all clients. Cost increase was determined by calculating the weighted average cost for each of three different periods: the period prior to the change in informed
1-215
consent procedures, the period during which the nurse-clinician/social service coordinator teams returned to clients previously assessed to obtain consent form signatures, and the period when the informed consent requirement had become part of the assessment process. The imposition of a new regulation had a substantial effect on the program's costs. These dollar costs are probably less significant when discounted over all the elderly who will benefit from the Triage experiment. However, when considering the opportunity cost of complying with the regulation, the study found that an additional 72 assessments could have been performed in the second period had there not been a change in the procedure. The change in nominal costs owing to the regulation was not large. A similar increase might be of' greater or lesser importance to another project depending upon the size and scope of a project, as well as the nature of the applicable regulation. Tabular data and 8 notes are provided.
and health insurance coverage. Organized health care settings for ADM treatment appare_My reduced subsequent medical care use, and most of the studies involved contexts where general health and ADM services were integrated. If the findings of the studies prove to be valid, then it could be supposed that insurance coverage for ADM services may produce reduction in insurance costs paid for general health care. Recommendations are offered for improving the methodologies and the scope of future research in the areas examined. A review and critique for each study is appended. Tabular data and references are provided.
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Mental health services, Evaluations/outcome of health care programs.
Descriptor(s): Cost/benefit analyses, Present legislation/regulations, Medicare, Evaluations/outcome of health care programs. 477. Impact of Comprehen._ive National Health Insurance on Demand for Health Manpower.
476. Impact of Alcohol, Drug Abuse and Mental Health Treatment on Medical Care Utilization. A Review of the Research Literature.
James M. Cultice, Roger B. Cole and Ann C. Lawlor. Bureau of Health Manpower, Hyattsville, MD 20782 DHEW/PUB/HRA-78-102 Jul 1976, 70 pp.
Kenneth R. Jones and Thomas R. Vischi. 1979, 82 pp. Availability: Medical Care v17 n12 pl-82 Dec 79.
A literature review examines whether alcohol, drug abuse, or mental health (ADM) treatments reduce subsequent medical care use, and it draws implications for ADM policies and programs. The 12 alcohol studies found evidence of decline in medieal care use following treatment for alcohol abuse in health maintenance organizations (HMO's) and employee-based alcoholism programs. However, only seven of the studies directly measured niedical care use; the others used indirect measures such as number of sick days or amount paid for sickness and accident benefits. Very little research has been done on the impact of drug abuse treatment on medical care use. The scant evidence available is consistent with the findings of the alcohol abuse treatment studies. Overall, the mental health studies strongly suggested that medical care use was reduced following outpatient psychotherapy in organized health care settings, particularly HMO's. Still, currently available research has not conclusively established that ADM treatments were the primary or sole causes of the subsequent reductions in medical care use. This uncertainty is due to the methodological limitations of the studies. The body of literature suggests varying policy implications for ADM treatment setting, linkage of ADM and health services,
I-21 o
Availability: National Technical Information field, VA 22161, HRP-0017895.
Service, Spring-
This study assesses the probable immediate consequences of the administration's 1974 Comprehensive Health Insurance Plan (CHIP) on the demand for selected health services and requirements for health manpower. The study used baseline data consisting of 1970 health service utilization rates by service category and population characteristic, a population projected to 1976 according to these characte:ristics, measures of average coinsurante before CHIP for each of these services, and a distribution of health manpower serving each health service area in 1970. The results indicate that the inlpact of CHIP on the demand for health care and the consectuent requirements for health manpower would vary significantly for different types of service. Demand for short-term hospital inpatient services could very well diminish under CHIP, depending upon the intervention of private supplemental insurance. CHIP may increase the demand for medical office services by 20 percent and may have a moderate impact on dental services. However, additional dental manpower requirements could be,substantial if the demand for dental care is quite high with resl_-'ct to price. Large-scale increases in the demand for pharmacy services are not foreseen unless price responsiveness is much higher than the data show. A total of 10 figures and 17 tables are given. (Author abstract modified)
Health Care Program_
Health
Manpower
Descriptor(s):
References.
Reprinted
Demand/utilization
November
1977.
479. Impact of Health System Changes on the Nation's Requirements for Registered Nurses in 1985.
of health care programs,
Supply/availability of services, Medical/surgical services, Dental services, Pharmaceutical services, National health insurance
Timothy C. Doyle, George E. Cooper and Ronald G. Ander-
(NHI).
Vector Research, Inc., Ann Arbor, MI 48104 Health Resources Administration, Hyattsville, Nursing. Jan 1978, 78 pp.
478. Impact of Family Structure on Children's Health Care Use.
Judith A. Kasper. Nov 1979, 18 pp. Availability: National Center for Health Services Research, Hyattsville, MD 20782.
The influence of family structure on children's use of physician services is examined. Several models are tested to study the relationship between at least one physician contact during the year, including a physical exam, and several independent variables representing family structure. The variables used to characterize family structure are number of children, number of adults, birth order of the child, age of child, and age of family head. The data derived from a representative sample survey of the noninstitutionalized U.S. population. Interviews were obtained from 11,619 people in 8,880 families regarding their use of health services during 1970. Only the number of children and child's age among all family structure variables in the model proved significant in explaining variations in physician contact and having a physical examination even when the other variables are used as controls, For physician contact, both the near poverty level and doctor visit insurance variables also were significant, suggesting that for children, family income and insurance coverage remain important influences affecting likelihood of physician contact. Doctor visit insurance was not significant in a similar model for whether children had a physical exam within the year. When need is included in the model for seeing a physician, doctor visit insurance is no longer significant, although other family characteristics are. Need, however, is not a significant factor in having a physical exam, when combined with other family characteristics, Tabular data are provided, and 18 references are included, Prepared for presentation at the 107th APHA Annual Meeting, Maternal and Child Health Section, New York, NE, November 5, 1979.
son.
Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-022-00615-4.
This report describes research that assesses the impact of three anticipated changes in the health care system on the future requirements for registered nurses. These changes are the introduction of national health insurance (NHI), increased enrollment in health maintenance organizations (HMO's), and the reformulation of nursing roles. To analyze the impact of these health system changes on nurse requirements, researchers estimated future requirements in the general absence of each change and quantitatively compared these to estimates incorporating substantial occurrence of the change. An empirical model of the health system was developed to estimate requirements. The model, which focuses solely on nurse requirements rather than on supply, provides estimates of future nursing employment levels without regard to any concomitant restraints on the availability of nursing resources to meet these requirements. Nurse manpower requirements estimates, based on 1972 data, were made to 1975 and then projected to 1985. The model estimates of registered nurse (RN) requirements indicate that the impacts of both national health insurance and role reformulation are potentially much greater than that attributable to any foreseeable increase in health maintenance organization enrollment. For example, NHI could result in a 7-percent to 14-percent increase in the requirements for RN's over the 1972 to 1985 projection period, but rapid expansion of HMO's would decrease the requirements for RN's by about 2 percent. The report discusses each of the health system changes in detail, discusses the processes by which it affects the requirements for nurses, and presents and analyzes the quantitative impacts resulting from that change only. The impacts of simultaneous health system changes are also reviewed. Recommendations are suggested. Tables, figures, footnotes, and approximately 120 references are included. Technical data are appended.
Health Manpower Descriptor(s): Demand/utilization of health care programs, Medical/surgical services, Preventive services, Participation in health care programs, Impact of third-party coverage,
MD. Diiv. of
References.
Descriptor(s): Nurses, Supply/availability changes re health care.
of services, Policy/
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480. Impact of HMOs. Evidence and Research Issues.
481. Impact of Membership in an Enrolled, Prepaid Population on Utilization of Heldth Services in a Group Practice.
Jon B. Christianson. InterStudy, Excelsior, MN 55331 Henry J. Kaiser Family Foundation, Palo Alto, CA. 1980, 14 pp.
Joel H. Broida, Monroe Lerner, Francis N. Lohrenz and Frederick J. Wenzel.
Availability: Jnl. of Health Politics, Policy and Law v5 n2 p354-367 Summer 1980.
1975, 4 pp. Availability: New England Jnl. of Medicine v292 n15 p780783 10 Apr 75.
Evidence oancerning the impact of health maintenance organization (HMO) growth on traditional providers is presented through examination of the results of three case studies. Medical care market studies were completed in Hawaii, Minneapolis-St.
This study considers whel:her prepayment or group practice is the crucial factor in obse_ed service utilization differences in
Paul, Minn., and Denver Colo. The three areas were selected because they represented different types of markets in which HMO's appeared to be significant forces. In Hawaii, there is one well established HMO, the Kaiser Foundation Health Plan, which had an enrollment of 107,000 by 1977. There are seven HMO's in the Minneapolis area, with enrollment covering about 13 percent: of the vicinity's population. The Denver market has two active HMO's, the Kaiser Foundation Health Plan of Colorado and Comprec, are. It is concluded that the primary impact of HMO development in all three areas has been to stimulate change in the financial and medical arrangements which define the delivery of medical services. Insurers have changed their benefit coverages and strengthened their cost containment activities, hospitals have altered their financial arrangements with payers and developed new methods of marketing their services, and physicians have altered practice styles to accommodate HMO participation. Furthermore, it seems clear that HMO enrollment growth in all three areas has stimulated the formation of new HMO's or similar organizations by hospitals, insurers, and medical societies. Thus, the range of choice for consumers in each area has been expanded. Five factors are hypothesized to be important in determining the extent of HMO impact on the community: employer attitudes, hospital capacity, physician supply, planning and regulatory decisions, and cornprehensiveness of health benefit coverage. Future research elforts will focus on the possible price increases effected by hospitals and physicians in response to HMO development, the impact of HMO competition on individual practice association (IPA) pertbrmance, and the effect of HMO growth on the manner in which medical care is provided. One table and 18 references are included. (Author abstract modified) Earlier version of this article was presented at the annual meetings of the Association of University Programs in Health Administration, Toronto, Ontario, Canada, May 6-9, 1979,
prepayment arrangements Many studies have reported that persons in prepaid group practices use a greater volume of ambulatory care services and a lesser volume of inpatient services than comparable patients receiving their medical care through traditional fee-for-service solo-practice arrangements. However, unless it is clear that prepayment, not group practice, is responsible for the observed utilization differentials, implementation of the health maintenance organization (HMO)strategy by superimposing HMO's on existing fee-for-service group practices might not produce the desired results. To clarify the issue, researchers evaluated the impact of introducing a prepayment system at the Marshfield Clinic, a fee-for-service group practice in Wisconsin. For the 2 years of the study (1971 to 1973), only a portion of the service population was covered by the prepayment arrangement so that both systems existed side by side with the same services, settings, and physicians. Study data were obtained from encounter forms and current master patient files of the clinic. Results indicated that the use of ambulatory care services doubled for the prepaid population from the last fee-for-service to the first prepayment year, while the comparable change for the fee-forservice population was only 11.2 percent. This effect persisted for the second year of the prepaid arrangement. The increase occurred in both clinic and hospital outpatient settings. Contrary to expectations, the use of inhospital services also increased, by 58.8 percent for the prepaid population buy by only 13.7 percent for the fee-for-service population. However, in the second year of the prepayment plan, there was a slight decrease in hospital use by both populations. These results run counter to conventional wisdom about prepayment. Limitations of the study setting should be considered., including short-term effects of the arrangement, the primarily rural setting of the study, physicians' ignorance of patients' payment status, and lack of data on diagnosis. Therefore, further research is needed before the results of this study can be generalized. Three tables and 14 references are supplied.
Descriptor(s): Health care costs, Supply/availability of services, Prepaid plans, Plan design/program provisions (under health plans), Competition/interaction among third-party payors, Comparisons of health care programs,
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Comparisons of health care programs, Health care costs, Health care/services, Outpatient facilities.
I-218
Health Care Programs
482. Impact of National Health Insurance on New York.
VA 22044 Jan 1976, 50 pp.
Marvin Licberman. Department of Health, Education, and Welfare, Washington, DC., Div. of Regional Medical Programs.
Availability: Trapnell (Gordon R.) Consulting Actuaries, Falls Church, VA 22044.
1977, 232 pp. A vailability: Prodist, New York, NY 10010.
Data are provided to show the impact of the various national health insurance proposals on the use of and spending for sight correction services. The principal effect of providing sight cotrection services in a national health insurance plan would be to transfer responsibility for paying some of these services from traditional sources to the new plan. An additional major effect would be to induce an increase in the total services used by the public. Under the Administration proposal for national health insurance, one of the three major plans would pay at least part of the cost for 8.7 million diagnostic examinations performed or supervised by optometrists and ophthalmologists and for 2 million pairs of corrective lenses dispensed to correct diagnosed conditions. About $99 million would be paid through State and employer plans toward the cost of these services. The total number of diagnostic examinations in the Nation would increase from 49.5 million to 53.2 million as a result of the previously unavailable services. The total number of pairs of corrective lenses dispensed would increase by 400,000 pairs to 47.4 million. As a result, total spending in the United States for sight correction services would increase by $41 million to $3,476 million, an increase of 1 percent over current spending. Most of the cost would be for diagnostic examinations of children in lower income families. Under the Kennedy-Mills proposal, which does not have any deductibles for vision care services, most of the cost would be paid for 32.7 million diagnostic examinations and a large proportion of the cost of 3.2 million pairs of new corrective lenses. Under this proposal, total spending for sight correction services is estimated to rise about 8 percent, to $3,715 million. Almost all of the increase is due to the cost of additional diagnostic examinations. Appended are results from surveys of optometrists and opticians to determine services provided and fees charged. Tabular data and footnotes are provided.
The 11 papers in this volume cover a variety of topics relating to the impact of national health insurance (NHI) plans proposed in 1974 on New York, with particular attention to ambulatory services. These studies were commissioned by the Task Force on the Impact of National Health Insurance of the New York Metropolitan Regional Medical Program to stimulate discussions at their meetings. A summary of the Task Force's deliberations is followed by a report that served as an agenda for the group's activities and an interim study assessing its accomplishments after several months. Patterns of ambulatory care in voluntary and public hospitals in New York City are described, and the implication of NHI for these services are examined. One controversial paper argues that New York City should provide primary care in freestanding units now operated by the New York City Health Department. Another proposal advocates the establishment of primary care centers for prenatal and early childhood care supervised by the Health Department. The costs of nursing home care are discussed, as are the possible effects of NHI on New York City's health budget. Other articles consider how NHI could influence costs of health care and utilization patterns in New York City and examine the National Health Planning and Resources Development Act of 1974. A framework for developing an information system to assess the impact of NHI on the health delivery system of New York City is presented. Other issues treated in this volume include State regulation of organized ambulatory services and the effect of NHI on labor-management health plans. Tables and chapter references are provided. Information on task force meetings, papers, and seminars is appended, Selected papers commissioned by the Tnsk Force on the Impact of National Henlth Insurance of the New York Metropoh'tnn Regional Meak'cal Progrnm, July L 1974-September L 1974. Descriptor(s): National health insurance (NHI), Demand/utilization of health care programs, Health care cost trends/projections, Medical/surgical services, Inpatient facilities, Long term care facilities, Outpatient facilities.
Desc_ptor(s): Demand/utilization of health care programs, Health care cost trends/projections, Vision/hearing services, Plan design/program provisions (under health plans), National health insurance (NHI).
484. Impact of Proposition 13 on Mental Health Services in California. 483. Impact of National Health Insurance on the Use and
John A. Talbott.
Spending for Sight Correction Services.
1979, 7 pp. Availability: Hospital and Community p677-683 Oct 79.
Trapnell (Gordon
R.) Consulting Actuaries,
Falls Church,
Psychiatry
v30 n 10
I-2L_
This study assesses the impact of Proposition 13 on California mental health services. Interviews were held with 58 county and 2 city mental health directors, as well as with additional persons involved in and affected by the mental health system. It was found that while some counties increased or maintained their provision of mental health services during the first year of Proposition 13, most had been forced to reduce services. California shifted from a State-operated, hospital-based, centralized mental health care delivery system in 1957 to an almost entirely cornmunity-based, decentralized system by the 1970's. The local level funding sources and responsibilities for mental health care are most affected by Proposition 13's limits on property assessments and taxes. However, while services have been markedly curtailed, the result has been change, not disaster. The most obvious deleterious effect has been the decrease in personnel and services in mental health programs. The budget-cutting process has also affected staff morale and the work climate. Other results included an increased use of hospitals and a tendency of programs to try to pass their clients or responsibilities to other programs now that mental health services might be completely State-supported. Some counties that had strong, unified constituencies report a split along interest lines and destructive infighting. On the other hand, the budget cuts have encouraged improved management of mental health services, a diminution of single-interest group lobbying, an increasing realization that government cannot do everything, and greater citizen involvement in the yearly planning process. Other States may fare differently with a different leadership, with a better understanding of what taxes support what levels of government, and with less propensity for faddism, Eleven references are provided.
that care. Both the Economic Stabilization Program (ESP) alLd the statewide Prospective Reimbursement (PR) indirectly lcgulate prices, and it is believed, constrain diffusion. A rcvicw of the literature on service diffusion is provided, a service adoption model developed, and specification and estimation proccdure_ discussed. The American Hospital Association data tapes for 1969 to 1974 provided infi_rmation on facilities and services, hospital statistics, and costs for 145 hospitals located in upstate New York, plus 120 matched control hospitals, mostly in Ohio and Wisconsin. New York Uniform Financial Reports and Medicare Cost Reports prc_vided information on revenues, depreciation, the value of major movable equipment, gifts and bequests, and net income. The exogenous demand variables were taken from the 1970 Census of Population and other census and medical publications by county. It was shown that ESP and PR lower the rate of adoption of expensive services, and in the case of ESP, also lower the adoption rate of community services. The evidence implies that price regulation which lowers profits can change the service mix of hospitals, but only slowly over time and within certain limits. Hospitals do compete with each other, leading to higher adoption rates and, as a result, overexpansion and utilization of equipment, leading to higher costs and, in some eases, substandard medical performance due to infrequent at'tivi-ty. Health planners need to better understand the nature of this competitive structure. Furthermore, variables such as income and the specialty mix of physicians that economists associate with the demand for medical services were found to be important in explaining adoption. Twenty-eight references are provided and three tables summarizing data. Discussion Paper No. HCSA-1.
Desc_qptor(s): Mental health services, Economic/commercial
in-
fluences, Outpatient facilities, Present legislation/regulations, Funding/financing of health care programs,
Descriptor(s): Inpatient facilities, tions, Medical technology impacts,
485. Impact of Rate Regulation on the Diffusion of New Technologies in Hospitals.
486. Impact of Social and Economic Security Systems.
Jerry Cromwell. Abt Associates, Inc., Cambridge, MA 02138 Social Security Administration, Washington, DC. Office of Research and Statistics. Oct 1976, 29 pp. .4 vailability: Abt Associates Inc., Health Care Systems Area, Cambridge, MA 02138.
Anna Maria Rappaport ancl Peter W. Plumley. 1978, 30 pp. Amilabih'ty: Transactions of the Society of Actuaries p245-275 1979.
This paper focuses on the potential impact of public price regulalion on the diffusion of technology, and hence on the increased co._ts of health care and any associated decrease in the quality of
1-220
Present legislation/regulaCost/benefit analyses.
Changes on Financial
vXXX
This paper explores our societal systems for providing economic security, and the changing s4xzial and economic context. It examines the societal structure underlying these systems and shows how change in the society can affect the systems for providing security. The systems dealt with include private pensions, social security, life insurance, and ]aealth insurance. The forces in socie-
Health Care Pr,_g; ......
ty examined are changes in the family and the role of women, inflation, the changing age composition of the population, and the changing values as expressed in the psychology of entitle-
NCHSR
ment. Demographic, attitudinal, and economic data have been included to document the societal changes described,
Descriptor(s): Cost containment efforts, Inpatient facilities, Present legislation/regulations.
Descriptor(s): National economic conditions, Demographic tures of population, Trends in health status.
Research Digest Series, Report
No. NCHSR
77-21.
fea-
488. Impact of State Government Rate Setting on Hospital Management. 487. Impact of State Certfficate-of-Need Care Costs and Utilization.
Laws on Health Alan N. Coiner. 1977, 13 pp.
David S. Salkever and Thomas W. Bice. Johns Hopkins Univ., Baltimore, MD 21218 National Center for Health Services Research, Hyattsville, MD. Jan 1976, 16 National pp. A variability: Center for Health Services Research, Hyattsville, MD 20782.
This study is an empirical analysis of the impact of Certificateof-Need (CON) regulation on hospital costs and use for the period 1968 to 1972. The data employed pertained to the 48 contiguous States and the District of Columbia. CON impacts on hospital investment were estimated, and the effects on costs and use resulting from these investment impacts and from other influences of CON regulation were measured. In both stages, multiple regression was used to measure CON effects. Results from the first stage indicated that CON regulation tended to reduce expansion in bed supplies but that this reduction is accompanied by an increase in other types of hospital investment, such as new equipment. While the composition of hospital investment is altered by CON, the total level of investment is not reduced. The second stage of analysis indicated that the volume of patient days per capita was reduced under CON regulation but that the level of per capita expenditures on hospital services was not decreased. This study showed that CON programs did not dampen hospital cost inflation from 1968 to 1972 and may actually have exacerbated it. The net effects of this pattern were to lower overall use of inpatient hospital services and raise costs of care. These results are clearly not consistent with the widely held view that CON regulation serves the public interest and suggest that the desirability of encouraging its adoption should be critically examined, although professional standards review organization programs may moderate this trend. Clearly, further research on the structure and processes of CON regulation and the incentives it creates is needed. Four references, one figure, and four tables summarizing the data are provided. (Author abstract modified)
AvMlability: Health Care Management Review v2 nl p37-49 Winter 1977.
The impact of State Government rate setting on hospital administration is examined in this article. State legislatures have sought to regulate hospital finances and slow soaring health care costs through rate setting commissions. As a result, hospital administrators have developed several techniques for managing their institutions within the constraints imposed by the commissions. Although the character of rate setting varies among locations throughout the Nation, particularly in terms of history, politics, legislation, and methodology, general statements can be made with regard to how hospital administration has been affected by rate setting. In each case, a State agency reviews a hospital's finances on a prospective basis to limit increase, in all or some of its rates and its overall budget. Since income levels are controlled, internal finances must be strictly planned _md monitored by administrators, and administrators must be sensitive to the effect this control has on relationships with the medical staff. Rate setting systems usually do not encompass all aspects of hospital costs, and administrators must pursue certain strategies to maximize income. For example, generating more ancillary service and patient day volume in a particular manner can help ease an institution's budgetary concerns. In the future, many additional State governments will have the statutory authority to regulate hospital finances prospectively. New Jersey has begun experimenting with a methodology intended to generate case mix profiles of hospitals to facilitate more accurate interhospital cost comparisons for more equitable reimbursement decisions. In addition to rate setting, governmental efforts to control cost increases include certificate of need laws which regulate investment in new facilities. Nineteen references are included. (Author abstract modified)
Descriptor(s): Inpatient facilities, Present tions, Methods of payment determination.
legislation/regula-
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489. Impact of the Rhode Island Catastrophic Health Insetance Plan.
ice Lynn Ahmuty. Federal Mediation and Conciliation
Blair Lord and Sylvia Lane. 1979, 20 pp. Availnbility: Jnl. of Consumer ter 1979.
search, Washington, DC 20037 Labor-Management Services Administration, Washington, DC. 1979, 483 pp. A vMlability: Superintendent of Documents, Government Printing Office, Washington, DC 20402.
Affairs v13 n2 p186-205 Win-
Service t)ffi_c of Re-
This article describes the provisions and assesses the impact of Rhode Island's statewide Catastrophic Health Insurance Plan (CHIP), in effect since 1975. Under this plan Rhode Island pays catastrophic medical expenses over and above a "personal resource payment" (out-of-pocket) that varies with income and amount and type of health insurance coverage. Those with quafffled plans (plans providing more services) pay less out-of-pocket, The analysis concludes that the structure of the CHIP act dis.. tributes benefits (i.e., payments for catastrophic medical ex.. penses) unevenly, so that benefits accrue mainly to some middle-income households. The structure of the personal re.. source payment largely prevents and will continue to prevent the very poor and very rich from receiving benefits. CHIP has also not solved problems for the lower or middle-income people under 65 who do not carry qualifying medical expense insurance and who cannot afford the personal resource payment of $5,000 or one-half their allowable income, whichever is greater. Nor has CHIP solved problems for those who need but do not carry additional insurance, and who are covered by medicare but unable to meet the personal resource payment of $1,000. Furthermore, CHIP has created pressure on the medical expense insurance market by increasing demand for health insurance with qualifying coverage, by increasing utilization of medical care, and thereby increasing premiums for medical expense insurance policies. Although smaller, CHIP has similarities to proposed national health insurance systems, and therefore, it bears implications for them. Thus, the impacts of more insured, more utilization, and higher prices may be expected from any similar national health insurance program. Footnotes, tabular data, and 24 references are provided. (Author abstract modified) Giannini Publication
No. 541.
Descriptor(s): Plan design/program provisions (under health plans), National health insurance (NHI), Evaluations/outcome of health care programs, Mandated benefits, Participants in health care programs, Competition/interaction among thirdparty payors, Publicly sponsored/mandated health plans,
490. Impact of the 1974 Health Care Amendments to the NLRA on Collective Bargaining in the Health Care Industry. Lucretia
I 222
Dewey Tanner,
Harriet Goldberg
Weinstein and A1-
This is a three-part examirLation of the impact of the 1974 National Labor Relations Act amendments on collective bargaining in the health care industv.¢. Part 1 examines the evolution of public policy toward collective bargaining and the history of bargaining, with emphasis on the major unions representing workers in the private sector institutions. Part 2 presents a profile of current collective bargaining, an analysis of the board of inquiry process, and a review of the characteristics of strikes in the health care industry. Part 3 is devoted to the influences of the third-party payer on reimbursement agencies and the decision of the National Labor Relations Board regarding the structure of collective bargaining in the health care industry. Of particular interest is a survey which describes and evaluates the effect of the third-party payers as well as the positions of labor and management. Fifteen bargaining relationships in New York State during the 3 years following the 1974 amendments were selected; 30 interviews s_ith chief labor and management negotiators were conducted Both labor and management regard the third-party payers issue as the most important topic during negotiations. The influence an bargaining extends to prenegotiations and bargaining strategies for management and unions. This issue is seen to lengthen negotiations, hold down wage and fringe benefits gains, and increase deferred first-year wage gains (backloading). Both hospital and labor positions in regard to boards of inquiry, binding arbitration, and the inability-to-pay issue are examined. For the most pa:rt, third-party payers want to avoid involvement in collective bargaining because it is tantamount to being asked to pass through labor costs above established prospective reimbursement rates; would possibly require participation in the major hospital-union negotiations; and would ultimately require involvement in daily hospital operations. Both labor and management reject the concept of including the payers directly at the bargaining table. Finally, comparison of 21 agreements throughout the United States and the 15 New York State agreements found the New York settlements were 4.5 percent in contrast to the nationwide average of 8 percent wage increases. Survey instruments, tabular data, chapter notes, and approximately 300 references are provided.
Descriptor(s): Impact of third-party coverage, Limitations on coverage, Present legislation/regulations, Providers of health care services, Economic/commercial influences.
Health
Care Progra,,,
491. Impacts of Health Maintenance on Community Health Care Costs.
Organization Growth
Thomas E. Ramsay and Richard D. Wright. 1978, 10 pp. Availability: Socio-Economic Planning Services v12 n5 p241246 1978.
Rand Corp., Santa Monica, CA 90406 RAND/R-2505-HCFA/HEW Health Care Financing Administration,
This report analyzes the implementation This paper presents a model of health maintenance organization (HMO) growth, traditional health delivery system response, and total community health care costs. The belief is that HMO growth and competitors' response form a closed system ofmutual influences, and hence the model studied is closed, with a state variable, feedback process viewpoint. Simulations are run using a range of assumptions about the response of Government and the traditional sector to HMO growth: no response, resistance to HMO growth, reform of other hospital use, reform of excess inflation, utilization and inflation reform, and most optimistic reform package. While further work is needed to verify model components and specify the model to a particular community setting, the current version suggests four conclusions. First, extrapolation of current differences in HMO and other sector hospital utilization and inflation rates implies a tremendous potential for HMO expansion. These projections are so striking that it seems certain that the present state of affairs cannot persist; some kinds of feedback control mechanisms will appear to warp the current system. Secondly, HMO growth reduces total community health costs, but a substantial fraction of HMO subscribers' savings is added to the cost of other sector subscribets, at least over the short run. The adjustment time for reducing hospital overcapacity is a major determinant of the fraction of potential community savings realized. Capacity Control should be a major concern of Government, employers, and insurance carriers. Thirdly, HMO cost savings depend as much on HMO control of inflation rates as on control of hospital use. Finally, while HMO's can have significant impact even when they share hospital resources with the traditional HMO's must control captive hospitals in order to achieve all of their potential savings, growth, and community impact. Figures, tables, and 18 references are provided. A dynamo equation listing is appended, (Author Abstract modified) Descriptor(s): Health care cost trends/projections, Prepaid plans, Comparisons of health care programs, Cost/benefit analyses, Health information/data systems, National economic conditions.
492. Implementing the End-Stage Renal Disease Medicare. Richard A. Rettig.
Program of
Washington,
DC.
Sep 1980, 255 pp. Availability: Rand Corp., Santa Monica, CA 90406.
of the End-Stage Renal
Disease (ESRU) program of medicare from its 1972 authorization through its first 5 years of operation. Basically, the program extends Medicare coverage to individuals who are under' 65 years of age, fully or currently insured, or entitled to monthly social security benefits, and have permanent kidney failure requiring either dialysis or a transplant. The medicare benefit payments for ESRD in 1974 were $283 million and have increased to about $1.2 billion in 1979. Benefits for ESRD now exceed 4 percent of total medicare expenditures. In many ways, the ESRD program is a success. Patients are receiving treatment, bills are being paid, and access to care is no longer an issue. Success is attributable to many factors, including clear congressional intent, early reimbursement policies, prompt medicare payment, and competence in this aspect of the health care system. Notwithstanding its successes, however, the ESRD program is not to be regarded as a model of implementation. Implementation problems arose from the administrative system, the planning and operational stages, and the substance of reimbursement and medical issues. Highlighted herein is the behavior of and relations among the major organizations of the Department of Health and Human Services and the Bureau of Quality Assurance of the Health Services Administration. The report also documents the design of ESRD networks, the 32 regional entities created to coordinate services on a regional basis and to ensure that high quality care is provided to patients. In addition, the inability of the Government to create adequate data systems for program management is discussed. Tables, footnote references, and appendices are ineluded. (Author abstract modified) Descriptor(s): Medicare, Present legislation/regulations, Evaluations/outcome of health care programs, Economic/cornmercial influences.
493. Improving Access to Health Care Among the Poor. The Neighborhood Health Center Experience.
Roger A. Reynolds. Robert Wood Johnson Foundation, Princeton, NJ. 1976, 36 pp. Availability: Milbank Memorial Fund Quarterly/Health
and
Society v54 nl p47-82 Winter 1976.
1-223
The effectiveness of neighborhood health centers (NHC's) in serving low-income segments of the population is assessed. The study period covers four quarters beginning in October, 1972. Data derive from quarterly reports of 32 NHC's published in summary form by the Office of Economic Opportunity. Findings indicate that although NHC's have not been placed in areas with a high concentration of poverty, the majority of the individuals served by the centers in those communities have been those most in need of care: blacks, low-income families, members of large families, and individuals with poor health status. Health care improvement has been especially evident in the South and in rural areas. Despite the benefits of such programs, the question remains whether NHC's can be justified as an economically viable means of serving the poor in light of the high cost of the comprehensive approach to health care delivery. Because NHC's derive most of their income from Federal grants, they operate on a fixed annual budget. From that budget, centers must determine the optimal mix of services to be provided to the community. If the center is operating at full efficiency, this will necessitate trade-offs among the number of persons to be served, the range of services to be offered, and the amount of care to be provided to careseekers. The Federal Government has taken an interest in improving third-party reimbursements and collecting direct pay.. ments at NHC's to expand NHC capacity without increasing costs. Efforts to limit the budget of NHC programs have focused on encouraging efficiency by using capitation grants after the health maintenance organization model and on cuts in hospitali., zation benefits at some centers. Unfortunately, preoccupation with efficiency and costs tend to divert attention from the pur-. pose and benefits of NHC's and may even have been the reason for the decline of an earlier generation of NHC's. Problems of NHC's in retaining physicians can perhaps be resolved bY using
typically favor relatively urban areas, as well as specific group practice factors which have allegedly drawn groups to rural areas. The relative importance of these factors are examined in order to explain changes between 1969 and 1975 in the number of group practice physician,; in nonmetropolitan areas. The nonmetropolitan areas that experience the greatest difficulty in attracting and retaining physicians are relatively rural ones with stable or declining populations. Results indicate that group practice does not easily overcome the perceived disadvantages of medical practice in rural arums. To the contrary, strong evidence is found for the hypothesis that many of the factors that make an area to 1975 period, physicians were attracted to areas with reasonably rapid population growth, a comparatively complex specialty mix, and relative!ty easy access to urban medical resources. Moreover, rural medical resources and geographic isolation of an area had an important additional impact on the growth of group practice. More rapid growth occurred in those places with higher initial physician-population ratios that were closer to metropolitan areas. Thus, relatively rapid growth of group practice physicians, liike that of all physicians, occurred in the more urban types of nonmetropolitan areas. The provision of inpatient services by groups in an area does not appear to be a necessary ingredient for group growth, but the ability to provide more geographically dispersed inpatient services, through creation of satellite facilities, may be important. Although group growth in some areas may may be important. Although group growth in some areas may have been accomplished through the annexation of existing nongroup practice, high technical capabilities do not appear important for rapid group practice growth. Tabular data and 28 references are appended. (Author abstract modified)
paramedical personnel, which are less costly than physicians, and by training members of the community as paramedics. Ta-. bles and a bibliography are supplied.
Earlier draft of this paper presented at the Southern Association meetings, Ne_ Orleans, LA, November
Economtc 2-4, 197Z
Descriptor(s): Demand/utilization of health care Physicians, Supply/availability of services.
programs,
Descriptor(s): Evaluations/outcome of health care programs, Demand/utilization of health care programs, Supply/availabili.. ty of services, Outpatient facilities.
494. Improving Access to Medical Care in Underserved Areas. The Role of Group Practice.
495. Improving Health in America. U.S. Public Health Service Highlights of 1977-80,
Philip G. Cotterill and Barry S. Eisenberg. 1979, 13 pp. Availability: Inquiry vl6 n2 p141-153 Summer 1979.
Department of Health and Human Services Office of the Assistant Secretary for Health, Washington, DC 20201 1980, 65 pp. Availability: Public Health Service, Office of Public Affairs, Washington, DC 20201_
An instrumental variables technique is employed to assess the relative importance of general physician location factors which
This report is a summary of the Nation's health status, the accomplishments of the Public Health Service (PHS), and plans
1-224
Health Care Programs
to address remaining problems. The principal strategies of PHS plans include disease prevention and health promotion, delivery of health services to the unserved and underserved, research, and health planning. The intent of this report is to place PHS activities in the context of both Department of Health, Education, and Welfare health care financing and national economic strategies, It is a survey, not a comprehensive discussion of all PHS activities, and is limited to fiscal years 1977 to 1980. The study reviews the accomplishments of the PHS in the protection of the public health (hazards of medical care, disease control), delivery of health services (training and distribution of health professionals, health maintenance organizations, mental health, hospices), research, statistics, and technology (biomedical, health services research, health statistics, health technology), and cost containment (health planning). The major new initiations for fiscal year 1980 are also surveyed. In prevention and protection, these include consumer protection, environmental and occupational health, lifestyle, and preventive services. In delivery of health services, these include services for underserved groups, adolescent pregnancy, mental health, and alcoholism and drug abuse are included. In delivery systems improvement, health maintenance organizations and health professions training are included. In research, statistics, and technology, initiatives include research planning principles, biomedical and behavioral research, health services research, health statistics, and health care technology. In cost containment, initiatives in health planning and cost reduction are reviewed. Finally, PHS initiatives in international health are discussed. The appendix contains a statistical profile of health in America, including ten figures.
Descriptor(s): Trends in health status, Supply/availability of services, Demographic features of population, Cost con "tainment efforts, Medical technology impacts, Prepaid plans, Mental health services, Preventive services, Providers of health care services,
Policy/changes
496. Incentive
re health care.
Tax for Medicare, Medicaid
and National
Health Insurance. Walter
vide no incentive for communities to contain health care expenditures, since there is no way a community can decrease its tax burden by its own actions in constraining health care costs. The proposed incentive tax is Federal, but it could be adopted by States with a State income tax. The tax would be a Federal health care surtax on corporate and personal income; the surtax rate would vary by health system agency area according to per capita health care expenditures in that area. The surtax would be a fiat percentage of corporate and personal income tax which the firm or individual would pay in addition to regular income tax; however, the percentage rate would be higher where per capita health care expenditures are excessively above average and lower where per capita expenditures are average or below average. The surtax could replace all current Federal health care payroll taxes, as well as the amount of general revenue support for health care determined by Congress. There is no intent to make Federal health care expenditures in local areas self-supporting through the surtax; the area surtax rate should be independent of Federal health care expenditures in tbe area. All surtax revenue would be eomingled and paid into the Federal trust fund to be disbursed by medicare and medicaid in the usual way. The administration of the surtax, the area surtax rate, and proposed formulas for area surtax rates are discussed. Three notes and tables are provided.
Descriptor(s): Medicare, Medicaid, Funding/financing care programs, Policy initiatives, National (NHI), Source of premium payment.
health
of health insurance
497. Income and Illness. Paul W. Newacheck, Lewis H. Butler, Aileen K. Hal_er, Dyan L. Piontkowski and Patricia E. Franks. National Center for Health Services Research, HyattsviUe, MD. Robert Wood Johnson Foundation, Princeton, NJ. 1980, 12 pp. Availability: Medical Care v18 n12 p1165-1176 Dec 80.
McClure.
California
Univ., San Fransicco,
CA. Health
Policy Program.
1980, 15 pp. Availability: Jnl. of Health Politics, Policy and Law v5 nl p10-24 Spring 1980. An incentive tax is proposed al health insurance (NHI). and medicaid is by payroll also the tax sources usually
for medicare, medicaid, and nationThe present financing of medicare tax and general revenue. These are proposed for NHI. Such taxes pro-
Analysis of unpublised data from the 1977 health interview survey of the National Center for Health Statistics reveals that a substantial health gap exists between poor and nonpoor families, a gap largely attributable to the disproportionate number of low income individuals with ekronic conditions which limit activity Although the poor and nonpoor report the same types of chronic conditions, these conditions are more prevalent and more severe among the low-income population. The marked degree to which chronic conditions affect the health status of low-income people should be an important consideration in the allocation of re-
1-225
sources to meet the health needs of this population. The current mix of social welfare programs, particularly medical programs, does not match the needs of the chronically ill. Government financed medical care is oriented toward acute rather than chronic care. The goal of care is to stabilize this degenerative process as well as possible, maximizing the remissions and minimizing flare ups. Medicare and medicaid are similar to traditional health insurance as devices for paying bills. These Government programs are not designed to guide people to uppropriate care. The low-income, chronically ill person is the least capable of conducting such a search, often gaining admittance through the emergency room and ending up in the most expensive institution in the medical care world, the hospital. Furthermore, the method of payment rewards mismanangernent of chronic illness, with no reward for good continuing care at reasonable cost. There is a gradual shift in Government spending from social programs toward spending for medical care. This shift is a mismatch with the finding that chronic, no_ acute, illness is tile source of the health gap between poor and nonpoor. To a far greater degree than with acute illness, chronic illness requires an approach that treats the social and psychological as well as the biological aspects of disease. Spending more tax dollars for medical care at the expense of other Government social programs makes little sense for low income people. The problem in not fine tuning existing policy, but rather reshaping it; reshaping is a challenge that must be undertaken if the health gap between the poor and the rest of the population is to be
fled for an exemption, but has since repealed its hospital commission effective March 1, 1'980. This analysis compares hospital expenditure increases for these eight States to those expenditure increases in States without mandatory hospital cost control programs. The rates of increase for three expenses were compared: expenses per day, expenses per admission, and total hospital expenses. The study shows that hospital expenses in the eight States operating mandatory hospital cost containment programs increased at a lower rate than the national average. Critics of the mandatory control progra ms note that while the rate of increase in these eight States is lower, the actual cost of hospital care in these States is significantly higher than in the rest of the States. With the exceptions of Washington and Wisconsin, where actual hospital costs are below the national average, this is true. However, the gap between the actual hospital costs in these eight States and the rest is narrowing. Methodology is discussed, and five tables comparing hospital expenses in mandatory and nonmandatory States are provided.
closed. Ten references are provided. (Author abstract
499. Individual Accident and Health Loss Ratio Dilemma.
modified)
Descn'ptor(s): Demand/utilization of health care programs, Policy initiatives, Trends in health status, Publicly sponsored/ mandated health plans.
Descriptor(s): Cost containment efforts, Policy initiatives, Inpatient facilities, Comparisons of health care programs, Present legislation/regulations.
Joe B. Pharr. 1979, 14 pp. AvMlability: Transactions p373-387 1979.
of the Society of Actuaries
vXXXI
498. Increases in Hospital Expenses, 1976-1979. A Compari.. son of States With Mandatory Cost Containment Programs and States Without Mandatory Cost Containment Programs.
The principal objective cf this paper is to discuss the rather significant misconceptions and distortions commonly encountered in the use of individual accident and health insurance loss ratios. These ratios are used routinely in periodic filings with
Russell W. Hereford.
regulatory
National Conference of State Legislatures, Denver, CO 80202 Nov 1980. 8 pp. A vMlability: National Conference of State Legislatures, Den.. ver, CO 80202.
ance industry, and discussions among insurance company management groups. Much of the distortion is traceable to the actuarial approach used to reflect active life additional reserve
President Carter's proposed Hospital Cost Containment legislation of 19"79exempted hospitals in States operating mandatory rate review programs. Had the legislation passed, eight States would have been exempted from Federal controls: Connecticut, Maryland, Massachusetts, New Jersey, New York, Rhode Island, Washington, and Wisconsin. Colorado would have quati-
1-220
authorities,
communications
within the health insur-
changes in the loss ratios for level premium business. A typical pattern of incurred loss ratios is projected over a reasonable lifetime of a block of level premium individual health insurance policies. These ratios then are modified by (1) changing the active life additional reseJwe method, (2) adjusting the interest rate assumption inherent in the additional reserves, and (3) using realistic assumptions as tc_interest, mortality, withdrawal, motbidity, and underwriting selection in the reserve calculations. (Author abstract modifleci)
Health
Care Programs
Descriptor(s): Premium determination/underwriting, ployment related plans.
Non-em-
S00. Industry and HMOs. A Natural Alliance.
Richard H. Egdahl and Diana Chapman Walsh. Boston Univ. Health Policy Inst., Boston, MA 02215 1978, 117 pp. Availability: Springer-Verlag, New York, NY 10010.
This monograph is designed to be an up-to-date report on the progress of health maintenance organization (HMO) development and the possibilities for industry's involvement in this movement. The organized systems of care known as HMO's represent an effort to infuse competition into the health care industry and thereby effect some reduction of health care's spiraling costs. The initial chapter delineates the potential mutual benefits of corporate sponsorship of HMO's. Corporate strategies and goals are then evaluated, revealing a series of obstacles to the HMO model. Among these obstacles are data deficiencies and relations problems with labor, the medical profession, and even local communities. To clarify available options, one article characterizes various distinct types of HMO's, such as salaried group HMO's, fee-for-service HMO's, and emerging new variations of the basic model. Formidable legal obstacles are identified by another article that analyzes liability issues for the HMO and matters of corporate liability, State and antitrust laws, and regulations of the Federal Employee Retirement In.come Security Act of 1974. Issues to be resolved in the future are summarized in conclusion. For industry, these include the setting of realistic goals and expectations for health cost curtailment. HMO's need to amass useful data and establish credible records for documenting their effectiveness. For national policymakers, there is also the issue of deciding who should reap the benefit of potential savings to be realized through the HMO movement. Notes and tabular data are included with individual articles. Appendices contain excerpts from proceedings of several conferences on HMO's.
Based on conferences held March 10, 1978, Washington, DC; September 15, 1978 in Aspen, CO; and April 1978 in Boston, MA on related HMO activities. Springer Series on Industry and Health Care, No. 5.
Descriptor(s):
Voluntary
initiatives, Prepaid plans.
501. Industry Roles in Health Care.
Seymour Lusterman. Conference Board, Inc., New York, NY 10022 1974, 130 pp. Availability: Conference Board, Inc., New York, NY 10022.
This study's principal aim is to describe current trends in company health care involvement and to identify the dominant shaping influences. Employee health care programs are considered as one aspect of the business health care role. The study involved a survey of over 800 companies and interviews with numerous business executives, medical and personnel directors, and nonbusiness health professionals and planners. The report includes a statistical examination of present company health care programs and changes since 1964, narrative descriptions of various activities that depart from traditional modes, and a presentation of often conflicting opinions about appropriate management responses to key issues of policy. The focus is on the larger employer, the company with at least 500 employees. The study found that a sizable minority of firms report the introduction of new health services for employees, provided either inhouse, by contract with outside physicians or clinics, or through some expansion of earlier programs. Preemployment health screenings are given to some or all new employees by 71 percent of companies, compared with 63 percent in 1964; work-related periodic examinations by 53 percent versus 40 percent in 1964; and general periodic examinations by 57 percent versus 39 percent in 1964. A small but increasing number of companies are expanding their role as health care providers from the traditional one of limiting services to work-related injuries or illnesses to broader roles including ambulatory services, special counseling programs for high risk groups, and the development of health maintenance organizations (HMO's). Most companies are involved in cornmunity health affairs, principally in the forms of financial support of hospital and voluntary health agencies and participation by company executives and specialists in the work of such organizations. Business initiatives have spurred health planning activities, also. Case histories of industry and community involvement, tables, footnotes, a list of tables, and appendices detailing the survey methodology, a multiphasic health screening program, industry health reports, and major health insurance proposals are included. (Author abstract modified)
Conference
Board Report No. 610.
Descriptor(s): Third-party payors, Private health care plans, Voluntary initiatives, Comparisons of health care programs.
1-227
502. Industry's Voice in Health Policy.
Unitl the formation of the Maryland Health Services Co_t Rc view Commission, hospital prices in the State were increasing
Richard H. Egdahl and Diana Chapman Walsh. Boston Univ. Health Policy Inst., Boston, MA 02215 1979, 136 pp. Availability: Springer-Verlag, New York, NY 10010.
faster than the average increases in other locations. Since the establishment of the commission, the increase in costs has been consistently and substantially below the national average. Six States had mandatory hospital regulation between fiscal 1975 to 1978. The rate of inflation in the regulated States for that 3-year period was 16 percent lower than the rates in unregulated States. Five tables illustrate the effect of inflation on costs and charges in Maryland. They present the annual percentage change in the hospital daily service charges component of the consumer price index; increases in the medical care component of the consumer price index for Baltimore and the averages for U.S. cities; calculated increases in cost per equivalent inpatient day (EIPD); the rate of increase in expense per EIPD and expense per admission and expense per EIDP for the 6 regulated States, the 44 unregulated States, and for the United States as a whole. These last two tables also include the actual dollar cost per admission and per EIPD, showing that some of the regulated States with smaller average percentage 'increases had an initial higher actual dollar cost.
lndustry's past and potential role in helping shape a national health policy is examined in several papers that cover issues such as national health insurance, industry in local health planning, private sector cost containment, and industry in communitylevel coalitions to influence health care. An introductory section urges increased business participation in local health planning and the translation of new social values into quality programs, Under the general heading of government perspectives, separate papers discuss President Carter's principles for health care cost containment and national health insurance; the Department of Health, Education, and Welfare initiatives in health maintenance organization (HMO) development and health promotion; and future congressional health policy. Other papers review the case for antitrust enforcement and the States and health care costs. Papers with a private sector perspective examine private sector cost containment initiatives and the viewpoint of labor concerning national health insurance. Next, public and private actions at the local level are explored in papers on industry in local health planning and industry in community-level coalitions. Finally, five problems that require solutions, either by private industry or by publie efforts, are considered. These are the relationship between rising hospital costs and the use of highly expensive technologically advanced equipment, biomedical research in which priorities are being made, physicians (how many, what kinds, and what they charge), the need for more long-term care facilities, and utilization review and control. Commentaries and a list of conference participants are provided.
Descriptor(s): Health care cost trends/projections, facilities, Present legislation/regulations.
Inpatient
504. Inflation, Unemployment and the Medicaid Program. William Scanlon and John Holahan. Urban Inst., Washington, DC 20037 National Center for Health Services Research, MD. Feb 1979, 44 pp.
Based on the Waslu'ngton Business Group on Health 1978 AnhUM Meeting, Washington, DC Springer Series on Industry and
Availabib'ty:
Health Care, No. Z
Using data from medicaid programs in 14 States, this paper examines the relative effects of inflation and unemployment on medicaid expenditures. Continuing inflation in medical care prices is a problem for medicaid because it purchases services on the general health care market and is subject to Federal regulations which limit cost containment options. Medicaid must preserve access to services for its clients, and therefore cannot risk actions which might cause providers to refuse to participate in the program. The size of the medicaid population varies positively with the level of unemployment. In a depressed economy, State revenues may decrease and have problems funding increased medicaid services. Data on persons receiving Aid to Families with Dependent Children (AFDC) was analyzed from 1967 to 1975 to show the impact of the 1974 to 1975 recession on numbers of eligibles, participation rate, number of services
Descriptor(s): Cost containment efforts, Economic/commercial influences, Funding/financing of health care programs, Voluntary initiatives,
503. Inflation in Hospital Costs and Charges in Maryland. Myron E. Hatcher. Jun 1980, 7 pp. Availability: Maryland Health Services Cost Review Commission, Baltimore, MD 20201.
1-228
Urban Inst., Washington,
Hyattsville,
DC 20037.
Health Care Programs
per recipient, the mix of services demanded, and the price of services. Equations were developed to calculate the share of the expenditure increases in each State in fiscal 1975 that were attributable to the recession, the removal of price controls on health services, and other causes. Simulations were then performed for three scenarios, which assumed full employment during 1975, continuance of price controls, and both full employment and price controls. The results strongly suggest that inflation in medical care prices was the principal source ofmedicaid expenditure increases in 1975. The criticism that medicaid is a cause of inflation is not completely justified because other third-party payers influence the health care market. Furthermore, medicaid is politically vulnerable because it is a welfare program. The recession did contribute substantially to cost increases in some States, and it is important to revise the methods to calculate the Federal share of medicaid to reflect cyclical conditions rather than outdated indicators of relative income.
ronment, and provider support. The most common clement of successful IPA's is that they require the presence of prepaid group practice competition as well as the support, cooperation, and participationoflocalphysicians. Few other marked similarities exist among IPA's. A multiplicity of motivational factors, physician arrangements, reimbursement methods, uti]Lization controls, and levels of success were exhibited. Major differences between the IPA's studied and prepaid group practice HMO's include reluctance by physicians to change practice patterns; concern with physician control of medical care delivery in the area; resistance to changing reimbursement methods; desire to maintain referral patterns; and lower capitalization requirements. In addition, in a favorable environment, an IPA might be developed in a year for a cost of $400,000. An additional $1 million would most likely be required to cover initial operating losses until the organization breaks even.
The simulations indicated that growth in participation rate of eligibles and expenditures per recipient had a greater impact on expenditures than numbers of eligibles. Since inflation is the main source of variation in expenditure per recipient, its impact on rising medicaid expenditures is understandable. Tables, 16 footnotes, 24 references, and policy dummies for each State are provided. (Author abstract modified)
From 'Skills Development for the HMO 1980's,' p 280-291, 1980, edited by Eugenia
Working
Managers Warhol.
of the
Descriptor(s): Prepaid plans, Comparisons of health care programs, Funding/financing of health care programs, Physicians.
Paper 986-1. 506. Influencing Federal, State, and Local Oral Healtli Poli-
Desc_ptor(s): Medicaid, National economic conditions, Health care cost trends/projections, Policy/changes re health care.
ties. Chester W. Douglass. 1980, 9 pp. Availability: Family and Community Nov 80.
505. Influence of Competition by Prepaid Group Practice on the Development of an Individual Practice Association. Health Maintenance Organization. James B. Kingston. 1980, 12 pp. A vailability: Group Health Association of America, Inc., Washington,
DC 20036.
This article reports the results of a study of individual practice associations (IPA's) conducted to determine the feasibility of an INA Heatthplan, Inc., involvement in developing and managing IPA's. Visits to six operational IPA's, discussions with individuals involved with IPA's, and a review of all pertinent literature were used to gather data. Findings indicate that the following basic essentials for a successful prepaid group practice health maintenance organization (HMO) are also applicable to IPA requirements: motivation and commitment, good management, measures to monitor and control expenses, an appropriate envi-
Health v3 n3 p81-89
There are four overlapping major policy areas in which e:ctensive debate occurs and leads to decisions that affect the oral health and oral health care of Americans: resource planning, quality of care, education of health professionals, and health insurance coverage. Policies have been developed in these areas in response to problems concerning access to care, quality and kinds of available health services, costs of health services, and geographic distribution and specialization of health care providers. The 1974 National Health Planning and Resources Development Act authorizes health systems agencies to be the central focus for planning health care services on a regional basis. Quality assurance issues have been addressed in the Professional Standards Review Organization (PSRO) legislation, which has also created a body of professional persons who review services that are currently paid for by Federal funds. In addition, the education and supply of providers have been addressed in a series of health professions educational assistance acts, which intitially stimulated the training of more physicians, dentists, and other health
1-22_}
personnel. The fourth major policy area, insurance coverage, is dominated nationally by the medicaid and medicare sections of the Social Security Act. Cutting across these main policy areas are three process issues that have emerged from the Federal Trade Commission (FTC). According to the FTC, its m-andate for action concerning the dental profession comes partly from the existing national policy of providing universal access to high quality dental care. To the extent that the country, retains a private enterprise dental care delivery system and to the exte;at that the system is inaccessible to large portions of the population for economic reasons, pressure to increase competition will co:atinue. Moreover, another FTC policy favors consumer choice in the marketplace, or consumers right to receive information on the availability and price of preventive services from dentists and allied professionals. Finally, the potential public benefits of preventive dentistry have been well documented and indicate a need for public action at Federal, State, and loca! levels. D.'_lrablc
with their use of covered a:ad noncovered services; and (3) mechanisms must be built into the information system to ensure accuracy, timely data collection and processing, and useful applicat;..ons of data to management, policy, and evaluation activities. Inclusion of specific language in NHI legislation is recommended to ensure the implementation of the foregoing principles. The report does not explore the details of the informazion system's organizational structure, costs, or data content. Rather, a conceptual framework is presented as a base from which these decisions can be made. Diagrams are supplied.
health care policies may be achieved if health care professionals and concerned citizens take appropriate, well-p|aaned action One table and four references are supplied.
508. Injuries at Work Are Fewer Among Older Employees.
Descriptor(s): Health information/data rRealth insurance (NHI), Policy/changes
systems, National re health care.
Norman Root. Descriptor(s): Policy/changes
Dental services, Present re health care.
legislation/regc_ations,
507. Information Needs of National Health |nsurtmee. A Discussion of Principles, Issues, and Legislative Reeo[nmenclarions, National Center for Health Statistics, Hyattsville MD 20782 DHEW/PUB/PHS-80/1159 Apr 1980. 12 pp. Availability: National Center for Health Statistics_ l-Iy_ttsville, MD 20782.
Central concepts and information needs of any national health insurance plan (NHI) are discussed. The National Committee on Vital and Health Statistics aims in this study to eliminate unnecessary or duplicative collection of health data while achieving a common minimal level of uniformly defined data t):,at will permit ne_mssary sharing and comparison of resultant h_dth and health services information, with strict observance of confidentiality. The following principles are especially important: (1) the information system must have the capability to count the number of persons enrolled, the number served, and the set-vices used, while linking these measures to available resources, NIH revenues and expenditures, and health status; (2) if the entire population is not covered by the plan, then the information system must have the capability to estimate periodically the size an¢i demographic characteristics of covered and uncovered groups, along
1-230
1980, 5 pp.. 4vailability: Monthly
Labor Review v104 n3 p30-34 Mar 81.
Based on data collected in the Bureau of Labor Statistics Supplementary Data System (SI)S), this article analyzes information _¥om more than 1 million workers, compensation records from agencies in 30 States that participated in the SDS program during 197"7. It examines the age distribution of injured workers rel_.tive to their exposure by industry and occupation and looks at injury characteristics and costs associated with the age of the :njured worker. While previous studies offer conflicting results in determining the age groups more prone to accidents on the job, these new data show that occupational injuries occur at a tower rate to older workers than to younger ones. The frequency of occupational injuries d,_lines steadily up to age 64 and then drops even mare sharply for workers age 65 and over. Data also reveal the positive effect of experience in avoiding injuries. Training for new workers to reduce the occurrence of injuries in _he workplace should be encouraged. Work injury ratios employed in the study are based on the percentages of work injuries and employment within each industry or occupation. Among _mployees age 16 and over, the largest proportion of workrelated injuries, 30.3 percent, occurred to workers age 25 _hrough 34. This pattern is similar for all industry divisions except finance, insurance, and real estate. Moreover, the age of the injured worker is strongly correlated with length of service. More than 40 percent of injuries to workers under age 35 occurred among those in the first year of employment. However, the more severe cases, fatalities and permanent disabilities, accounted for larger proportions of the cases among older workers zhan among younger ones. The most frequently occurring injuties to all workers were sprains and strains, cuts and lacerations,
Health Care Programs
contusions and bruises, fractures, and burns. Back injuries accounted for one out of five injuries to all workers. Five tables and nine footnotes are included.
Descriptor(s):
Workers compensation, Trends in health status.
509. Insurance Benefits, Out-of-Pocket Payments, and the Demand for Medical Care. A Review of the Literature.
Joseph P. Newhouse. Rand Corp., Santa Monica, CA 90406 RAND/P-6134 Department of Health, Education, and Welfare, Washington, DC. May 1978, 56 pp. Availabih'ty: Rand Corp., Santa Monica, CA 90406. This review of the literature examines numerous studies that relate the demand for medical care services to variation in out-ofpocket payments. Medical care services include physician, hospital, dentist, and drugs. Demand for all these services increases as out-of-pocket payments fall, but the exact magnitude of the response is somewhat uncertain. Overall demand and coinsurance and deductibles are examined. Insurance premiums for policies with different coinsurance rates reveal how overall demand responds to coinsurance. For example, one study found that as one moves from 25 percent to 10 percent coinsurance, demand increases 6 percent. In addition, theory suggests that the responsiveness of demand to deductibles is nonlinear. At very high levels of the deductible, most individuals expect not to exceed the deductible and so act as if uninsured. Although some believe that eliminating out-of-pocket payments for ambulatory services decreases hospitalization as well as overall costs, the preponderance of evidence suggests the contrary. Evidence from the medicare and medicaid programs and from Canada supports the hypothesis that demand responds to variation in out-ofpocket payments. One study found, for example, that among individuals of "average" health status, those eligible for medicaid made nearly 50 percent more physician visits and had nearly twice as many hospital days than the non-medicaid-eligible poor. The paper has 17 footnotes and approximately 80 references. (Author abstract modified)
Descriptor(s): Demand/utilization of health care programs, Medical/surgical services, Inpatient facilities, Physicians, Dental services, Pharmaceutical services, Deductible/coinsurance, Comparisons regarding foreign health policies.
510. Insurance Cost Savings Due to an Adequate Alcoholism Health Benefit. Kenneth C. Sarvis. National Inst. on Alcohol Abuse and Alcoholism, MD 20857
Rockville,
Florida State Dept. of Health and Rehabilitative Services, Tallahassee, FL. Alcoholic Rehabilitation Program. Nov 1976, 31 pp. Avallability: National Inst. on Alcohol Abuse and Alcoiholism, Rockville, MD 20857. This paper provides information that will facilitate an employer's decision to include an adequate alcoholism health benefit for employees within a prepayment program for health care. The contentions of this paper are that problem drinkers use a disproportionately high portion of health benefits but also have a high rehabilitation rate. It is further contended that there is a significant reduction in the use of health and sickness benefits by rehabilitated problem drinkers and that an employer can expect significant health insurance savings by providing employee health insurance for alcoholism. Data documenting these contentions cite mortality rates, sickness, absenteeism, and accident frequencies for employees with a drinking problem and relate these to employer costs of group hospitalization. For instance, the problem drinker's overall accident rate is 3.6 times that of other employees; digestive and musculoskeletal disorde,rs are also more frequent for alcoholics. Companies which have: a formal mechanism for the early identification and referral of problem drinking employees to rehabilitation programs are listed and their experiences summarized. Formulas are explained for comparing the problem drinkers referred as percent of total employee population with the percent increase in total preJ_ums due to cost of the alcoholism benefit, whereby an employer can estimate the insurance cost savings to be expected in terms of claims payments and premiums if an alcoholism health l_nefit is provided. Appendices give the cost savings formulas, exmnples of calculations,
and initial calculations.
National Inst. on Alcohol Abuse and Alcoholism ance Resource
Kit, Industry
Health Insur-
and Labor.
Descriptor(s): Cost/benefit analyses, Mental health servi_s, Exclusions from coverage, Voluntary initiatives, Trends in health status.
511. Insurance Coverage and Access. Implications for Health Policy. LuAnn Aday and Ronald Andersen. Robert Wood Johnson Foundation, Princeton, NJ.
1-231
National Center for Health Services Research, Hyattsville, MD. 1978, 9 pp. Availability: Health Services Research v13 n4 p369-377 Willter 1978. Data are presented
from a recent survey of the United States
population that compared the characteristics and levels of aeons to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third party coverage. The data were collected by the Center for Health Administration Studies and the National Opinion Research Center at the University of Chicago. Between September 1975 and February 1976 interviews were conducted with 7,787 persons in 5,432 households representing the civilian noninstitutionalized population of the United States. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coyerage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. The findings imply that persons who are self-employed or who work in trades or profusions that do not usually provide health insurance benefits should receive considerable attention as alternative national health insurance proposals are being weighed. Findings also suggest the utility of considering health maintenance orgarqzations or other organizational arrangements in tandem with expanded financial coverage to produce cost-efficient and equitab!e access to the health care system. Three tables and four refereaces are given, Desct4ptor(s): Participation in health care programs, Partici_ pants in health care programs, Non-participants in health care programs, Demand/utilization of health care programs Private health care plans, Publicly sponsored/mandated health plans.
try. Information about tile sources and extent of hospital-cost inflation in recent years is presented, and an overview is given of issues related to health insurance, regulation, and other factors, such as the effect of physicians and unions on hospital performance. The book develops theories of hospital behavior and describes the sample of 1,228 hospitals selected for study, methods of data-file construction, dependent and independent variables, and the econometric properties of the input equations. Additional chapters provide indepth discussions of third-party reimbursement and hosFital regulation, present statistics pertaining to private health insurance, and give a detailed overview of current regulatory trends affecting hospitals. The study found that, as a group, regulatory programs did not succeed in constraining the growth in hospital costs during the 1970's; that both private health insurance and public programs demonstrated positive effects on hospital costs; and that cost-push factors, including unions, caused a substantial proportion of the rise in hospital costs over the first half of the 1970's. The study concludes hospital be attributed to both external that forces and a cost lack increases of internalcancost-consciousness. The study further suggests that policymakers
show caution
in con-
tinuing future hospital controls because of the study's lack of evidence showingbe the effectiveness of such Furtherof research should conducted in such areas controls. as the effects hospital investment cont:rols and of the physician decisionmaking process in hospitals. Three figures and 38 tables are given. Eleven appendices contain study variables, a bibliography of about 200 references is given. (Author abstract modified)
Descriptor(s): Health irformation/data systems, Health care cost trends/projections, Cost containment efforts, National economic conditions, Private health care plans, Publicly sponsored/ mandated health plans, i[npatient facilities, Present legislation/ regulations, Pohcy initiatives, Supply/availability of services, Impact of third-party coverage, Outcome/evaluation of health administration.
513. Insuring Intensive Psychotherapy. 512. Insurance, Regulation, and Hospital Costs. Frank
Steven S. Sharfstein and Howard L. Magnas. 1975, 5 pp
A. Sloan and Bruce Steinwald.
National MD.
Center for Health Services Research,
1980, 266 pp. Availability: D.C. Heath and Co., Lexington,
Hyattsville,
MA 02173_
This book examines factors that have influenced hospital costs and employment of inputs during the !970's and explores the effects of health insurance and regulation on the hospital indus-
1-232
Availability: American 1256 Dec 75.
Jinl. of Psychiatry
v132 n17 p1252-
The economics of insurance coverage for mental illness is examined to determine the fea_dbility of such insurance benefits. Many private insurance programs that currently cover mental disorders eliminate intensive psychotherapies, including psychoanalysis, from the range of treatment options by placing restrictions
Health
Care Programs
on the number of visits covered. Opponents of comprehensive mental health coverage under national health insurance (NHI) argue that unlimited benefits for mental health care would bankrupt the system because of the influx of new cfients who would seek these services. In their view, strict limits on mental health coverage are necessary to insure the financial viability of the insurance fund. In contrast, proponents of unrestricted mental health coveraqe note the lack of any support for the inevitability of such an influx. They believe that mental health benefits would precipitate an initial increase in costs which would then reach a stable plateau and that users of mental health benefits would decrease their expenditures for physical ailments. Although there is no definitive evidence for either side of this argument, an increasing flow of evidence supports the contention that cornpreheusive mental health coverage does not radically change existing utilization patterns for mental health care. In the experience of private high option coverage plans, a small number of recipients utilize a large portion of services, especially in the crucial high-cost area oflong-term intensive psychotherapy. Despite these findings, certain issues must be resolved if NHI is ever to provide unlimited mental health coverage on an equitable basis to all individuals regardless of class. First, the definition of the nature of catastrophic illness must be clarified, as high-cost mental health treatment for relatively healthy individuals undermines the catastrophic analogy. Second, the effect on the provider system of the potential demand for long-term psychotherapy available to the general population must be assessed to assure the availability of an adequate provider supply. Finally, the costeffectiveness of inteusive psychotherapy must be carefully scrutinized. Sixteen references and four tables are furnished,
Read at the 128th annual meeting of the American Association, Anaheim, CA, May 5-9 1975.
Descriptor(s): ance (NHI),
Psy¢ln'attic
Exclusions from coverage, National health insurMental health services, Demand/utilization of
health care programs, Private health care plans,
514. Insuring the Nation's Health. An Evaluation of Three Approaches.
Judith Feder, Jack Hadley and John Holahan. Urban Inst., Washington, DC 20037 Department of Housing and Urban Development, Washington, DC. Ford Foundation, New York, NY. Jun 1980, 257 pp. A vailabih'ty: Urban Inst., Washington, DC 20037.
This paper examines three proposals for national health insurance (NHI), discusses their likely effects on health care costs, and suggests additional goals for NHI. The Martin bill, designed to fill a major gap in coverage with minimal changes in health care financing, provides protection against catastrophic expenses to low-income people not currently eligible for medicaid, to people who cannot obtain health insurance through employment, and to the employed population. It promotes choice and competition in the market for health insurance, but it reinforces the increased demand for costly services. Its payment methods assure that medical costs will continue to increase rapidly. Like the Martin bill, the Carter bill focuses on gaps in coverage and partially reforms payment mechanisms in order to limit costs. The bill proposes the use of fee schedules for governmental health care plans, but it would ultimately have to control private as well as public fees to control inflation. The Kennedy-Waxman bill proposes an entirely new system of insurer organization and provider payment to promote efficient resource allocation and cost containment. However, because of ceilings on individual premiums, general revenues rather than individuals would bear the primary burden of the increased cost of insuring the sick. Expectations that competition will encourage changes in service price and use seem particularly unlikely because of the lack of cost-sharing obligations and because of the regulatory constraints of the bill. The bill requires the Government to make decisions on how much to spend and offers mechanisms to enforce those decisions, but elements of an efficient resource allocation process are lacking. All of these plans, however, could be modified to promote greater equity and efficiency. People in equal circumstances should be treated equally by an NHI and all payers should be required to pay providers no more than the rates set by public plans. Furthermore, the fmancing scheme should not take a greater share of income from the poor than from the rich. Decentralization is preferable to the establishment of a single, federally administered plan covering the entire population. If multiple plans are employed, the tax system should be neutral about the choices and measures would be required to protect against selection of low risk enrollees. The NHI plan should adopt financing arrangements similar to Canada's to allow government to control its spending decisions and to permit spending to vary with local and State preferences. There are 124 footnotes and a chart summarizing the three NHI insurance proposals.
Wortdng Paper No. 1400-1.
Descriptor(s): National health insurance (NHI), Comparisons of health care programs.
1-233
515. Interaction of Supply and Demand in the Market for Physician Services.
p405-432 _'inter
Gall R. Wilensky and Louis F. Rossiter. Aug 1979, 8 pp. Availability: National Center for Health Service_ Research_ Hyattsville, MD 20782. The theoretical foundation and the empirical specification of physician services are described. The discussion's focus is on the aggregation of individual behavior to the local market level and the interaction of money price and time price as an equilibrating mechanism for local markets as they move to equilibrium. This analysis is part of an ongoing series of analyses which comprise the National Health Care Expenditures Study. The major goal of the larger study is to analyze alternative national health incurance proposals. The data used in this paper's analysis were taken from the National Medical Care Expenditure Survey, which will give a detailed description of the personal health care expenses and the level of health insurance coverage of the American peopie in 1977. ]'he survey had three aspects: (I) a survey of 13,500 randomly selected households, (2) a survey of the physicians and hospitals that provided care to household respondents during 1977, and (3"_ a survey of insurance companies and employers responsible for the private insurance coverage of the household respondents. Basic models of consumer and physician behavior are described, and then it is shown conceptually how individuai behavior can be summoned to form the market aggregates which are the study's primary focus. Separate local markets are considered in developing equilibrium prices and quantities, under the assumption that the service-intensive nature of physician ,__are precludes a national market or a single national equilibrium, Several empirical specification issues are discussed befor,__ eso timating the developed model and the demand for medical care in general. These include issues of disaggregation, the unit of analysis, and endogeneity. An illustration of how the model would work is provided_ Eighteen references are included.
In examining the current health care debate, the paper notes that the interfacing of various health and welfare programs does not receive the full scrutiny thai it deserves and that the major national health insurance proposals may work at cross purposes with present and proposed income maintenance programs. A strong work incentive is central to all discussions of welfare reform; theoretically, a welfiLre recipient is always better off working. In practice, however, the combined net income from welfare and earnings may actually decrease as earnings increase, creating a serious disincentive to work. Income-tested health care financing seriously compromises income maintenance objectives, such as work incentive and equity. The only way to avoid this problem is to make health care universally available without regard to income or special status, as with free public education. Five proposals for individual national health insurance are before the 94th Congress, and they are analyzed to determine how each will intel_face with cash transfer programs. The five bills are the Corman.-Kennedy bill, the Ullman bill, the Burleson-McIntyre bill, the Downing bill, and the Long-Ribicoff bill. All five bills assume that no person should be denied health care because of the inability to pay, but most perpetuate many of the benefit coordination problems of existing medicaid programs. The proposals reflect the conflict in health care financing between premiums and taxation. Premiums assign health care costs on the basis of actuarial risk, whereas taxation allocates costs on the basis of ability 1:opay. The Corman-Kennedy bill relies mainly upon taxation i:nstead of premiums, avoiding the problems associated with the ability to pay, more honestly facing up to the redistributive implications of health care financing. The altempts to shore up the pri_ate insurance approach by providing special subsidies to the poor risks undermining meaningful welfare reform. Tabular data, graphs, footnotes, and 24 notes are provided. (Author abstract modified) Descriptor(s):
Presented at the Amerlc'an Statistical Association M_tin_ Joint Business and Econom,cs Sta Ostics Section/Biometrics tion, Invited
Paper Session, August
Desc_ptor(s):
Demav, d/uulization
Supply/availability
1979, Washington, of heahh
the Sec-
Present legislation/regulations,
ing of health care programs, Policy/changes tionat health i.asurance (NHI).
Funding/financre health care, Na-
DC
c_,-re progiams,
cf serv_zes, Physicians.
516. Interfacing National Health Insurance and Income Maintenance. Why Health and Welfare Reform Go Together. Gerben DeJong. 1977, 28 pp. Availability: Jnl. of Health Pohtics_ Policy and Law vl n,L
11-234
1977.
517. Iaterim Report to Congress on Occupational
Diseases.
Department of Labor Assistant Secretary for Policy, Evaluation and Research, Washington, DC 20001 Jun 1980, 138 pp. Availability: Department of Labor, Washington, DC 20210.
This report on occupational diseases addresses (1) their magnirude and severity (especially respiratory and pulmonary dis-
Health Care Programs
eases), (2) the status and adequacy of current disability programs, (3) alternatives for improving disabifity compensation, and (4) the status and adequacy of prevention programs. A self-report study found that almost 2 million workers reported severe or partial disability from an occupationally related disease; approximately 700,000 suffer long-term total disability, The 1.2 million partially disabled workers were either temporarily out of the labor force or limited in the kind of work they could perform. The data include chronic cases of totally disabling byssinosis and asbestosis, as well as partially disabling diseases, such as varicose veins, arthritis, and ulcers. Public and private income support programs replace about 40 percent of the wages lost from occupational disease, compared with a 60 percent replacement rate for occupational injury. Those severely disabled from disease receive social security (53 percent), pensions (21 percent), veterans' benefits (17 percent), welfare (16 percent), workers' compensation (5 percent), and private insurance (1 percent). One out of every four receive no income support, and one in every three receive multiple benefits. The Black Lung Program, a compensation program for victims of the disease, provides benefits to about 450,000 disabled miners, widows, and dependents. Compensation benefits can be improved by building on to the social security disability insurance program, strengthening worker's compensation, and implementing substance-bysubstance programs. Research must establish a list of eompensable diseases; develop presumptive standards, analyze alternative financing mechanisms, and estimate the population in need. Tabular data are appended,
Descriptor(s): Competition/interaction among third-party payors, Workers compensation, Trends in health status, Health care cost trends/projections, Preventive services, Comparisons of health care programs, Participation in health care programs.
518. International Dental Care Delivery Dental Health Policies.
Systems.
Issues in
Ballinger Publishing
Company,
Cambridge,
reference notes. Short biographies are also supplied.
of the authors and an index
Proceedings of a Colloquium sponsored by The Institute of Medicine and The Pan American Health Organization. First of a planned series.
John I. Ingle and Patricia Blair. Kellogg (W.K.) Foundation, Battle Creek, MI. 1978, 263 pp. Availability: 02138.
other nations are intended to help planners in the U_litcd Sta'es develop a comprehensive unified national health program for dental care delivery. Following introductory comtnctlts, the volume presents a series of national reports categorized geographically: New Zealand; the Americas; Europe; China; and the United States. The New Zealand Dental Nurse Program is considered a pioneering landmark in the field of dental history. Established in the 1930's, the program, which formalized and legalized the delegation of intraoral professional operations to dental auxiliaries, is assessed for its effectiveness in delivering health care to children as well as for its shortcomings in the area of dental health education. Programs modeled after New Zealand's are reported for Australia and Canada. Innovative programs from the Americas include reports from Mexico, Venezuela, Ecuador, and the Republic of Cuba. Cuban solutions to dental manpower problems seem particularly well suited for application to rural areas. European experiences include those of the United Kingdom, Czechoslovakia, Eastern Europe, Norway, Sweden, and the Netherlands. While Czechoslovakia represents an example of a working system without patient freedom to choose a dentist, it also illustrates an approach to periodic relicensure of dentists and to continued professional education issues. The Swedish program has the most applicable models for adaptation in the United States. Dentistry in mainland China is characterized by a rigid organization where options are provided only at the governmental level. The chapter on the Urdted States contains a thorough review of the country's dental care system, along with recommendations that are both imaginative and controversial. Two papers describe research endeavors: one deals with sociological variables to be considered in devising national health programs on the basis of studies in a eros section of seven countries of the world; the other describes a plaque control program in Sweden which demonstrates the effectiveness of the Swedish thrust into preventive dentistry. Audience participation is summarized in an edited version of a question and answer session. Appended are listings of program speakers, moderators, and participants. Individual papers contain tabular data and
MA
The papers compiled in this volume stem from a symposium that explored various alternatives for the provision of dental care under national prepaid programs. They represent the ideas of an international panel of experts concerning approaches to the delivery of dental health care in diverse parts of the world. These examples of how dental manpower problems are being solved in
Descriptor(s): Supply/availability of services, DenUd services, Comparisons regarding foreign health policies.
519. Issues in Dental Health Policies. 1979, 100 pp. Availability: Jnl. of Dental Education
v2 part 2 of 2, pl-100
1-235
(special issue) Oct 79. Following an introductory statement detailing the decisionmak-. ing process adopted by the Council of State Governments Na-. tional Task Force on State Dental Policies, drafts of suggested legislation are presented. The task force viewed protection of public health and safety as the main purpose of regulations and felt that as many varieties of service as could survive in the competitive market should be permitted. The proposed laws establish a State Board of Dentistry, define licensing and testing procedures for all personnel involved in dentistry, and delineate disciplinary procedures. Legislation is also suggested to create a Health Occupations Council composed of professionals and consumers to coordinate certain functions now performed by in-. dividual licensing boards, such as budgeting, office location, staffing, investigations, and professional discipline. The second half of the task force report contains seven position papers that provided background information for their deliberations. The first presentation discusses dental licensure laws from a public policy and consumer perspective and then examines licensure testing procedures based on the Central Regional Dental Testing Service. The impact of outdated State dental practice acts on dental education is explored, and reforms are outlined which would promote research and upgrade educational programs. A description of the organization and functions of State dental boards is followed by an analysis of dental health care delivery systems which concludes that licensure has inhibited the development of a modern delivery system. The history of national dental manpower policy is reviewed over the past 15 years, and alternatives for using the present manpower supply are offered, including increasing the demand for dental services. The final papers consider denturism, a movement of dental laboratory technicians to obtain independent licensure, and State responsibilities to assure continuing competency of individual dental practitioners. A bibliography of eight references is provided.
examining regulation in the United States, a descriptiori of the anatomy of regulatory failu_:e, an approach to regulatory relbrm to make Government intervention more fruitful, and options open to health care regulalors. The framework, anatomy, and approach to regulatory reform are then applied to specific health care regulation challenges, including problems associated with health resource allocation, cost of service ratemaking, certificates of need, and the drafting of health care regulations. Also addressed are problems associated with the implementation of health care regulations ancL administrative and legal problems associated with bargaining and negotiating regulatory proposals and programs. The main problem in the health sector for which regulation continues to be proposed is the need for control of health service costs. The cost control problem is complex because most costs are not paid for by the consumer but rather by insurance or Government agencies. It can be argued that market failure correction involves more than just regulating prices; correction must also be directed at limiting the demand which allows prices to rise. Lack of consumer information and thirdparty payment prevent consumers from questioning the value of expensive technology and other excessive costs. Even if health maintenance organizations are a long-term answer to cost control, continuing cost escalatJLon and other problems will generate pressures for Government action and intervention now. Issues which must be considered a_reidentification of the problems that require Government intervention, alternative courses of action, and determination of the most effective approach for solving problems. An index, chapter reference notes, and tables are ineluded. (Author abstract modified) Regulation
of American
Business and Industry
Series.
Descriptor(s): Cost containment efforts, Economic/commercial influences, Policy/changes re health care, Third-party payors.
Descriptor(s): Dental services, Policy initiatives, Supply/availability of services. 521. Issues in Regulating Quality of Care and Containing Costs Within Private Sector Policy. Howard
L. Bailit.
520. Issues in Health Care Regulation.
National MD.
Center for Health Services Research,
Richard S. Gordon. 1980, 375 pp. Availability: McGraw-Hill 10020.
1980, 7 pp. Availability: 80.
Book Company,
New York, NY
This book e_plores the pitfalls of the classical approach to reguiation and suggests alternatives more suitable to health care cost containment efforts. Topics include an analytical framework for
l 230
Jnl. of Dental Education
Hyattsville,
v44 n9 p530-536
Sep
This paper presents an analysis of some of the more important issues relevant to the development of policies on dental care quality. Before quality assurance systems can be introduced into dentistry, existing problems must be defined and measured, and
Health Care Progr,m_
the relative costs and benefits of alternative approaches to their resolution must be evaluated. In the United States, data are available to measure the technical quality of both amalgam restorations and the treatment of periodontal disease. These data indicate that 80 to 85 percent of restorations are properly placed and that those which are improperly placed tend to be coneentrated in a small percentage of the population from all sociodemographic groups. In contrast, the data for periodontal disease show that only about 20 percent of the population estimated to need treatment actually receive it. Analyses of the determinants of dental disease show that variables such as patient age and oral hygiene explain most of the variance in the condition of a person's teeth. Thus, it is difficult to support a proposal for standards to improve the quality of dental care that would impose additional costs on the system without any evidence to suggest that the objective would be met. Such a review system for periodontal disease would undoubtedly increase the demand for dental care, with a concomitant increase in dental expenditures. Seven tables and 25 references are included. (Au-
persons at high risk of needing services, there will be less variation among subscribers in the actual costs of serving enrollees than presently exists in capitation systems for acute care:. Finally, the purchaser of services would most likely be the Government, not private employers. Those interested in exploring the possibility of establishing a capitation plan should define the eligibility criteria, estimate the per capita costs, and develop an organizational framework. Eligibility criteria could limit enrollees according to their source of income or health coverage, location, age, and functional ability. Per capita costs will depend upon the scope of covered services, services utilization, and cost per service. These plans could be organized in a variety of ways in terms of dependency on public funds and existing providers of longterm care, intake services, and risk sharing with agencies with which the plans contract. The capitation plan creates incentives for the proper placement of institutional patients and would enhance the likelihood of innovative patterns of service delivery. Three footnotes, a table, and 60 references are included.
thor abstract modified)
Earh'er version presented'at the 29th Annual Scientific of the Gerontological Society, New York, 1976.
Paper presented at the Annual Meeting of the American Association of Dental Research, March 2L Los Angeles, CA.
Descriptor(s): assurance,
Dental services, Outcome/evaluation
522. Issues Involved in the Development tion Plan for Long-Term Care Services.
of quality
of a Prepaid Capita-
Sharon Winn and Kenneth M. McCaffree. 1979, 7 pp. Availability: Gerontologist v19 n2 p184-190 Apt 79.
This paper explores the ramifications of establishing an alternative method for financing long-term care services which could integrate the financing of services presently provided by Federal and State agencies. The suggested alternative, capitation, is a method of payment for services in which an individual or institutional provider is paid a fixed amount for each person served per time period without regard to the number or nature of services provided to each individual. Differences exist between a capitation payment plan for long-term care and capitation plans presently in existence. First, the scope of benefits covered would be different -- i.e., coverage for acute episodes of hospitalization would not be included. Second, a capitation system for long-term care is more likely to cover a population at high risk of needing services, primarily the elderly and the functionally disabled, Third, because the enrolled population will probably consist of
Meeting
Descriptor(s): Health care costs, Eligibility requirements, Publicly sponsored/mandated health plans, Long term care facilities, Methods of payment determination, Policy/changes re health care.
523. Japan's High-Cost 1]lness Insurance Program. A Study of Its First Three Years, 1974-76. Joel H. Broida and Nobuo Maeda. 1978, 8 pp. Availability: Public Health Reports v93 n2 p153-160 Mar/ Apr 78. The 1973 amendment to Japan's basic Health Insurance Law enacted to provide catastrophic illness coverage is examined and its effects are assessed. The new coverage was extended to dependents of insured workers enrolled in the employer-employee insurance plans and to all persons under the so-caUed national health insurance plan. Before that time, dependents were required to pay 30 percent of physician, hospital, and other charges out of pocket. Under the new system, they are still required to pay 30 percent out of pocket, but they have a maximum liability level of 30,000 yen ($120) during any calendar month. Health insurance covers 100 percent of the excess charges above the personal liability level. Data on the first 3 years of the program derive from a number of Japanese health and medical agencies. Findings for the 3-year period indicate an
1-237
increase of more than 70 percent in the frequency of high-cost cases. The trend was evident in all six major health plan studied, The average expenditure increased 5.7 percent from 1974 to 1975 and 14.6 percent from 1975 to 1976, regardless of plan, with marked differences by diagnosis. The average length of hospital stay for high-cost cases remained relatively stable. Cancer patients had the highest average charge and the longest hospital stays. Rises in high-cost illness frequency and expenditures are attributed to increased access of care, transformation of unmet need into demand, physician and patient knowledge of maximum patient liability, increases in service intensity because of new technology, two increases in physician reimbursement rates during the study period, and general inflation of medical care costs. A shortcoming of the system is that it provides no incentives for the providers or patients to reduce the intensity of services or the length of hospital stays. Without such incentives, rising utilization, rising costs, and financial deficits become the rule rather than the exception. Five references and four tables are furnished. (Author abstract modified)
ents. Hospital charge data associated with this use was also reported on the basis of routine room and board charges, ancillary charges, and total charges on a per case basis. The 113 hospitals included in the study were classified into 7 major groupings designed to reflect differences in bed size, geographic location, existence of major teaching programs, and medical school hospitals. Also included is an analysis of the number of days patients spent in the hospital between the day of admission and the day of surgery. The study found that on behalf of the participating employers, Blue Cross paid for 662.8 days per 1,000 subscribers during 197_;, while for all Blue Cross groups 715.8 days per 1,000 subscribers were paid. The report includes 10 charts, 9 exhibits, and 5 appendices presenting additional data. (Author abstract modified)
DesctCptor(s): Demand/utilization of health care programs, Cost containment efforts, Service benefit plans, Inpatient facilities, Voluntary initiatives, Outcome/evaluation ance.
of quality assur-
Descriptor(s): Comparisons regarding foreign health policies, Comparisons of health care programs, Demand/utilization of health care programs, Health care cost trends/projections. 525. Justice for the Patient and the Dentist. Quality Assurance Activities of the W.K. Kellogg Foundation and the American Fund for Dental Health. 524. Joint Health Cost Containment Program. Hospital Utili. zation Report. Blue Cross of Greater Philadelphia, Philadelphia, PA 19107 Penjerdel Corp., Philadelphia, PA 19124 Greater Philadelphia Chamber of Commerce, Philadelphia, PA 19124 Health Services Council, Inc., Philadelphia, PA 19103 Sep 1979, 137 pp. A vailabH#y: Blue Cross of Greater Philadelphia, Philadelphia, PA 19107.
This hospital utilization report analyzes the 1978 aggregated claims payment data for the 37 participating employer groups of the Joint Health Cost Containment Program covered under Blue Cross of Greater Philadelphia, Pa., and compares this data to the 1977 experience. The analysis is designed to assist in the development of more cost-effective health care use by employees and their dependents. This report examines 30,339 inpatient claims paid by Blue Cross in 1978. Hospital charges for these 30,339 inpatient cases totaled $58 million. The utilization data examined for the 13 major diagnostic systems include 100 percent of the inpatient claims paid for 1978. In each diagnostic category, average length of stay (ALOS) was reviewed by age and by day of the week admission for both the employees and their depend-
1-238
Maynard K. Hine and Eric M. Bishop. 1978, 7 pp. Availabib'ty: Jnl. of the American Dental Association p179-185 Feb 79.
v98 n2
This article delineates the goals of a project to develop a dental quality assurance system anti discusses problems, such as developing sanctions and handling costs, that the system will face. Quality assurance in dentistry was first discussed but not delineated in the 1950's. The advent of group dental prepayment, however, was marked by a greatly increased insistence of proof of quality, to be monitored by the dental profession itself. This research project, funded by _;he Kellogg Foundation and implemented by the American Fund for Dental Health, has the following goals: to develop systems for measuring dental services quality, collect data on care quality in private practice, and develop data systems that l_:rmit multipractice comparisons of oral care that meet basic standards; to evaluate the dental profession's current peer review system; to develop methods of quality assurance; to train dental professionals in dental care evaluation; and to train peer review committees. In addition, the project attempts to answer questions concerning definitions, unjust indictments, methods of documentation, costs, sanctions for inferior care quality, lay participation in quality assessment, and patient behavior. Problems in defining and measuring quality
Health Care Programs
arise in developing standards, recording treatment, and preserving evidence, while cost problems center on whether the added financial burden of an effective quality assurance system will be offset by benefits to the patient. Finally, the quality assurance program will have to protect dentists' reputations, and honor patients' privacy in gathering evidence for complaints or disputes, Seven references and one photograph are included.
Descriptor(s): assurance.
Dental services, Outcome/evaluation
526. Kaiser's Financial Strategies HMOs.
of quality
and Some Cues for Other
Availability: Winter
Health Care Management
Descriptoffs): Prepaid plans, Comparisons of health grams, Funding/irmancing of health care programs.
and Develop-
care pro-
527. Law and Legislative Summaries. Federal 1979. Fiirst Session, Ninety-Sixth Congress. National Clearinghouse for Alcohol Information, MD 20852
Robert A. Vraciu and David B. Starkweather. National Center for Health Services Research ment, Hyattsville, MD. 1978, 12 pp.
long-term debt are not always available to HMO's, and high debt positions result during development states and expansion periods. HMO's need to effectively manage the risk of insolvency. Kaiser's strategies for achieving self-sustaining operations, generating capital, and managing the risk of insolvency has lead to its success. Five tables and 17 references are provided.
1979, 24 pp. Availability: National Clearinghouse for Alcohol LLS section, Rockville, MD 20852,
Rockville,
Information,
Review v3 nl p29-40
1978.
The financial structure and operating experience of the Kaiser Medical Care Program, a prototype of the health maintenance organization (HMO), provides useful insights for managers of similar health services. The strategies of the Kaiser program are not unique, but they have been skillfully applied. Kaiser's financiai performance can be measured in four major areas of financial analysis: short-term liquidity, profitability, long-term debt position, and funds flow. Financial strategies involve three major activities: generating sufficient funds to cover short-term operating needs, generating new capital, and managing both the shortterm and long-term risk of insolvency. An integral part of the budgeting process is insuring that there will be sufficient revenues to cover operating expenses. Kaiser's success in this area is largely determined by its forecasting accuracy, a task enhanced by the prepaid, closed panel nature of the health plan. Permanent capital is generally required by any organization for working capital needs, expansion and replacement of plant and equipment, and for contingency reserves. Kaiser's ongoing strategy for raising capital, a mixure of long-term debt, earned surplus, and a small amount of philanthropy and grants, may not be feasible for other HMO's. However, Kaiser's strategies of short term liquidity management can be followed by other HMO's, although the t'me tuning required may be unworkable for new or financially troubled HMO's. Kaiser's long-term risk management policy focuses on restricting the use of long-term debt when purchasing plant and equipment; such an ability to raise permanent capital is vital to the long run viability of any organization. Alternatives to financing capital purchases with
These law and legislative summaries focus on major Federal alcohol-related legislation pending or enacted thus far in the 96th Congress. They are intended to provide professionals, program administrators, staff, and community interest groups with a source of information on Federal legislation relating to the alcohol field. Emphasis is placed on major bills of siqnificance in the alcohol field, such as a bill to develop methods of prevention and treatment related to domestic violence and other purposes; a comprehensive act that encompasses alcoholism prevention, treatment, and rehabilitation; and a bill to protect the privacy of medical information maintained by medical care facilities. Legislation is listed by title, bill number, sponsor, status, introduction date, and conqressional session. Source information and a summary of the bill are included. The report also contains a subject index, and legislative references are listed under each subject category. (Author abstract modified) Descriptor(s): lations.
Mental health services, Present legislation/regu-
528. Law and Legislative Summaries. States 1979. National Clearinghouse for Alcohol Information, MD 20852 1979, 57 pp. A vailabilJty: National Clearinghouse for Alcohol LLS section, Rockville, MD 20852.
Rockville,
Infolxnation,
1-239
These summaries focus on major alcohol-related legislation passed by each State during 1979. They are intended to provide alcoholism professionals, program administrators and staff, and community interest qroups with a source of information on State legislation relating to the alcohol field. The report covers enacted State legislation listed alphabetically by State; bills still in the legislative process have not been included. Examples of alcoholrelated health insurance legislation include an act requiring
nies and increasing competition. The newest industry, investorowned hospitals and hospital chains, is characterized by rapidly growing but still relativelLy small companies. The appendix, ineluded to illustrate certain social, economic, and political issues, focuses on Medtronics, a highly scientific, fast-growing firm producing electronic pacx'.makers. Tables, footnotes, and 28 references are included. (Author abstract modified)
group and plans to offer benefits health fi_r theinsurance care and policies, treatment contracts, of alcoholism in licensed or
Descrlptor(s): Medical technology impacts, Supply/availability of services, National economic conditions, Inpatient facilities.
certified programs and to provide for minimum levels of benefits when such coverage is elected (Alabama); an act requiring insurers who issue group, blanket, or franchise disability insurance to offer coverage for the necessary care and treatment of alcoholics (Florida); and an act stating that no contract providing major medical or outpatient care benefits is to be sold unless the master policyhohler is offered the option to purchase the minimum benefits for treatment of alcoholism (Kentucky). Each bill is listed by title, law number, sponsor, effective date, and congressional session. An abstract and availability and price information are included as is a subject index.
Descziptor(s): Private health care plans, Mental health services, Present legislation/regulations, Mandated benefits.
529. Laws of Motion in the For-Profit Theory and Three Examples.
Health Industry.
A
Gelvin Stevenson. 1978, 22 pp. Availability: International 256 1978.
Jnl. of Health Services v8 nl p235-
This article discusses a theory of growth of the for-profit health industry and examines three industries representing different stages of product and market development. The dynamics generated in the for-profit health industry by the drive for accumulation combine with the life cycle of a product to produce, within a given political structure, trends toward certain types of industry framework. The evolution of this structure is characterized by increased concentration of economic activity in diversified multinational corporations which combine health and nonhealth products. Three industries representing different stages of product and market development are analyzed in this article. The pharmaceutical industry is a mature industry dominated by large diversified multinational corporations which grow mainly through expansion abroad and diversification. The medical and dental instruments and supplies industry is newer, smaller, and faster growing. Its growth potential is attracting many compa-
1-240
530. Legislative Response to the Medical Malpractice Constitutional Implications,
Martin H. Redish. AHA-2001 American Hospital Association, Chicago, IL. 1977, 67 pp. AvMlability: American Hospital Association, Chicago, 60611.
Crisis:
IL
Legislative alternatives designed to curb the medical malpractice crisis are described, and l:heir likely reception by the courts is examined. It is likely that _medieal malpractice reform legislation will not fail as a result of an equal protection attack. Such legislation should be tested on a "rational basis" test, which allows the legislature wide latitude in enacting social reform. It is also likely that, in the majority of States, legislatively imposed limits on the amount a plaintiff may recover or for which a health care provider can be liable will be held constitutional. There is a possibility, however, that in some States the courts may invalidate this legisl_.tion because it limits a common law right without providing a quid pro quo, although such a requirement is dictated by neither case precedent nor constitutional policy. State legislatures may be allowed to reduce the statute of limitations in medical malpractice eases, as long as the period is not so short that it is unr_tsonable. Exactly what period of time would be held to be unreasonable is not clear; however, it is likely that any statutory period of 1 year or more will be constitutional. The use of screening panels will probably be held constitutional in most States. It has been argued that allowing the panel's findings into evidence at a subsequent trial will so prejudice the jury that it will violate the losing party's constitutional right to jury trial. This argument iis not well taken; even though it has on occasion been accepted by certain courts, it has been rejected by others. More serious constitutional problems are presented by plans to impose compulso_ arbitration of medical malpractice disputes. Such plans are likely to violate the constitutional right to jury trial and the right of access to the courts. Since these
Health Care Programs
rights are waivable, however, legislative plans providing for enforcement of voluntary agreements to arbitrate medical malpractice disputes do not present these difficulties. Extensive footnotes are provided.
Also See "Constitutionality Legislation• A Supplemental
Descriptor(s):
Economic/commercial
lation/regulations,
531. Licensing
of Medical Report."
Malpractice
Reform
influences, Present legis-
Policy initiatives,
Restrictions and the Cost of Dental Care.
Lawrence Shepard. 1978, 15 pp. Availability: Jnl. of Law and Economics Apt 78.
v21 nl p187-201
This paper assesses how licensing practices by State authorities influence the availability of dental services. Particular attention is devoted to the refusal of most dental boards to recognize licenses granted in other States. Average fees for 12 dental services are compared between States that recognize out-of-State licenses and those that do not. Using a dental service price index, the effects of licensing practices on fees and dentist income are identified econometrically. The potential impact of tic.ensure reform is subsequently considered. The paper concludes that dental licensing boards inhibit competition through restrictive licensing practices such as limiting the entry of nonresident practitioners or the number of new dentists trained in their States. The study provides evidence that where regulatory authorities have constructed competititve barriers, dentists systematically raise fees augmenting their earnings. It is estimated that the price of dental services and mean dentist income are between 12 and 15 percent higher in nonreciprocity jurisdictions when other factors are accounted for. Overall, the annual cost of this form of professional control is approximately $700 million. Pending proposals for licensure reform could eliminate these costs while effecting a more efficient geographical distribution of dentists. Thirty-six footnotes and 4 tables are included. (Author abstract modified)
Giannini
Foundation
Research
Desc_ptor(s): Supply/availability Present legislation/regulations.
Paper 476.
of services, Dental services,
532. Lifetime Health-Monitoring proaeh to Preventive Medicine.
Program.
A Practical
Lester Breslow and Anne R. Somers. Robert Wood Johnson Foundation, Princeton,
Ap-
NJ.
1976, 8 pp. Availability: New England Jnl. of Medicine v296 nl I p601608 17 Mar 77.
Proposed is a lifetime health-monitoring program (LHMP) that uses clinical and epidemiologic criteria to identify specific health goals and professional services appropriate for 10 different age groups: the pregnancy and perinatal period, infancy (first year), preschool child (1 to 5 years), school child (6 to 11 years), adolescence (12 to 17 years), young adulthood (18 to 24 years), young middle age (25 to 39 years), older middle age (40 to 59 years), the elderly (60 to 74 years), and old age (75 years and over). Health goals and professional services are listed for each of these age groups. The following criteria were applied in selecting procedures to implement LHMP's goals: (1) the procedure is appropriate to the health goals of the relevant age group and is acceptable to the relevant population; (2) the procedure is directed to primary or secondary prevention of a clearly identified disease or condition that has a definite effect on the length or quality of life; (3) the natural history of the disease associated with the condition is understood sufficiently to justify t:he procedure as outweighing any adverse effects of intervention; (4) for purposes of screening, the disease has an asymptomatic period during which detection and treatment can substantially reduce morbidity or mortality; (5) acceptable methods of effective treatment are available for conditions discovered; (6) the prevalence and seriousness of the disease or condition justify the cost of intervention; (7) the procedure is relatively easy to administer and generally available at reasonable cost; and (8) resources are generally available for follow up diagnostic or therapeutic intervention if required. Specific procedures for applying these criteria to two of the age groups are suggested. Overall, this preventive program would eventually reduce the amount of expensive curative care now needed. The cost of such preventive measures should be covered by health insurance programs, whether based on fee-for-service or capitation. References are provided. Descriptor(s): Cost containment Voluntary initiatives.
efforts, Preventive
533. Linking Physicians, Hospital Management, talnment and Better Medical Care.
services,
Cost Con-
Marvin R. Weisbord and Johannes U. Stoelwinder. 1979, 7 pp.
1-241
Availability: Health Care Management Spring 1979.
Review v4 n2 p7-13
patient's perspective or the perspective of a member of the patient's family, of who initiated the demand for each visit. Findings show that the majority of physician visits (53 percent)
Elements of a successful cost containment strategy with regard to hospital services are discussed in this article. Hospitals, the major component of the medical care system, are presently caught in a dilemma involving rising costs and deteriorating services. Physicians, who are to a large extent, outside the medical care management system hold the key to both costs and quality of care because of their status, power, and dally decisions. One study estimates that 75 to 80 percent of medical care expenditures are determined by physicians. Physicians decide whether to admit patients, and when to discharge them. Physicians also determine the cost per patient day through specification of how much of a hospital's resources are required for patient care. Physician relationships to hospitals usually are expressed in terms of staff appointments, salary source, and location of office. Accountability to hospital administration is indirect compared to that of other staff. Solving the cost problems of hospitals requires a magnitude of change far beyond the tacit acceptance of control systems. Professionals and managers must learn to share the risks and responsibilities for costs and quality of care with each other and with the public. A successful approach should include specific criteria as guidelines for hospital change strategies. These factors include joint problem-solving efforts on the part of physicians and administrators, realistic orientations, enhancement of the self-esteem and competence of all involved parties, a method for assisting physicans to understand how their actions affect the hospital system, a total hospital view, specific procedures for effecting policy change, and measurable impact on hospital costs. One figure and 24 references are included in the article. Descriptor(s): Inpatient facilities, Physicians, Policy/changes health care, Cost containment efforts.
during 1977 were initiated by patients, with 39 percent initiated by the physician. Economic factors and market tions are shown to influence the probability that the initiated by the physician. Decreases in the proportion of
being condivisit is the bill
paid by the family are associated with increases in the probability that the physician initiated the visit. Waiting time is another measure of the economic and market conditions. Waiting time in the office is negatively associated with inducement, presumably reflecting the dominance of the increased time cost to the patient; waiting time for an appointment is positively associated with inducement, presumably reflecting the dominance of a reduction in practice costs. Some characteristics of the patient are also important. Poorer health status is more likely to be associated with physician-initiated visits, while higher family income is less likely to be associated with such visits. Increases in the physician's age are associated with decreases in the probability the physician initiated the visit. Physician-initiated visits for the other specialty physicians are more difficult to explain. Except for waiting time in the o_ice, economic and market conditions do not appear important. Of patient-related characteristics, age, poor health, and college education are all negatively associated with the likelihood of inducement. The most interesting finding is that outside income is negatively associated with the likelihood of inducement. Findings suggest that national health insurance proposals which maintain a fee-for-service system and which decrease the proportion of the bill paid by the family may substantially increase the probability
of physician-initiated
visits.
Prepared for presentation at the World Congress on Health Economics, Leiden Univ., The Netherlands September 8-1L 1980.
re Descriptor(s): Demand/utilization of health care programs, Supply/availability of services, Medical/surgical services, Outpatient facilities, Physicians, Policy/changes re health care.
534. Magnitude and Determinants sits in the United States.
of Physician Initiated Vi-
Gail R. Wilensky and Louis F. Rossiter. Sep 1980, 41 pp. Availability: National Center for Health Services Research, Hyattsville, MD 20782. Results are reported from a study that examines whether physician-induced demand exists and, if so, its magnitude and the factors that determine its occurrence. Data were obtained from the National Medical Care Expenditure Survey, particularly the household survey, which provided a direct measure, from the
1-242
535. Mail-Order Medicine. An Analysis of the Sears Roebuck Foundation's Community Medical Assistance Program. Robert L. Kane, Robert Warnick, Paul H. Proctor, Donna M. Olsen and David Gourley. Bureau of Health Planning and Resources Development, Washington, DC. Sears-Roebuck Foundation, Chicago, IL. 1975, 5 pp. Availability: Jnl. of the American Medical Association v232 nl0 p1023-1027 9 Jun 75.
Health Care Programs
This 1973 study of the Community Medical Assistance Program (CMAP) of the Sears Roebuck Foundation presents data on the 253 rural communities involved, relates community characteristics to success in obtaining physicians, and comments on the success of CMAP. CMAP, established in 1957, assisted rural communities in building clinics to attract physicians, for which it spent a total of $1.3 million. Communities judged strongly motivated to solve their physician shortage were accepted for assistance and provided with plans and professional help in constructing the clinic, as well as with organizational and financial guidance, if necessary. The communities themselves financed clinic construction and rented their completed clinics to physicians. Nevertheless, CMAP was phased out in 1970 due to its apparent lack of success. In 1973, all 253 rural communities were surveyed for the effect of CMAP on rural medicine; socioeconomic information, experience with recruiting physicians, and demographic data on physicians and their families were obtained. Data from the survey were tabulated and compared with l 3 variables cited by literature as causing physician dissatisfaction with rural medicine. Of the 253 communities, 165 built clinics with CMAP assistance and 163 were able to recruit physicians. In addition, by 1973, 132 still had physicians and 10 others were providing medical care in their facilities. A total of 433 physicians had been recruited, with a mean length of stay of 54 months. In 1973, clinics had been open an average of 9.42 years, with physician coverage available for an average of 7.35 years, The 13 variables causing physician dissatisfaction include cornmunity population, distance to the nearest hospital or physician, number of physicians and service clubs within the community, proximity of schools. However, none was significantly related to physician recruitment. Only two--number of service clubs and distance to nearest physician -- were related to retention. Fifteen references, diagrams, and tables are included,
be less efficient and less responsive to innovation and change while at the same time ending freedom of choice, fueling inflalion, and creating a radical disruption of a complex economic and social system. Given appropriate Federal legislation which encourages competition and assures nondiscrimination among all types of carriers, the private health insurance business can respond more effectively to the needs for comprehensive coverage for all dtizens and to the control ofhealth care costs. Therefore, Government should establish minimum benefit standards for group and individual health insurance plans as well as reasonable premiums in relation to benefits. In addition to fostering effective cost containment, proper exemptions from antitrust legislation for insurers would permit the development of State pools for coverage of low-income groups and medically uninsurable individuals (to be subsidized by the Government). Independent studies of medicare claim costs have revealed that private fisc_ intermediaries are more efficient and have lower expense ratios than the Social Security Administration. Moreover, comparison of the privately run Federal Employees Indemnity Benefit Plan with medicare also shows a lower expense ratio for the private carriers. A greater degree of uniformity under national health insurance (NHI) would be desirable as long as standardization would not become excessive and thereby stifle innovation and experimentation. Patient cost sharing would reduce the total cost of NHI and discourage overuse of limited health care resources. The disadvantages of cost sharing (i.e., deterring necessary care as well as costing more) are open to serious question, although they are also offset by the positive effects. The private, nonprofit National Center for Health Education financed by the health insurance industry, has been created to stimulate the development of more effective health education programs within the private sector. Section references are appended.
Descriptor(s): Supply/availability of services, Outpatient facilities, Physicians, Private health care plans, Voluntary initiatives,
Descriptor(s): Cost containment efforts, Competition/interaction among third-party payors, Private health care plans, Policy initiatives, National health insurance (NHI), Voluntary initiatives, Cost/benefit analyses, Funding/financing of health care programs.
536. Major Issues in the Financing and Management of Health Care. 537. Malpractice Crisis. What Was It All About. Health Insurance Inst., Washington, DC 20006 Health Insurance Association of America, Washington, DC. 1976, 34 pp. Availability: Health Insurance Inst., Washington, DC 20006.
This booklet examines the major issues in health care financing and management facing both Government and the insurance industry. Compared to the private sector, an all-Government health care system, lacking the discipline of competition, would
James K. Cooper and Sharman K. Stephens. 1977, 14 pp. Availabih'ty: Inquiry v14 n3 p240-253 Sep 77.
This article reviews the causes of the 1975 national malpractice insurance crisis and assesses the insurance aspects, legal aspects, and the quality of care aspects of suggested alternatives. The
1-243
malpractice crisis was characterized by nonavailability of insurance coverage and by dramatic rate increases. In northern California, for example, in spring 1975 a 300 percent rate increase was requested for Bay Area physicians. Increases in malpractice claims and in the size of malpractice awards contributed to these problems. In addition, the economic stabilization program of 1972 and 1973 prevented insurance companies from raising their premiums. The severe recession that followed lowered the value of the carrier's investment capital, causing some companies to drop malpractice insurance. The suggested insurance alternatires include using joint underwriting associations (JUA) and other risk-spreading pools; using a channeling mechanism in which one group of insureds can be covered by the insurance contract of another; and developing a claims-made underwriting policy in which the insured is only covered for claims reported during the policy year. Suggested legal alternatives include decreasing the attorney's percentage as the award increases, reducing the statute of limitations to 3 years, developing a no-fanlt insurance system, and establishing limits on award payments. In addition, peer review programs and stronger licensing boards are recommended to reduce some injuries resulting from malpractice. The article concludes that malpractice cannot be ignored when considering the issue of national health insurance (NHI). Forty-one
notes and references
Descriptor(s):
are given.
National economic conditions,
Non-employment Policy
Funding Emerges as a LNitical Issue.
James E. Ludlam. 1975, 8 pp. Availability:
Hospital Medical Staff v5 n3 p9-16 Mar 76.
California's experience in trying to fund physician malpractice coverage is described and assessed. Due to the prohibitive cost and restricted availability of traditional malpractice insurance for physicians, various proposals for resolving the crisis have been advanced in California, One proposal is to pass malpractice costs on to the hospital, which in turn passes it on to the health insurance carriers. This approach creates obvious reimbursement problems under medicare and medicaid and complicates tax problems. Also, the cost implications of such a proposal trouble hospitals. Another approach would be to levy a tax or assessment on health care premiums, excepting medicare and medicaid premiums. In some States, this would be unconstitutional, because of limitations on the taxing of insurance companies. A third strategy would involve levying a tax equivalent to
1..244
Descriptor(s): Economic/commercial influences, Economics of third-party payors, Inpatient facilities, Funding/financing of health care programs, Phys:icians, Policy initiatives, Non-employment related plans.
539. The Malpractitioners.
related plans, Physicians, Present legislation/regulations, initiatives, Health insurance industry.
538. Malpractice.
a sales tax on the gross income of health care providers. In addition to being difficult to ,enforce, this special tax would raise constitutional issues. A fourth approach would use general tax funds to finance malpractice coverage. This approach may be unlawful, since the use of general funds for this purpose may be held to be a gift to a private individual. Also, there are obvious political problems; in California, for instance the Governor has promised no new taxes. A fifth proposal would use a claimsmade or claims-paid policy form. This proposal only defers the financial impact of malpractice claims and should be used primarily as a method of buying time while major tort reforms are adopted and implemented. The complications of claimsmade or claims-paid policies require detailed study. (Author abstract modified)
John Gunther. 1978, 347 pp. Availability: Doubleday 11530.
and Co., Inc., Garden
City, NY
This book investigates medi,_d malpractice as an increasingly evident American phenomenon. The malpractice crisis is manifesting itself in widely publicized medical horror stories as well as in the ever increasing numbers of less spectacular malpractice claims cases (60 percent incr_mse in frequency of claims between 1974 and 1977) and in the 400 percent rise over the same period in doctor's malpractice insurance premiums, the costs of which are being passed on to the patients. Over 50 case histories of injured patients are examined in a search for the cause of this crisis. The roles of doctors, hospital administrators, lawyers, judges, juries, politicians, and drug manufacturers -- all of whom have aggravated the problem -are investigated. It is concluded that insurance companies are among the major culprits in cornpounding and perpetuating the problem by having succeeded in turning crisis into profit. As health care costs continue to rise, malpractice poses a gigantic economic problem in addition to being a tragic physical one. The book not only outlines the issues, but proposes solutions intended to serve the best interests of the public as well as the medical profession. Among the measures proposed are the institution of malpractice arbitration boards, the provision of free medical evaluations in malpractice disputes, the reform of the jury award system, and the provision of mal-
Health Care Programs
practice insurance to providers on a fiat-rate basis through a national company operating under Federal guidelines. A bibliography of about 50 references, notes, and an index are supplied. Descriptor(s): Providers of health care services, Economic/commercial influences, Health care/services, Third-party payors, Demand/utilization of health care programs, Policy initiatives.
540. Management 1979.
and Policy Issues in HMO Development,
Group Health Association of America, Inc., Washington, DC 20036 1979, 285 pp. A vzilability: Group Health Association of America, Inc., Washington, DC 20036. Management and policy issues in health maintenance organization (HMO) development are contained in this 1979 report of the proceedings of the 29th Annual Group Health Institute. Following the keynote address, three general session papers discuss an update on the Federal HMO program, prepaid group plans as oases in the medical care wasteland, and competition as the ultimate regulator of health care costs, goundtable discussions cover the financing of HMO's; provider productivity, particularly that of physicians; areas in which HMO's and HSA's can work together, including the governing body membership, the official spokesperson for the HMO, and the use of consumer members; and the elements of a liability prevention and control program, Other topics in the roundtable discussions include HMO occupational health services and the Rhode Island Group Health Association experience, employers' perspectives, health care labor relations, HMO promotion, and health education. In addition, papers on governing boards, allied health professionals, and hospital affiliation are included. Contributed papers deal with the subject areas of enrollment and market analysis, such as market forecasting using multivariate analysis techniques; clinical management, including the free-standing alternate birth center and a university-affiliated HMO; and research, provider roles, financial management, mental health services, and quality assurance in HMO's. Footnotes are included.
Proceedings Arizona,
of the 29th Annum
Group Health
Inst., Phoenix,
June 3-6, 1979.
Descriptor(s): ing/financing als.
Cost containment efforts, Prepaid plans, Fundof health care programs, Allied health profession-
541. Managing Medicaid Drug Expenditures. Divergent Approaches.
An Analysis of
Stephen G. Sudovar and Susan D. Rein. Roche Lab., Nutley, NJ. 1978, 20 pp. Availability:
Health Issues, New York, NY 10019.
Cost-containment approaches in the Texas and California medicaid drug programs are examined, and implications are drawn. The Texas program uses few constraints on the use and price of prescriptions but operates an efficient administration and management program. California, on the other hand, relies on numerous controls over the availability and price of drugs without pursuing extensive front-end claims management procedures. The study hypothesized that stringent regulatory controls, particularly those governing pharmaceutical product availability and pricing in medicaid drug programs would result in reduced costs to the States. According to the hypothesis, California would prove to have the most cost-effective approach. A number of factors were identified which may have an effect on the overall expenditures for drug services. They are accessibility of primary medical care, patterns of propensity to visit a physician, and variations in disease patterns. Other population characteristics which could have directly affected drug use are age and sex distributions in the two medicaid populations. These factors as well as program approach may have contributed to CaLifornia's spending 9 percent more on drugs per recipient than did Texas. Although all factors that might have contributed to tiffs result were not analyzed, findings suggest that controls over price and availability of drugs are not necessarily the best means of controlling expenditures. Efficient use management may prove to be more important. It is also possible that the use of some controls may prove to be counterproductive by adding more in administrative cost than can be saved through the controls. Aclditional study should be undertaken to determine the specific, and independent effects of individual drug use management programs and the effects of various combinations of such programs. Tabular data are appended. Descriptor(s): Cost containment efforts, Medicaid, Pharmaceutical services, Comparisons of health care programs, Outcome/evaluation of quality assurance, Outcome/evaluation of health administration.
542. Mandated Community-Rating bursement Issues.
and Underlying Reim-
Roger W. Birnbaum. 1980, 6 pp. A vailabih'ty: Group Health Association
of America, Inc.,
1-245
Washington,
DC 20036.
543. Manpower Policy for Primary Health Care. Richard M. Scheffier, Neil Weisfeld, Gloria Ruby and E.
Mandated community rating for health maintenance organiza.. tions (HMO's) is causing severe marketing problems in oompeting with the experience-rated indemnity health insurance plans. This article argues, however, that the HMO's should resist an expedient rush to experience rating. Rather than contorting their economic structure to conform to an alien concept, HMO's should work to develop and seek implementation of an independ-. ent approach to support their own community-rated pricing concept. This requires breaking the dependence of HMO's upon the group-by-group rating practices of the traditional health insurance industry. One reason for retaining community rating is that it is a major distinguishing characteristic of prepaid group practice HMO's, compatible with the organizations' basic economic structure because it recognizes that the HMO's prepaid revenues support largely fixed-cost staff and facility resources not directly related to the units of service provided to any single group but to the anticipated needs of its overall membership, Furthermore, in contrast to an insurance company's risk exposure, the costs and use of an HMO's organized services are largely controllable and predictable through sound budgeting and monitoring. With experience rating the fiscal and medical integrity of the group practice, which now estimates a sum of money for a given spectrum of services per member covered, could be broken by receiving more revenues for those groups receiving more services. This would constitute a reversion to the disincentive to cost and use controls evident in the fee-for-service sector. Community rating minimizes administrative costs and may actually enhance an HMO's competitive position. The real issue is the continued dependence of HMO financial support upon the indemnity premium levels of traditional carriers. The basic objective is to release HMO premiums from this dependence. One approach to this end may be the Federal employees' model, which is based on the average cost of the largest participating plans. The proposed medicare amendments offer another alternative: if HMO's were reimbursed the adjusted average per-capita cost of the privately insured individuals in their service areas, their dependence would shift from a group-specific to a communitywide cost basis, permitting retention of community rating.
From "SlaYls Development for the HMO 1980%' p 156-161, 1980, edited by Eugenia
Managers WarhoL
of the
Descriptor(s): Prepaid plans, Competition/interaction among third-party payors, Reimbursement, Premium determination/ underwriting, Methods of payment determination, Present legislation/regulations.
1-246
Harvey Estes. Robert Wood Johnson Fotmdation,
Princeton,
NJ.
Kellogg (W.K.) Foundation, Battle Creek, MI. 1978, 5 pp. AvailablJity: New England Jnl. of Medicine v298 n19 p10581062 II May 78. A National Academy of Sciences study of policy options for the supply of primary health eare manpower has produced a cornprehensive set of recommendations. The study committee reviewed evidence and opinions from a variety of sources, including participants at azt open heating and background papers prepared by staff memlmrs. Although the committee recognized that a wide variety of health professionals are engaged in primary care, the report emphasizes the activities of physicians and new health practitioners (nurse practitioners and physician assistants). The study finds an adequate overall supply of physicians but a shortage of primary health care practitioners. It recommends maintaining current enrollment levels in medical schools, instituting training programs for nurse practitioners and physician assistants, and increasing the proportion of primary care residents. To enhance the availability of primary care, the report advocates reimbursernent for all physicians within a State at the same payment level ior the same primary care service, a reduction in payment differentials between primary care services and nonprimary care services, and reimbursement for educational and preventive services and for new health practitioner services. The report supports a team approach in primary care training and recommends that all medical students obtain clinical experience in a primary care setting and some instruction in epidemiology and behaviorM and social sciences. Twenty-four references are provided. (Author abstract modified) Descriptor(s): Supply/avadability Nurses, Allied health professionals.
of
services,
Physicians,
544. Measurement of Expenditures for Outpatient Physieian and Dental Services. Methodological Findings from the Health Insurance Study. Kent H. Marquis, M. Susan Marquis and Joseph P. Newhouse. Rand Corp., Santa Monica, CA 90406 RAND/R- 1883-ITEW Department of Health, Education, and Welfare, Washington, DC. Apr 1976, 33 pp. A vailabili(y: Rand Corp., Santa Monica, CA 90406.
Health Care Programs
This study examines the extent to which one-time surveys can obtain precise, unbiased estimates of expenditures for outpatient medical care. In this report, estimates of mean gross and net (family out-of-pocket) expenditures obtained by two indirect personal interview approaches and one, direct, self-administered approach are compared with expenditures estimates based on nonsurvey data compiled by the Social Security Administration (SSA). Mean estimates obtained by the two surveys using indirect approaches correspond closely with the SSA estimates of gross and net dental expenditures and gross physician expendi• tures. However, these surveys produced higher estimates of net expenditure means for outpatient physician care. All mean expenditure estimates derived from the self-administered surveys exceeded those of the SSA. Examination of the pitfalls of using record checks to estimate survey bias reveals that pure prospective and retrospective designs can produce results that make random measurement error appear as bias. Results of the Health Insurance Study's (HIS') record eheck of reported gross expenditures for dental care show that interview estimates exceed record estimates. This fending is probably due to prospective record check design bias, because a comparison of the mean derived from the whole sample to the nonsurvey estimate did not indicate any bias. A procedure developed in this study for estimating response error variance showed 44 percent of the total measured variance in the HIS interview reports of gross dental expenditures and 39 percent of the total variance in record reports were response errors. A "best estimate" strategy, based on a least squares solution using both interview and record data, resulted in a new expenditure measure in which only 26 percent of total measured variance is response error. The report coneludes that surveys can obtain unbiased estimates of gross private sector expenditures but that problems created by the large amount of response error remain. Response error will reduce estimation precision and attenuate standardized bivariate and multivariate coefficients of association, such as the product-tooment correlation. Tables, footnotes, an appendix of the derivation of estimates, and approximately 45 references are included, (Author abstract modified) This report presented at the November American Public Health Association.
1975 meeting
of the
Descriptor(s): Outpatient facilities, Reimbursement, Dental services, Medical/surgical services, Health care costs, Health information/dam systems.
545. Measuring Disability veys.
and Utilization.
Availability: National Center for Health Statistics, ville, MD 20782.
Hyatts-
This paper compares two national health surveys conducted in 1977, the National Medical Care Expenditure Survey (NMCES) and the Health Interview Survey (HIS), to evaluate the measuremerit of disability and health care utilization in the U.S. population. Both surveys are based on independent probability samples of the civilian noninstitutionalized population of the United States. The NMCES sampled was about 14,000 households, and the HIS approximately 10,000. However, the NMCES was designed as a one-time survey to provide information on the utilization of medical care during 1977, expenditures, sources of payment, and other related health information, whereas HIS was designed as a continuous survey to provide information on illness and disability, utilization of health care, and other related health information. This paper compares estimates of the number of persons by education and health status and estimates of the number of days lost from work because of accident or illness, the number of days spent in bed, and the number of den_al visits from both surveys. The two surveys used different methods and procedures to stimulate recall of certain events. The HIS used a 2-week recall period with a 2-week calendar card visual aid to measure disability days and dental visits. The NMCES had a longer recall period, ranging from a minimum of 2 weeks for some interviews to 8 to 12 weeks for most. It was hoped that the NMCES and the HIS would produce similar estimates when they both measured the same phenomena. However, it was hypothesized that if there was a difference, the NMCES should be lower than the HIS for the first quarter of 1977 mainly due to the long length of the recall period in NMCES. The 1o_,_:_ estimates of bed-disability and dental visits in the NMCE_ d, consistent with this hypothesis, and the underreporting i_ aboti the level expected. What was not expected, however, v,'as thar_ one item, work-loss days, would be either the same or higher m the NMCES than in the HIS. The unexpectedly high eslimate of work-loss days from the NMCES may arise from the administration of the work-loss questions to persons who were not currently employed, as the NMCES data do not allow for the distinction between employed and unemployed persons. Further analysis of subsequently collected data is needed in this area. Two tables summarizing the data, a sample interview sheet, and six references are provided. Descriptor(s): Demand/utilization Health information/data systems.
of health care programs,
Two Health Sur-
Robert A. Wright and Gordon Scott Bonham. 1978, 5 pp.
546. Medicaid and Cash Welfare Recipients. An Empirical Study. Charles P. Hall, John A. Flueck and William F. McKenna.
1-247
1976, 8 pp. Availability:
547. Medicaid. Inquiry
Current
Issues and Potential
Retorms.
v14 nl 1343-50 Mar 77 .Iohi: Holahan and William Scan!on.
This paper studies the impact on the poor of the failme e: some States to provide optional services for dental care, eye ca:re, and prescription drugs in conjunction with inpatient hospitalization
Urban Inst., Washington, DC 20037 Mar 1977, 72 pp. A _.aHablTity:Urban Inst., Washington,
DC 20037.
and physic,ans' services under medicaid. Data on medicaid eligibles collected questionnaires by a personal interview, pr._ducedwere completed for more survey tt:an wific_ 3,00_: cas!a welfare cases encompassing more than 8,0C_3recipients m the metropolitan areas of Atlanta, Ga., Li:de Rock Ark., Oklv_hom a City, Okla., and Trenton, N.J. These four sites were chosen to provide a spectrum of optional service coverage with locai agency cooperation. Specifically, the New Jersey medicaid plogtara provided all of the options under co_sidcratmn, (ieoig_a an,;[ Arkansas a somewhat more limited benefit structure, a,,_d Oklahoma provided none of the optional benefits considered. The data were collected from June to September 1973. The _urvey population consisted ofnoninstitutionalized, cash-welfare recipi.ents enrolled in either the Aid to the Permanently and Totally Disabled, Old Age Assistance, or Aid to Families with Dependent Children programs in the four local areas. The result,,; of the study indicate that the presence of medicaid coverage .':learly removes a significant financial barrier to the availabi_Aty of health care services. In addition, the comprehensiveness of the medicaid package appears to have a substantia! effect on the use of each individual service. However, serious shortages and/or maldistributions of providers and facilities can more thm_ ofi;,.{:t the benefits of programmatic coverage. Mm_over, _¢i-,_-er. there are comprehensive benefits and eligibles _b_- are we!l-ini _¢_-._ed as to their benefit entitlement, as in Trenton, interracial differences in a._e, out-of-pocket payment.% ana pe, ceptlens _f need tend to disappear. However, these dual conditio::s are lacking ia the other three sites studied, and interracial diO_ere_,,ce_a_e substantial. Furthermore, the evidence strongly suggests tim.: re!a.tivel?_ few medicaid eligibles in the s_tes studiec were depweed of the benefits of prescribed medication reoardles_ o_."p_;,gram co_erage. A highly controversial and potentially costly Lenefi::, whether incorporated under medicaid or propose_ n:::tio.qal health insurance, is full co verage of prescriptmT_ medicine.', Since
Problems in the Medicaid program are reviewed, and several reform options available at both State and Federal levels are
a major policy concern of most heahh benefits preg_:ams, is ::_ reduce or eliminate unequ_l access _'o c_'rc, it could :_,.us i-,e
DescriprorO_): Medicaid, Policy initiatives, payment. National economic conditions, _-mnts.
suggested that for any future ptogran_ wh'_cb >:ust i\_r e_:¢:,zomic or other reasons stop short of full coverage f:._., __d!b,.nefit,;, prescription coverage could be excluded with only a'.inm al impact on the health status of the covered F
analyzed. Following a description of the program's structure, t_aree aspects of medicaid financing are identified as primary areas of concern to Federal and State governments. Because costs and assistance levels vary with the economic cycle, demands for services increa,;e when State revenues decline in a recession period. Medicakl is vulnerable to longer-term price inflation because it purchases services in the general health care market which has suffered from excessive inflation and overutilization of services. Finally, wide disparities exist in different States regarding the availability and extensiveness of medicaid services to poor persons. Several solutions to remedy medicaid's problems are discussed, including formula adjustments to make Federal contributions to State programs more sensitive to economic conditions, altering financial arrangements to reduce expenditures and redistribute resources, and national health insurance. Federalization of the existing medicaid program is tile alternative that is most likely to be adopted in the near future, but a preferable approach would rely on State administrative capacities and provide stronger incentives for States to pursue Federal program objectives. In this scheme, the Federal Governmen t would mandate eligibility determination criteria and a uniform benefit package. Medicaid funds would be dispensed as block grants based on the number of program enrollees in a State with matching grants that could respond to economic fluctuations. States would lose Federal funds if they reduced eligibility, but would retain a major portion of monies saved through detection of fraud or abuse. Tabular data and 3 6 footnotes are provided (Author
abstract
modified)
Working Paper 5057-4. Source of premium Eligibility require-
548. Medicaid Experience. Descriptor,s'): Medicaid, Dental services, Pharmaceutical serviccs, Policy initiatives, Vision/hearing services, S__:p;ly/:_vailability of services.
1-248
Allen D. Spiegel. 1979, 402 pp. Availability: Aspen Systems Corp., Rockville,
MD 20850.
Health Care Progr_,m_
.-''
This comprehensive survey of the medicaid experience is tomposed of essays by contributors who assess the program from a variety of perspectives. Overview papers survey issues and indicators of medicaid and review program data. Eleven articles illustrate lessons to be learned from specific experiences in providing medicaid services. These include a State by State analysis of 1977 medicaid service and a comparison of State limits on the amount, scope, and duration of services. Areas of service represented by other articles are abortion, audiology, dentistry, drugs, home health care, long-term care, mental health, shared health facilities, and sterilization. Twenty-two additional articles illustrate lessons from administrative and operational aspects of medicaid program management. Examples of program aspects addressed in these papers are the medicaid management information system; on-line billing for physician's services; problems in procuring, administering, and monitoring medicaid insurance contracts; review of medicaid eligibility; mandated second opinions for surgery, rates and correlates of expenditure increases for personal health services; medicaid costs in the health maintenance organization setting; impact of utilization controls, foreign medical graduates; and physician participation with the mediCal program. Papers in the concluding section summarize a decade of medicaid achievements and problems; explain why Texas physicians are dropping out of the medicaid program; and interpret consumer problems with prepaid health plans in California in terms of implications for servicing medicaid recipients through health maintenance organizations. Also considered are improper and wasteful payments in the medicaid program, the medicare-medicaid antifraud and abuse amendments, and a perspective on national health insurance through the medicaid experience. Tabular and graphic data and an index are provided,
This paper presents data on medicaid, medicare, and private health insurance coverage at the community level. It ,explores how third-party coverage varies by geographic locatio_; how socioeconomic, demographic, and health characteristics are related to private and public health insurance coverages; and how medicaid coverage is related to private insurance coverage among low-income populations. Data in this report were collected in 1975 in five areas: the Roxbury area of Boston, Mass.; the Peninsula area of Charleston, S.C.; the Southside area of Atlanta, Ga.; the Wayne Miner area of Kansas City, Mo.; and the East area of Palo Alto, Calif. The number of persons in interviewed households ranged from 3,251 in Kansas City to 5,160 in Atlanta. The findings showed that third-party financing mechanisms for health care operating in a community can leave a large residue of the population without any kind of health insurance protection. In addition, although it was well known that medicaid eligibility varies among States, very little effort was made to implement the program more equitably. Blacks in the study areas had better third-party coverage than whites except in Charleston; in the remaining areas, medicaid had more than made up for the lower private insurance coverage of blacks. The report concluded that more investigation was needed to establish a cause-and-effect relationship between relatively high medicaid and low private insurance coverages or low medicaid and high private insurance coverages found in these areas. Although prirate insurance seemed to compensate somewhat for the low medicaid coverage of the poor and medically needy in some areas, the cost of such insurance could be an added burden. Furthermore, private insurance presents greater barriers to care than public health financing because of limited benefits, deductibles, and coinsurance requirements. Twelve tables and four reference notes are included.
Descriptor(s): Medicaid, Eligibility requirements, Health care/ services, Plan design/program provisions (under health plans), Policy initiatives, Outcome/evaluation of quality assurance, Outcome/evaluation of health administration, Providers of health care services, Health care costs, Health information/data systems.
Descriptor(s): Private health care plans, Medicare, Medicaid, Demographic features of population, Participants in health care programs, Impact of third-party coverage.
550. Medicaid Mills. Fact or Fiction.
Janet B. Mitchell and Jerry Cromwell. 549. Medicaid, Medicare, and Private Health Insurance Coyerage in Five Urban, Low-Income Areas.
Louise M. Okada and Thomas T. Wan. Health Services Administration, RockviUe, MD. Office of Planning, Evaluation and Legislation. 1978, 9 pp. Availability: Inquiry v15 n4 p336-344 Dec 78.
Health Care Financing Administration, Washington, DC. 1980, 13 pp. Availability: Health Care Financing Review v2 nl p37-49 Summer 1980.
Results are reported from a study that examined the characteristics of large medicaid practices (LMP's), defined as those in which at least 30 percent of the patients are eligible for medicaid. The primary data base for this analysis was the 1976 physician
1-249
survey conducted by the National Opinion Research Center for the Health Care Financing Administration. This survey was a nationally representative sample of 3,842 physicians in 15 specialties. All physicians were in private practice, and the vast majority were office based. An extensive questionnaire was administered to all physicians by telephone. The questionnaire yielded data on practice costs, work effort, size and type of practice, physician income, and fees. Results indicate that most
emergency room. Although the medicaid population ha_ a slightly lower waiting time tbr an appointment, it has a coitsistently longer wait time at the site of care. The mo_t stoking finding of the preliminary data is the apparent instability of the medicaid population; only slightly more than half were on medicaid during both periods of the interviews. Tabular data are provided. (Author abstract modified)
LMP's are not "medicaid mills," practices characterized by fraudulent behavior and low-quality care. LMP physicians earn what other physicians make at best; often they earn less. No indications were found of widespread abuse of ancillary services, skimping on auxiliary staff, or excessive markups over costs, all characteristics of medicaid mills. Visit lengths are shorter in LMP's, but only by a minute or two. A substantial "credentials" gap does extst, however, with the medicaid market being dominated by less qualified physicians. LMP physicians tend to be older, non board certified, and graduates of foreign medical schools. Any program reform should improve both ace,s and
Presented at the 106th Annum Meeting, Health Association, Medical Care Section, October 15-19, 1978.
quality of care by providing incentives for more qualified physicians to enter the medicaid market. Tabular and graphic data, 13 references, and a few footnotes are provided.
552. Medical Benefit Cost Containment
American Public Los Angeles, CA.
Descziptor(s): Demand/utilization of health care programs, Medicaid, Participants in health care programs, Facilities providing health care.
in the U.S.A.
J. G. Albert. Descriptor(s): Medicaid, quality assurance.
551. Medicaid
Participation
Physicians,
Outcome/evaluation
of
and Medical Care.
(Jail R. Wi!.ensky, Judith A. Kasper and Deborah A. Freund. Oct 1978, 17 pp. Availabilitv: National Center for Health Services Research, Hyattsville, MD 20782.
Data on medicaid participation and use are presented from the: early findings of the National Medical Care Expenditure Survey. The data were obtained from rounds 1 and 2 of the household survey -- a series of interviews with 13,500 randomly selected households interviewed 6 times over a 15-month period during !977 to 1978. Rounds 1 and 2 were conducted during JanuaryMarch 197"7, and April-June 1977, respectively. The findings indicate a medicaid population of about 17 million. Although this number is in the range of other survey findings, the estimated population may change as additional survey data are produced. As expected, the medicaid population is younger, less educated, and more likely to be female and nonwhite than the privately insured population. The medicaid population is also more likely to report a poorer health status. Furthermore, the medicaid population is less likely to go to a private doctor's office and more likely to go to a hospital outpatient department or
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1979, 7 pp. Availability: 79.
Benefits International
v8 nl0 p2,4,5,7-10
Apr
An overview is provided of the scope of the rapidly rising health care costs in the United States, the causes, and several possible solutions in various stages of development. Between 1950 and 1960, the health care induslry's share of the gross national product had increased from 4.6 percent to 5.2 percent. In 1975, that share had grown to 8.3 percent, and by the end of 1977, it stood at 8.8 percent. Some of the causes of this rapid inflation of medical costs are increased public expectations for high quality medical care; and near uniw'.rsal coverage of medical costs under individual, employer, union, and government plans, which increase the demand for quality medical services. The growth of the proportion of older people in relation to the general population is another cost factor as are a slow rate of growth in physician supply; an increase in physician specialization, particularly in surgery, and an increase in physician expenses, notably malpractice insurance. Rapid technological growth in medical services and competition between hospitals for the latest equipment have pushed up costs, and the growth of government bureaucracy vis-a-vis the medical industry, has contributed to increased administrative expenses. Other factors influencing the rise in medical costs are employee wage increases associated with increased unionization, a decline in charitable donations and government grants, and increases in construction and maintenance costs. Efforts at cost control have focused on a combination of measures, including elements of benefit plan designs which provide incentives for consumers to reduce their use of health ser-
Health Care Pro_;lams
vices and increase preventive health care services, health care delivery system changes which increase competition (prepaid group plans), the development of more cost-effective administrative procedures, and public/employer/government pressure through various government and community agencies. Descriptor(s):
Health care cost trends/projections,
ment efforts, Economic/commercial Voluntary initiatives.
influences,
Descriptor(s): Cost containment efforts, Health care: costs, Health insurance industry, Outcome/evaluation of quality assurance, Plan design/program provisions (under health plans), Source of premium payment.
Cost containPhysicians,
553. Medical Care Plans. How to Control the Costs.
554. Medical Care System Under National Health Insaranee. Four Models. Walter McClure. InterStudy, Excelsior, MN 55331 National Center for Health Services Research, Hyattsville, MD.
Philip M. Alden. 1980, 7 pp. Availability: Management Digest v3 n8 p20-26 Feb 81.
1976, 46 pp. AvMlability: Jnl. of Health Politics, Policy and Law v:[ nl p22-67 Spring 1976.
This study outlines the steps employers should take in their efforts to provide employees sound, attractive medical plans over which cost control can be maintained. The ideal medical plan is simple in design, offering broad protection (including high limits for profound expenses and limited coverage of budgetable expenses), substituting low-cost for high-cost treatment where possible, avoiding duplication of benefits, and giving employees a stake in cost control. Achieving such a plan requires a number of simultaneous efforts by the employer: (1) the plan must be designed properly; (2) the proper financial medium must be selected; (3) the employer should be involved in plan administration; and (4) users of the plan should be educated concerning its provisions and preventive health care. Benefit design involves attention to deductible amounts, coinsurance or the reimbursement ratio which comes into play after the deductable has been paid, inside limits which are dollar limits the policy will pay for services (making the employee a copayer), employee contributions which involve the employee in the cost of the plan directly through the payment of premiums. Other matters which benefit design should consider are ambulatory surgical care, preadmission testing, diagnostic x-ray, extended care and home health care, routine physicals, second opinions, and alcohol or drug abuse care. Finally, the employer should consider cash incentives as a way of bringing the employee into the attempt to control program costs. There are three types of plan financing available: conventional experience-related plans, minimum premium plans, and administrative services-only plans. In choosing between these approaches, employers should consider differences in expense reduction and improvements in cash flow. Employers can contain costs through involvement in plan administration by reducing plan complexity, avoiding benefit duplication, administering claims more efficiently, and reducing claims by monitoring the reasonableness of charges for services. The last area for potiential cost savings is education. Two figures are provided.
National health insurance (NHI)offers the opportunity to exercise leverage to move the medical care system in the desired direction. However, there is little public consensus as to where the system should go and little awareness that significant change will be needed. The medical care system needs broad, informed, searching public debate of the issues. The proposals most difficult to implement are the ones most likely to meet the goals of protection from catastrophic medical expenses, equitable distribution of health care, improved effectiveness, and cost containment. The central issue in the NHI question is the kind of medical care system needed, yet the variables of eligibility, benefits, financing, and administration depend upon cost containmerit. Furthermore, the medical care system has received little attention in the current debate on NHI. The present medical care system, financed through third party payments, perhaps with some public utility regulation, is likely to fail at containing costs. Thus, four NHI models which might counteract incentives in the present system that are dysfunctional in terms of costs and quality of care are major risk insurance, alternative delivery systems competing under universal coverage, allocation by public utility (the British model), and the public utility hospital. These four models emphasize cost containment through consumer cost sharing, provider incentives, and the public utility approach. Adequate strategies to alter the present medical care system structure and incentives require substantial change that will be politically difficult to achieve. There is no reason to avoid incrementally proceeding on all the potentially successful fronts at once before the adoption of NHI. Suggestions are made for steps that can be taken now. Seventy-four notes are provided. (Author abstract modified) Originally presented to the Panel on National Health h_surance, American Poetical Science Association, San Franch_co, CA, September 2, 1975.
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Descriptor(s): ance (NHI).
Cost containment
efforts, National
health insur-
555. Medical Care Use by a Group of Fully Insured Aged. A Case Study.
556. Medical Group Practice and Health Maintenance ganizations.
Robert G. Shouldice and Katherine 1978, 442 pp. Availability: Information Resources 20037.
Henneberger
Or-
Shouldice.
Press, Washington,
DC
Anne A. Scitovsky and Nelda M. Snyder. National Center for Health Services Research, Hyattsville, MD 20782 DHEW/PUB/HRA-75/3129 1975, 49 pp. Availability: National Center for Health Services Research, Hyattsville, MD 20782.
Designed primarily for students of medical group practice and health maintenance organizations (HMOs), the textbook includes information on history, law, organizational structure, and operating principles regarding prepaid group practice and HMOs. It introduces the HMO concept and various HMO models and surveys the history, philosophy, and objectives of HMOs. Legislative efforts to pass and implement a Federal law designed to foster HMO development are outlined. The discussion of organization structures of HMOs focuses on the method by which the HMO component parts can be arranged and ordered to achieve a functioning health delivery system. A section on the
The study provides information on the use of medical care by 500 persons aged 65 and over, all of whom had middle-to uppermiddle class backgrounds and ready access to medical services, The sample population lived at two retirement centers in Palo Alto (California) and had free access to the maximum amount
providers of the health delivery system (mainly physicians and hospitals) focuses on structure, reimbursement of services, and the attitudes of medical groups. Consumer opinions, attitudes, and roles are also appraised. The text suggests a framework that brings together the major components of the HMO during its
of services that older people might demand. Data were obtained from the records of the retirement centers and hospitals as well as from interviews with 80 percent of the study population. Two significant findings are reported: First, older people with middleclass standards of health care seem to have a very high demand for physician's services. The physician utilization rates of the study population were much higher than those found in any other studies of the use of medical care by older people. Second, it appears that when good nursing home care is available, older people are willing to shorten their hospital stay quite substantially by substituting nursing home care. Other findings indicate that women had a slightly higher utilization rate of physicians' services than men but a somewhat lower use of hospital services, Expenditures on all of the medical services (physicians', hospital, nursing home care, and other services) averaged between $1,150 and $1,200 per resident in 1969. Personal health care expenditures of the sample population were almost twice as much as per capita services by all persons aged 65 and over in fiscal year 1969. The study suggests that part of the demand for medical services is really an appeal for attention and that more research on such a possibility should be done. The study is supported by statistical data and includes 13 bibliographical references.
initial stages. Several stages of the HMO planning and development process are presented; critical areas of development are identified. The marketing of health services is explored in terms of a four-step process: analyzing the market, making choices available, marketing actively, and maintaining and increasing the number of accounts. Efficiency, productivity, utilization, and economies of scale are also discussed. The concluding chapter is devoted to financial management and covers financial planning models, risk management:, the use of underwriting techniques, and the actuarial aspects of capitation and premium developmont. An HMO glossary and relevant legislation are reprinted in the appendix. Footnotes, tabular data, organizational charts, diagrams, and chapter references are given.
Descriptor(s): Prepaid plans, Participants in health care programs, Premium determination/underwriting, Physicians, Present legislation/regulations.
557. Medical Malpractice Insurance.
Descriptor(s): Demand/utilization of health care programs, Participants in health care programs, Health care/services, Health care costs.
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A Legislator's
View.
Tarky Lombardi and Gerald N. Hoffman. 1978, 211 pp. Availability: Syracuse Univ. Press, Syracuse, NY 13210.
Health Care Programs
,_
This book presents an account of the malpractice issue as seen from the eyes of a State legislator. It is intended to explain not only the medical malpractice problem, but also the tremendous difficulty of legislating effective solutions in the face of conflicting arguments and interests. Although the principal conclusions and steps advocated from the legislative perspective aim to protect the patient and to preserve the health care delivery system, all sides of the issue are presented. The book begins with a consideration of the insurance aspects of malpractice, and continues with the views of doctors, the concerns of hospitals, and the role of trial lawyers. The concept of medical discipline is addressed. A review of the work of the U.S. Secretary of Health, Education and Welfare's Commission on Medical Malpractice cites comments of the commissioners and describes subsequent events. An illustrative case study on the issue is presented from New York, along with the ensuing legislative response. Also covered is legislative activity concerning the malpractice issue in other States and countries. Conclusions and recommendations for future legislative action are presented; the book emphasizes, however, that the underlying causative factors of the crisis remain. Notes and an index are supplied. Extensive appendixes document recommendations made in California and New York State, conclusions of the American Bar Association, the text of a statement from a New York State Senate public hearing and the summary of recommendations of the DHEW Secretary's Commission on Medical Malpractice.
quate examinations, failure to use appropriate diagnostic tests, proximate cause, diagnosis of nonexistent disease, and iatrogenic disorders. Other contexts for malpractice charges examined are incorrect or inadequate treatment, injuries from therapeutic agents, and injuries from equipment and premises. Vicarious liability and consent to treatment are considered as legal issues bearing upon the assignment of legal liability in medical practice, and intentional torts are discussed as the general legal framework for bringing malpractice suits. Defenses to malpractice actions are treated under the topics of contributory negligence, assumption of risk, emergency, release of tortfeaser, resjudicata, statutes of limitation, and charitable and governmental immunity. Malpractice and disciplinary actions, termination of the physician-patient relationship, and the malpractice caze in the legal process are also discussed. Notes accompany each major section of the presentation, and a subject index and selected bibliography with 28 citations are provided. A list of cases by jurisdiction and a list of Federal court decisions are also included.
Descriptor(s): Non-employment related plans, Physicians, Present legislation/regulations, Policy initiatives, Health care/services, Inpatient facilities, Economic/commercial influences.
559. Medical Malpractice Litigation Insurance. Essential or Expendable.
Descriptor(s): Economic/commercial influences, ]Facilities providing health care, Providers of health care services, Present legislation/regulations, Health care/services.
Under National
Health
George J. Annas, Barbara F. Katz and Robert G. Trakimas. 1975, 39 pp. Avnilnbib'ty: Duke Law Jnl. v1975 n6 p1335-1373 1975. 558. Medical Malpractice
Law. 2nd Edition. This article examines the workability
Angela R. Holder. 1978, 562 pp. A vailability: John Wiley and Sons, New York, NY 10016.
Based on examinations of existing law and judicial interpretations, this text focuses on legal aspects of medical malpractice, Legal dimensions of the creation of the physician-patient relationship are explored under the topics of contractual relations, the right to refuse to enter into a contractual relation, third-party contracts, and the physician's right to limit the contract. Legal interpretations of the physician's duty of care are portrayed in discussions of the general definition of "due care," application of the principles of due care, the locality rule, the specialist's standard of care, proximate cause, and proof of negligence. The following issues are considered as legal aspects of medical misdiagnosis: failure to obtain complete patient information, inade-
of the traditional
tort lia-
bility system with regard to medical malpractice. Recent problems are not inherent in the system but merely result from its current mode of application. Examination of the system is important because the impending passage of some form of national health insurance may be used as an excuse to eliminate: the tort system in medical eases. Medical malpractice denotes the basis for a civil action brought by a patient against a physician for injuries resulting from negligence. The current method for compensating victims of these occurrences is primarly a fault and liability insurance system. Many aspects of the tort liability systern have been attacked as contributing to the malpractice crisis. These aspects include res ipsa loquitur, informed consent, statutes of limitations, ad damnum clauses, damages for pain and suffering, unlimited damages, and the contingent fee: system. Careful analysis reveals that none of these factors accounts for the problem. For example, the doctrine of informed consent is criticized by the medical community because the infi)rmation
1-253
_iil unduly frighten the patient. However, the evidence indicates ;hat the well-informed patient is the least likely to sue the physician. Thus, major arguments against the system from the physician's perspective are unimpressive. Assuming that some form of national health insurance will be implemented in the near future, the impact of such a new fiscal and delivery system of health services upon the health care system must be determined before assessing the role malpractice litigation should play. Catastrophic health insurance or credit-subsidy proposals will not have much impact on the manner in which health care is cnrrently delivered. However, a system of comprehensive health insurance will have great impact. Under such a plan the current tort system should be retained as the primary method for quality control, and deductibles should be added to insurance policies to increase incentives for care and to decrease premiums. The tort system should remain in any form of a national health insurance plan. One hundred forty-six footnotes are included.
D,:scriptc,_(s): Economic/commercial National health insurance (NHI).
influences,
the effectiveness of panel systems. In others, the coopc_:mtm among panelists, parties,, medical societies, and lawycr_ h-t; tenhanced screening panel effectiveness. To be effective, pane! systems must be mandatory, determine both liability and damages, and legislation must exist to deter losing parties fiom pro ceeding to litigation. Some States have stipulated such lofty goals for screening panels that they are doomed to failure. The New York State panel effectively disposed of cases at a rate of 66 percent, yet the State Supreme Court investigation was pessimistic. If medical malpractice screening panels are to be effective, they must be designed with clear, realistic goals and be allowed the time to operate until conclusive data proves the worth of one of the most significant reforms of the mid-1970's. Tables, 42 reference notes, and an appendix containing summaries of screening panel procedures for all the States are provided.
Descriptor(s): Present legislation/regulations, Non-employment related plans, Economic/commercial influences.
Physicians,
561. Medical Malpractice 560. Medical Malpractice
Pre-Trial Screening Panels. A Re-
view of the Evidence. Peter E. Carlin. George Washington Univ. Intergovernmental Health Policy Project, Washington, DC 20006 }ieMth Care Financing Administration, Washington, DC. Oct 1980, 53 pp. _atat)_hty: George Washington Univ., Intergovernmental H,:altb Policy Project, Washington DC 20006.
u the mid- 1970's, a majority of State legislatures enacted pret rial sc;_ening panels to provide a quicker mechanism than conven_i_,_] litigation for resolving medical liability disputes, and hence reduce the volume of malpractice cases that ordinarily proceed to litigation. Panel hearings are usually informal, nonad,,treaty, and are designed to determine whether a claim has s'afficient merit to warrant proceeding to court. As of 1980, 26 States had adopted some type of screening panel mechanism, but _hree Stales -- Illinois, Missouri, and Florida -- had developed systems only to have their highest courts strike them down as unconstitutional. Opponents of screening panels note that doctots win nearly 80 percent of all decisions. On the other hand, several State panels are seriously underutilized. Furthermore, no screening panel model has been established by the States, and w_riations in administrative practices affect the overall performanet of the panels. In some States, the individual temperament and practices of the chairpersons seem to have a lot to do with
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Suits.
Douglas Conrad. 1977, 7 pp. Availability: Current His'_ory v73 n428 p22-26,36-37 77. Reasons for the dramatic
Jul/Aug
increase in the costs of medical mal
practice suits are given, and some proposed and instituted reforms are described. The growing number and size of medical malpractice claims have been influenced by (1) an increased willingness to sue for personal injury, (2) growing skepticism toward social institutions in furthering the public interest, (3) rapid increases in medical costs, (4) changes in tort law that have increased the probability of successful suits by plaintiffs, and (5) increases in the inherent riskiness of medical practice and rising patient expectations. Furl:her, malpractice litigation is influencing the pattern of medical practice through physician practice of defensive medicine and adjustment of their mix of services in order to lower individual premiums. In addition, such costs will be passed on to consumers as medical fees. Reforms include reducing the administrative costs of litigating medical malpracrice claims through such Cievices as voluntary binding arbitration and pretrial screening panels; revising tort liability statutes by lowering the probability of a successful malpractice action and by limiting the maximum .level of damages; and experimenting with alternative insurance mechanisms on the local, State, and Federal level. The article also briefly reviews the most revolutionary innovation being considered: no-fault medical malpractice insurance. Four tables and 26 footnotes are given.
Health Care Programb
Descriptor(s): Cost containment efforts, Physicians, Voluntary initiatives, Policy initiatives, Economic/commercial influences.
563. Medical Risks. Patterns of Mortality and Survival.
562. Medical Malpractice. The Response of Physicians to Premium Increases in California.
Richard B. Singer and Louis Society of Actuaries, Chicago, Association of Life Insurance Philadelphia, PA. 1976, 734 pp. Availability: Lexington, D.C.
Levinson. IL. Medical Directors
of America,
Heath and Co., MA 02173.
Albert J. Lipson. Rand Corp., Santa Moniea, CA 90406 RAND/R-2026-PSEC California Post-Secondary Education Commission, Sacramento, CA. Nov 1976, 171 pp. A vailability: Rand Corp., Santa Monica, CA 90406.
Findings and recommendations are reported from a study of the response of California physicians to sharp malpractice insurance premium rate increases in their State. Findings show that most physicians have passed at least part of the costs of rate increases on to the public through fee increases. Many physicians (between 8 and 18 percent) are going without insurance, and about 7 percent of insured physicians have made procedural changes in their practices to reduce insurance premiums. Malpractice rate increases have not yet reduced either the total physician supply in the State or the physician migration to it. Family physicians have tended to reduce their practice of surgery and obstetrics so as to reduce their premium rates; reports from local medical societies and surveys of physicians suggest that certain rural areas are being hit hardest by practice changes. Fragmentary evidence indicates that a number of physicians are finding "closed settings" such as salaried group plans and public hospitals more attractive since insurance rates have increased, since in such a setting, the physician does not have to pay malpractice costs directly. Insurance companies and the State should eonsider making rate structures more flexible so as not to discourage rural and part-time practice by competent physicians; family physicians, and specialists from performing medical procedures they are competent to perform; new physicians from locating in the State; and physicians from obtaining insurance. The State should also continue to analyze the effects of malpractice iusurance rate increases on the supply of physicians and medical services to assist in policymaking. Supplementary discussions and data on premium rates, physician supply, going without insurance, premium class changes, family practice, and MediCal are appended. Tabular data, figures, and footnotes are provided. (Author abstract modified)
This book is divided into two parts. Part I consists of 16 chapters. It is an interpretive text that reviews the mortality and survival data from the tabular abstracts in Part II. In addition, information is condensed in summary form to give bits of history, definitions, new advances, and the relationship of one disease to another. The introductory chapters provide a brief resume for those not familiar with the use of life tables and mortality studies. The other 13 chapters deal with specific medical risk factors, including physical, toxic, and other miscellaneous risk factors; cancer; neuropsychiatric disorders; coronary heart disease; hypertension, congenital and valvular heart disease; arrhythmias and ECG abnormalities; other cardiovascular diseases; respiratory diseases; digestive system diseases; genitourinary diseases; systemic disorders and endocrine and metabolic diseases. Part II of the volume contains the tabular abstracts, 'which are arranged in nine major categories of risk factors, as follows: physical, toxic, and other risks; cancer; neuropsychiatric disorders; cardiovascular diseases; respiratory diseases; digestive systern diseases; genitourinary diseases; systemic disorders and metabolic diseases. Each major category is subdivided into a number of subcategories. The text dealing with each of the abstracts follows a uniform order, giving the reference, the definition of the subjects studied, the follow-up and the results. The bulk of the data presented in this book is drawn from sources outside the insured population. However, some studies of life. insurance experience are included. Over 2,000 articles in the literature were screened and evaluated; only those published since 1950 have been included. These were found by scanning approximately one hundred medical journals and cover studies performed in the United States, Great Britain, Canada, Australia, New Zealand, South Africa, the Scandinavian countries, and Western Europe. Adequate follow-up was a prerequisite for inclusion. Experience, almost without exception, is reported in age groupings rather than by individual ages. The purpose of the publication is to make available, in a single volume, tables of comparative mortality and survival data for convenient reference.
Descriptor(s): Economic/commercial influences, Supply/availability of services, Impact of third-party coverage, Health care/ services, Physicians, Policy initiatives, Health care costs,
Descriptor(s): Trends in health status, Comparisons regarding foreign health policies, Premium determination/underwriting.
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'S_,l.. Medical
Self-Care Programs.
_!._meM Zapka and Barbara B. Estabrook. t_70, 7 pp. _.ailability: Health Care Management Review vl n4 p75-81 Fall 1976.
tne rationale behind the self-care movement, examples of succ_ssfiai models, and implementation issues are explored in this _rt_c'[e. Hearth serf-care is defined as the performance by con_macr_ of activities traditionally carried out by providers_ This _rc_cess includes preventive behaviors, screening and monitoring _:,r risk factors or disease, self-diagnosis, and treatment. Certain "_orms of self-care are prevalent, as it is estimated that only :ne-third of illness reaches medical attention and that a large ?e_eentage of persons who do seek professional care attempt _clf-care first. Although self-care has its roots outside of the ._aditional medical delivery system, potential advantages of such _:ffc_rtshave resulted in increasing integration within the delivery s .s_em. The two general societal trends which have contributed _o the self-care movement are consumer activism and increasing use of self-help strategies in dealing with problems such as alcoholism, smoking, and obesity. Potential advantages of the selfc_rc model include increased patient knowledge of specific dist:ase entities, appropriate utilization of professional resources, and reduction of episodic care. Several broad objective programs aimed at patient activation have developed over the past few ;ears. 16cusing on peer self-help, group self-help, and patient: _6ucation. Such programs include Reach for Recovery and. ,e_'avk_r modification programs sponsored by HMO's. Basic : d wiples of education and administration which must be consi,-tered when self-care approaches are introduced into the medi-. _:a_del ,,cry system are the commitment to planning, theneed for :2,cused objectives, and the maintenance of realistic impact goals "imp, coordination of efforts, and patience with the development i,rt_ccs_ are required for program success. In addition, patient: haracterisfics must also be a consideration in organizational lunching. Six references and one figure are included in the arti.i_. __:.._v,p_o,_s):Trends in health status, Preventive services, Cos_ __omainment efforts.
:05. Medical Technology. A Different View of the Conten.qoas Debate Over Costs. : ,,,,,has W. Moloney and David E. Rogers. .._79 7 pp 4 _'aiiability: New England Jnl. of Medicine v301 n26 p1413i4i9 27 Dec 79.
i- 75_,
This article presents evidence that technologies such as the CA T scanner account for far less of the growth in medical expenditures than do the collective expenses of thousands of small tests and procedures. The article notes the growing conviction that medical technologies are major contributors to escalating costs and that regulating them is generally viewed as the least contentious way to control expenses in the 1980's. Five forms of technology control include limiting the development of certain technologies while they are still in the research pipeline, using cost-benefit studies to set priorities for the development and distribution of technologies, and limiting the distribution of big and expensive technologies within regions according to population and epidemiologic characteristics. Other strategies would eliminate the use of technologies of no clinical value and provide reimbursement for technologies only when used according to protocols. All of these approaches aim to reduce costs by controlling big, expensive tecl_aaologies in the class of computed tomographic (CAT) scanning. It is suggested that each strategy for controlling large technology involves substantial practical and conceptual problems that would severely limit its effectiveness. Thus, a shift away from attempts to harness the big technologies is suggested. Rathe:r, physicians and hospitals should be encouraged to use all technologies more discerningly. Medical educators should instill in medical students and house officers the importance of a restrained, selective use of technologies in patient care. Insurers should design reimbursement plans to encourage hospital staffs and private practices to reduce collective costs of their standard use of technology. Because these approaches are interactive, all should be tackled simultaneously to control costs. A total of 59 references are provided. (Author abstract modified)
Descriptor(s): Medical technology impacts, Cost containment efforts, Plan design/program provisions (under health plans).
566. Medical Technology _md Hospital Costs. Judith L. Wagner and Michael Zubkoff. 1978, 27 pp. Availability: Neale Watson Academic Publishers, York, NY 10010.
Inc., New'
This paper examines the reasons for policy efforts to control the introduction of new technxflogies and explores gaps in existing knowledge concerning technological change, costs, and diffusion. Technology has been ,_ingled out as a particular problem of hospital behavior because ofinfiation studies linking technology to increased hospital costs, mounting evidence that many health services have made little difference in health outcomes, and the
Health
Care Program_
disappointing record of programs designed to control hospital capital expenditures. The paper divides the technology issue into two subproblems, each with its own policy implications: the problem of resource allocation and technology use, and the problem of technical change. Technology use can be related to three factors: structural changes in the nature of medical education; patient demands for technological sophistication; and failure of the cost-reimbursement system to keep hospitals from increasing their investment in expensive technology. To address this problem, policymakers need to change the present reimbursement system, establish a Federal agency to evaluate existing medical practices, and encourage medical schools to include research information on efficacy. The problem of technical change has engendered policymaking recommendations that appear contradictory because of inconclusive research, lack of knowledge about technology development, and scattered evidence on how hospital decisionmakers adopt new technologies. Studies on the economics of technological change suggest that new technologies appear to raise hospital costs but fail to clarify whether these increases are not offset by savings in other sectors. Studies concerning the diffusion of new hospital technologies show that hospitals are likely to adopt new technologies when they are large, complex, and wealthy, and that medical centers and teaching hospitals can be expected to be early adopters of new technologies. The paper concludes that increasing Federal attention should be paid to the generation of valid information on the efficacy of medical procedures, particularly those involving the use of new and existing "sophisticated services." About 50 references are given,
ernment level because of the increasing public inveslrne,t i, medical care and because those public expenditures have risen at nearly twice the rate ofprivateexpenditures. As govet_amental involvement poses a threat to professional autonomy, health care providers have consistently resisted change from that sector. With few exceptions, the 1970's was the first perkxt during which debate focused on the implications of medical technology as a generic issue. The history of the Food and Drug Administration illustrates the piecemeal approach and implementation of technology-related policies prior to that time. Major events in the policy area during the 1970's included the development of the Professional Standards Review Organization (PSRO), passage of the Medical Device Amendments in 1976, and consolidation of health planning programs into a system of health agencies. One of the major factors in approaching the overall problem may be lack of knowledge about the effects of medical technology on society. Five complementary strategies are suggested to ameliorate the situation. These strategies include the control of biomedical research, changing personnel policies to foster family practitioners, changing the financial incentives of the present health care system, increasing regulation under Federal law, and increasing and improving available medical technology information through efforts by the National Center for Health Care Technology. Thirty-three references are provided in the article.
Descriptor(s): health care.
Medical technology
impacts,
Policy/cl_Langes re
From 'Hospital Cost Containment. Selected Notes for Future Policy," p263-289, 1978, edited by Michael ZubkotE 568. Medical Technology. The Culprit Behind Health Care Costs. Descriptor(s): Cost containment efforts, Medical technology impacts, Inpatient facilities, Policy initiatives. Stuart H. Altman
567. Medical Technology.
Policies and Problems.
H. David Banta and Clyde J. Behney. 1980, 8 pp. Availability: Health Care Management
and Robert
Blendon.
Sun Valley Forum on National Health, Inc., Sun Valley, ID 83353 Health Resources Administration, Hyattsville, MD. Jun 1979, 306 pp. A vailability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-026-00077-1.
Review v5 n4 p45-52
Fall 1980. Medical technology is discussed as a policy issue of great importance to the public and private sectors. Technology was once considered automatically beneficial. Today, the health care industry is weighing the consequences as well as the advantages of medical technology, particularly in light of rapidly rising health care costs. The issue is especially significant at the Federal Gov-
This volume of 16 papers addresses the relationship between medical technology and health care costs. The Government's role in rising health expenditures during the last decade is discussed, as are studies which assess the impact of new technology on costs, the effect of ancillary services to treat common conditions, and the influence of technology on hospital costs. Also considered are types of technology which are probably most crucial in terms of cost implications. A typology of medical
1-257
technologies based on their medical objectives is presented as a guide for policymakers. Case studies focus on renal dialysis and transplantation, the computed tomography scanner, and clinical chemistry tests. Finally, policies to control the costs attributed to the use of medical technologies are suggested. Strategies proposed in these papers include anticipating the consequences of applied research in the developmental stage, changing reimbursement mechanisms for physicians and hospitals, and restructuring the delivery and payment system so that providers must operate in a more competitive marketplace. The need for a Federal agency to evaluate the needs and cost effectiveness of new technology is proposed, while opposing views outline argu-
ment level. Suggested approaches range from straight service limitations through governmental regulations to a complex mix of regulatory authority, private sector management, and voluntary efforts by the industry itself. Ultimately, it is the physician who bears the responsibility for patient care and who must determine the number and types of services delivered.
ments against Government regulation. An analysis of patientday cost increase data demonstrates that the impact of technological services on hospital costs has been overstated. The major
570. Medically Indigent. A State Perspective Problem.
findings of the conference are summarized, and options for Government action are suggested. Tables and references accompany each paper,
Joseph G. Beck and Calvin Pierson. New York State Dept. of Health Health Planning Commission, Albany, NY 12237 Apr 1980, 52 pp. Availability: New York State Dept. of Health, Health Planning Commission, Albany, NY 12237.
Proceedings
Descriptor(s): efforts,
of the 1977 Sun Valley Forum on NationM Health.
Medical technology
Diagnostic
services,
impacts,
Therapeutic
Cost containment services,
Inpatient
facilities, Policy initiatives,
569. Medical Enough.
Technology.
Charles A. Sanders. 1978, 5 pp. A vailabilio:" Hospitals
Who's To Say When We've Had
v52 n22 p66-69,72
16 Nov 78_
Issues relating to the use of medical technology and corresponding cost increases in health care are discussed in this article, Today, the application of medical technology is often attackexl as a means of inappropriately and needlessly maintaining life while increasing the costs of health care. Considerable evidence. supports the thesis that medical technology is a substantial contributor to the rapid escalation of health care costs. The most crucial issue remains how to effectively manage technology, recognizing that capacity to do so alone is not justification for maintaining life under all circumstances. Courts have attempted to clarify this question. In a recent Massachusetts case the court held that in all cases in which a decision is reached not to prolong the life of a terminally ill patient, the patient's family should seek the court's permission to discontinue life-support measures. In addition greater efforts must be made to rationalize distribution and application of available technology. This effort must derive from the systems rather than from the individual case manage--
1-258
Descriptor(s): pacts.
Cost containment
efforts, Medical technology im-
on a National
Issues associated with medical care for the indigent in New York State are discussed, and recommendations for financing and improving such care are offered. The "medically indigent" are those poor or near poor who are not on State and county systems of relief because their incomes are too high to qualify, yet they are uncovered or without adequate coverage for necessary medical expenses. Throughout tlhe United States 5 to 8 percent of the population are without he_dth insurance coverage, and in New York State, 8.8 percent of _:he population is medically indigent. New York State and New York City funding for medically indigent health services has steadily declined because of strong economic and fiscal pressures which have forced these governmental units to the brink of insolvency. Eligibility for medicaid once held a key for needy New Yorkers in obtaining necessary medical services. Today, medicaid no longer functions in such a capacity for a great many poor people. Income eligibility levels under which an individual or family qualify for medical assistance have declined in real dollar terms by about 60 percent since 1966. Within a climate of stringent rate controls, hospital outpatient services and medicaid ambulatory care expenditures have been curtailed, indicating a reduction in services available to the medically indigent. The provision of adequate medical care for indigents in New York State can be fully attained only when fiscal conditions at the State, local, and Federal levels make possible extended public spending; however, the current situation does lend itself to marginal improvements in the funding and delivery of services to the medically indigent. Recommendations are offered for the State to fashion a more coordinated, if fiscally constrained, medically indigent funding strategy. Supporting tabular data are appended; approximately 23 references are provided.
Health Care Programs
Descriptor(s): Supply/availability of services, Non-participants in health care programs, Medicaid, Funding/financing of health care programs, Policy initiatives, Characteristics of U.S. health care system.
572. Medicare and Medicaid Amendments of 1980.
Committee on Interstate and Foreign Commerce (U.S. House), Washington, DC 20515 Apr 1980, 204 pp. Availabi_ty: Superintendent of Documents, Government Printing Office, Washington, DC 20402.
571. Medicare After 15 Years. Has It Become a Broken Proraise to the Elderly.
Select Committee on Aging (U.S. House), Washington, DC 20515 Nov 1980, 112 pp. A vailability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 052-070-05458-1.
Based on numerous reports and findings obtained by thousands of questionnaires sent to senior citizens and health care providers, this congressional report analyzes the successes and shortcomings of the medicare program. What emerges is a picture of a highly successful Government program which is currently undergoing severe stress. Satisfaction with the program has been high in the past, but dissatisfaction is rising. Whether medicare continues as one of the most efficient Federal programs or whether it becomes another broken promise made to the elderly depends on the Congress. Improvements in home health, mental health, and prepayment for medicare coverage in heal_ maintenance organizations are a good start. However, the congressional committee has concluded that these efforts fall short of what is needed. The Committee on Aging recommends that the COngress immediately enact sweeping improvements to encourage physicians to accept specific assignments and to cover eyeglasses, hearing aids, dental care, and prescription drugs through a new self-financing part of medicare. The committee believes that such improvements cannot wait for the enactment of a broader national health insurance plan. The report presents statistical data on the medicare program, excerpts from letters written by the elderly with regard to medicare, a review of the major problems of medicare, an analysis of pending reform legislation, summary and excerpts from the hearings conducted on medieare's 15th anniversary, the committee's conclusions and recommendations, and supplemental views submitted by various Representatives. The provisions of the Bonker Bill are appended. (Author abstract modified)
96th Congress second session, Pub. No. 96-245.
Descriptor(s): Medicare, Policy come of health care programs.
initiatives,
Evaluations/out-
This report of the Committee on Interstate and Foreign Commerce, U.S. House of Representatives, contains the provisions of the Medicare and Medicaid Amendments of 1980, (H.R. 4000). These amendments were designed to make various benefit changes and administrative improvements in the medicaid and medicare programs. Provisions of the bill either affect only the provisions of the medicaid program or affect those areas where medicare and medicaid have common provisions or requiremerits. The bill includes provisions relating to the operation of the Professional Standards Review Organization (PSRO) Program, the availability and quality of long-term care services, and additional protection against fraud and abuse in the medicare and medicaid programs. For example, the PSRO provisions of the bill are designed to improve PSRO performance by focusing peer review activities on areas of abuse, increasing nonphysieian participation in the development and implementation of peer review activities, and tightening program administration. In the provisions dealing with long-term care, the bill authorizes the use of excess hospital beds as long-term care beds on a swing-bed basis. Other provisions concern a voluntary certification program for private insurance supplementing medicare and a revision in the current method for reimbursing health maintenance organizations (HMO) under medicare. The report also contains a section on the cost of carrying out the bill, a section-by-section analysis, and changes in existing law made by the bill. Tabular data are included.
96th Congress 2nd Session, Report
No. 96-589 Part 2.
Descriptor(s): Medicare, Medicaid, tions, Long term care facilities.
Present
573. Medicare and Medicaid Physician
legislation/regula-
Payment Incentives.
Ira L. Burney, George J. Schieber, Martha O. Blaxall and Jon R. Gabel. 1979, 17 pp. Availability: Health Care Financing Review vl nl p62-78 Summer 79.
1-259
This study used selected physician reimbursement data from medicare and medicaid program experience to analyze the nature and direction of the incentives contained in these programs and their effects on several important public policy issues. The study was premised on the basic economic assumption that prices affect physician behavior. Given the limited nature of the data, conclusions are concentrated only on the empirically observed direction of the relationships. Results suggest several
vate price of their services, and (3) a change in reasonable fees would affect demand for services as well as supply. In addition, although the simulation results do not predict a substantial increase in the assignment rate from raising reasonable fees to the level of prevailing ones, improvements in medical care access among the elderly may still occur. One figure, five tables, and five references are given.
hypotheses. First, the customary, prevailing, and reasonable physician reimbursement method employed by medicaid, medicare, and many private insurers is inherently more inflationary than fee schedules. Second, medicare beneficiaries appear to have about the same financial access to care as Blue Shield subscribers, but medicaid patients are at a distinct disadvantage. Moreover, physician participation in public programs appears to
Desc_qptor(s):
be highly responsive to reimbursement levels. Third, medicare and, to a lesser extent medicaid, would appear to provide f'mancial incentives for physicians to locate in high-income areas and to choose specialty over primary care practice. Finally, medicare and medicaid may also provide incentives for physicians to treat patients in hospital settings and to perform surgical, as opposed to medical, visit procedures. Five tables and 21 footnote references are included in the paper.
575. Medicare Coverage for the Treatment
Descriptor(s): Cost containment efforts, Medicare, Reimbursement, Policy initiatives, Physicians.
Administration,
1980, 15 pp. A vMlability: Health Care Financing 1980.
Washington,
DC.
Review v2 p75-89 Winter
This paper investigated the effect of private prices and medicare reasonable fees on both the voluntary and total medicare assignment rates of physicians. The data file used in this analysis consisted of all claims paid by medicare and medicaid to a cohort of northern California physicians during the second quarter of each of the years 1972 through 1975. A simple theoretical model which viewed the physician firm as a monopolistic competitor was used to predict the assignment rate responses of certain groups of physicians to changes in private prices and medicare reasonable fees. The model pointed out that (1) the assignment rates of medicaid participating physicians were not expected to respond positively to increases in reasonable fees, (2) increases in reasonable fees would induce physicians to increase the pri-
1-260
influences,
Medicare,
Health care cost trends/projections, Medicaid, Reimbursement, Physicians, Medical/surgical services.
of Alcoholism.
John A. Noble, Paul Widem, Henry Malin and Judy R. Coakley. National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD 20857 Sep 1978, 35 pp. AvMlability: National InsL on Alcohol Abuse and Alcoholism, Rockville, MD 2(1857.
Medicaid,
574. Medicare Assignment Rates of Physicians. Their Responses to Changes in Reimbursement Policy.
Lynn Paringer. Health Care Financing
Economic/commercial
This report describes the service needs of the elderly in the areas of mental health, alcoholism, and drug abuse and the current medicare limits of coverage for these services, as well as the arguments for and against extending such coverage. While no recommendations are made in this report, requested by Congress under the Rural Health Clinic Services Act of 1977, it does appear that the elderly are not receiving adequate mental health and alcoholism treatment services and that restricted medicare coverage is a major stumbling block. Persons over 65 appear to need mental health services in greater proportion than their representation in the population as a whole. For example, they constitute 11 percent of _:he population, but 25 percent of all suicides are committed by elderly persons. Several factors contribute to the low level of' utilization of services: the reluctance of the aged to seek psychiatric services, the tendency among the elderly to define their problems as physical rather than emotional, lack of training among mental health professionals in treating problems of the aged, the cost of mental health services, and the limited medicare coverage for such services, particularly outpatient mental health services. Analysis of present utilization of alcohol treatment programs by medicare beneficiaries and coverage under private insurance plans for alcoholism treatment suggests that if provider status were afforded under medicare to mental health centers and alcohol treatment centers, easily accessible and less expensiw: mental health care would be available for the elderly. If the $250 limit on outpatient benefits under medicare Part B were inc.reased to encourage use of outpatient
Health
Care Programs
services, and if inpatient mental health services had the same coverage as physical health services, the eldery might seek less expensive care. However, expanding medicare coverage in this way does not ensure the quality of mental health services provided. Overall costs of care may increase as the elderly whose needs were previously met by informal care givers would begin to use medicare coverage; this could possibly lead to a lack of staff trained in the problems of the elderly. Eight tables, an appendix, and 10 references are provided.
Excerpts
from September,
1978 Report
to Congress.
Descriptor(s): Supply/availability of services, Medicare, Mental health services, Limitations on coverage, Exclusions from coverage, Participants in health care programs.
576. Medicare. Health Insurance for the Aged and Disabled, 1975. Section 2. Persons Enrolled in the Health Insurance Program.
Health Care Financing Administration Office of Policy, Planning, and Research, Washington, DC 21201 DHEW/PUB/HCFA-062(11-78) 1978, 103 pp. A vaiIability: National Technical Information field, VA 22161, HRP-0029953.
Service, Spring-
Statistics on the number of persons insured under the medicare program as of 1975 are presented by age, race, sex, and place of residence. Also provided is information on the characteristics and the geographic distribution of disability beneficiaries under 65 years of age who are covered by the program. As of July 1974, 25 million persons were insured by medicare. Approximately 23.6 million elderly and disabled persons were covered by both hospital and supplementary medical insurance, and an additional 1.1 million persons were enrolled only for hospital insurance benefits. Data on the characteristics of the elderly and disabled population in the medicare program are examined in terms of changes in enrollment since the start of the program in July 1966. Consideration is given to the hospital insurance enrollment of the elderly, the enrolled and terminated in 1975, hospital insurance enrollment of the disabled, the supplementary medical insurance enrollment of the disabled, and the disabled persons newly enrolled and terminated in 1975. The provisions of the law and regulations dealing with eligibility, financing, and administrative aspects of the medicare program and with health maintenance organizations are addressed. Notes and extensive tables are included. (NTIS abstract)
Descriptor(s):
Medicare, Participants
in health care programs.
577. Medicare. Health Insurance for the Aged and Dibbled, 1977. Section 1. Reimbursement by State and County. Health Care Financing Administration Office of Policy, Planning, and Research, Washington, DC 21201 DHEW/PUB/HCFA-03001 1978, 108 pp. A vailabib'ty: National Technical Information Service, Springfield, VA 22161, HRP-O029907. Data on enrollment in medicare and on reimbursement under the program as of July 1977 are provided. Reimbursements totaled $20.5 billion in 1977 for both hospital insurance and supplementary medical insurance. Between 1976 and 1977, the monthly per capita reimbursement for the elderly under hospital insurance increased by 11.4 percent, from $41.80 to $46.56. Supplementary medical insurance increased by 15.5 percent, from $15.37 to $17.76. The monthly supplementary medical insurance average of $30.50 for the disabled (including beneficiaries with end-stage renal disease) was notably higher than the average figure for the elderly. The provisions of the law and regulations regarding the hospital insurance and supplementary medical insurance components of the medicare program are addresssed. Attention is also given to financing and administration of the program and to reimbursements received by health maintenance organizations. The statistical system of medicare, composed of the health insurance master file, provider record, hospital insurance (Part A) utilization record, and medical insurance (Part B) payment record is discussed. Much of the report contains statistical tables on medicare enrollment and reimbursement by State and county of residence. (NTIS abstract modified) Descriptor(s): Medicare, Participants in health care programs, Reimbursement, Health care cost trends/projections, Demand/ utilization of health care programs, Health information/data systems.
578. Medicare, Medical Practice, sion.
and the Medical Profes-
Ernest W. Saward. 1976, 5 pp. Availabib'ty: Public Health Reports v91 n4 p317-321 Jul/Aug 76.
1-261
This article discusses the effects of medicare on private medical practice. It begins with a descriptionofthepre-medicareclimate, which was characterized by scientific advancement, professional autonomy, and a relationship to patients who were self sustaining in the private sector. Social responsibility to assure health care to all persons was an abstraction of little relevance to doctots before the enactment of medicare. With the institution of medicare, the providers of health services were confronted with new tasks of compliance and accountability that extended to every aspect of the function of institutional providers, involving codes of nondiscrimination, safety, laboratory standards, accounting procedures, and review of the appropriateness of hospital care in its most fundamental sense. The open-ended cost reimbursement method of the program relieved physicians of the necessity to treat indigents without reimbursement and occurred at a time when expensive new intensive care services were introduced. Thus, the profession experienced a new affluence and a new attitude, culminating in cost overruns that were deemed a health crisis within 3 years of program operation. Ensuing legislative measures that advanced health maintenance organizations and required local peer review of professional standards and utilization served to polarize the organized medical profession and the Federal Government. Health legislation is in a rapidly rising curve, with hundreds of bills introduced each year; the response of the organized medical profession has been to litigate when it sees new legislation infringing upon its independence, Despite controls and regulations, the costs of medical care continue to rise at an accelerating rate. Advanced medical technologies, used to meet the quality of care imperative, are a major contributor to this rise in costs. In view of the present consumerist nature of society and the intensified pursuit of equity, it is
versies. The general subjects considered are program origins and scope, covered services, exclusions under part A and part B, furnishing part A and part B services, payment for physicians' services, payment for provider services, principles of reimbursement, provider appeals, administration of the program, applicable law, public disclosure, and experiments in prospective reimbusement. The discussion of the program's origins considers the history and legislative intent of medicare, and the description of the program's scope covers part A and part B programs and beneficiary eligibility. The section on covered services examines hospital insurance under part A, supplementary medical insurance under part B, and deductibles and coinsurance under medicare. Topics discussed in relation to payment for physicians' services are reasonable ,:harge determination, part B hearings and appeals, part B entitlement questions, paperwork problems, and suggestions for a different approach. Interim payments, annual cost reports, retroactive adjustments and reopenings, recoupment of overpayments, and the minimizing of reimbursement controve_'sies are explored in discussing payment for provider services. Social Security ammendments for 1972 to 1974 are appended, along with a "related-party" analysis, U.S. Code-Social Security Act cross-references, and a glossary.
predicted that fixed allocation of resources will be instituted and will significantly reorder the priorities from heavy spending on complex tertiary care to spending on more accessible and available primary and secondary service.
580. Medicare Reimbursement Controversies
Descriptor(s): Medicare, Facilities providing health care, Physicians, Present legislation/regulations, Medical technology impacts.
579. Medicare Reimbursement.
Descriptor(s): Medicare Eligibility requirements, Deductible/ coinsurance, Reimbursement, Exclusions from coverage, Present legislation/regulations, Methods of payment determination, Health care/services.
and Appeals.
J.D. Epstein, Dennis Barry and Jack C. Wood. 1976, 120 pp. Availability: Topics in Health Care Financing v2 n3 complete issue Spring 1976.
A series of articles covers the following general topics relating to medicare reimbursement controversies and appeals: the background of medicare disp_ates, overview of the medicare program, beneficiary entitlement appeals, health care entity status appeals, areas of controversy (reasonableness of cost or charge and coverage of service), benefic:iary appeals procedures initiated with
Jack C. Wood.
intermediaries
1975, 170 pp. A vailabdity: Topics in Health Care Financing vl n3 Spring 1975.
the Blue Cross Association era (1968-1972), intermediary hearing regulations, judicial review of intermediary hearing decisions, the provider reimbursement review board, and Section 1122 appeals (Federal certificate of need). The discussion of beneficiary entitlement appeals considers initial determination and request for reconsideration, appeals of reconsidered determinations, administrative law judge's decision and appeals council
These articles provide the health care executive with an overall view of the medicare program and of particular medicare contro-
1-262
and carriers, provider reimbursement
disputes,
Health Care Programs
review, and judicial review. Topics considered with reference to health care entity status appeals are categories of health care entities, adverse status determinations, appealing denials of applications for certification, appeals of determinations of program abuses, and nonappealable determinations. The description of beneficiary appeals procedures initiated with intermediaries and carriers deals with part A and part B appeals procedures, constitutional issues raised by part A and part B beneficiary appeals procedures, and appeals by health maintenance organization enrollees. Appended are selected regulations and Blue Cross Association's most recent statement of procedures; case studies of beneficiary appeals procedures under part A, the Blue Cross Association Provider Appeal Committee, and Provider Reimbursement Review Board hearing procedures; and selected doeuments pertaining to hearings before the Provider Reimbursement Review Board. References are provided for each article, and a medicare glossary is included.
Desc_ptor(s):
Medicare,
Reimbursement,
tion, Present legislation/regulations,
Claims
tivities: a consumer/provider education and marketing program, the obtaining of consultant cooperation, the development of special referral center procedures, the establishment of claims processing procedures, the finalizing of data collection activities, and the development of reimbursement methodologies. Each of these activities is discussed in detail. Also discussed are research design, data collection, program specifications, and source documerits. Sample program forms and graphic data are provided. (NTIS abstract modified)
Research
and Demonstration
Series, Report No. 2.
Descriptor(s): Medicare, Medical/surgical services, Plan design/program provisions (under health plans), Cost/benefit analyses.
administra-
Service benefit plans.
582. Medicare. The Politics of Federal Hospital Insurance. Judith Feder. Brookings Inst., Washington,
581. Medicare Second Surgical Opinion Demonstration ject. Greater New York.
Pro-
Patricia A. O'Connor. Blue Cross and Blue Shield of Greater New York, New York, NY 10017 Health Care Financing Administration, Washington, DC. Ofrice of Policy, Planning and Research. 1978, 170 pp. A vailability: National Technical Information Service, Washington, DC 22161, PB-290 873.
This is a report of the activities that have occurred during the preimplementation phase of Greater New York's Second Surgical Opinion Programs for eligible medicare Part B beneficiaries, as well as the activities projected for the duration of the contract, The purpose of the experiment is to provide data necessary to determine whether coverage of second and third surgical opinions produces a net cost savings or lower morbidity and mortality rates among the medicare population. The experimental benefit will be made available to 1.5 million Part B medicare beneficiaries in the 17 southern counties of New York State. The experiment is designed to cover 3 years -- May 1978 to May 1981. The total use projected for the test period is about 3,000 beneficiaries. The program is voluntary, and the coiusurance and deductible requirements have been waived as an incentive to encourage use of this benefit. The 6-month preimplementation phase, beginning November 1, 1977, involved the following ac-
DC 20036
Harvard Univ., Cambridge, MA 02138 Social Security Administration, Washington, DC. National Center for Health Services Research, HyattsviUe, MD. 1977, 177 pp. Awilabill"ty: D.C. Heath and CO., Lexington, MA 021173. The development of medicare policy on hospital
payment is
traced from the passage of the medicare law to the period just before the reorganization of medicare in 1977. The fundamental premise of the book is that medicare policy toward hostfitals has been profoundly influenced by the perspectives and goals that its administrators acquired in a social insurance agency. The social insurance perspective emphasizes efficient claims payment rather than controlling the impact of payment on costs and quality of medical care. In implementing the provisions of the medicare law, the Social Security Administration was faced witlh several basic choices, including whether to pay for care to the elderly in any hospital regardless of hospital conditions, whether to evaluate or ignore how physicians and hospitals practice medicine, and whether to be stringent or liberal in determining what costs should be reimbursed by the insurer and if an upper limit should be set on costs. The Social Security Administration could have faced these choices independently, simply "muddling through," or it could have adopted one of two consistent strategies. With a balancing strategy, policy choices could be made by identifying relevant political factors, weighing their influence, and comproraising their interests to minimize conflict. With a cost-effectiveheSS strategy, policy elioices could be made by calculating the
1-263
most efficient and effective way to finance health services, defining conditions on hospital payment accordingly and risking conflict to see them observed. Because the immediate objective was to ensure the success of the new program, the balancing strategy was pursued. Although this approach perpetuated inadequate and unsafe institutions and exacerbated medical cost inflation, ideological predisposition and aversion to political risk made the agency resistant to change. To revamp medicare policy, it is therefore necessary to alter administrators' predispositions through changes in personnel and organization and to modify the risks they face in change versus status quo. Responsibility for alteration of medicare policy thus rests less with administrators than with Congress and the President. Chapter notes, an index and about 200 references are supplied.
Descriptor(.Q: Medicare, Cost containment efforts, Hospital services, Present legislation/regulations, Outcome/evaluation of health administration, Policy/changes re health care.
583. Medigap. States Response to Problems with Health Insurance for the Elderly. T. Van Ellet. George Washington Univ. Intergovernmental Health Policy Project, Washington, DC 20006 Health Care Financing Administration, Washington, DC. Oct 1979, 61 pp. A vailabiliO:" George Washington Univ., Intergovernmental Health Policy Project, Washington, DC 20006.
This publication discusses the problems and the abuses encountered by the elderly with medicare supplementary insurance; regulations in the various States to combat the problems; a States' regulatory model; and a survey of States' insurance departments. Due to increasing costs of health care and subsequent out-of-pocket expenses, the elderly are turning to private health insurance to supplement medicare protection gaps. However, the efficacy of these policies is often questionable. Federal intervention is difficult because the insurance industry is regulated by the States, although some States are taking steps to curb abuses and solve problems. A discussion of medicare reveals that its coverage of the elderly is decreasing due to increases in cost sharing to curb government expenditures and delineates medicare benefits and limitations. A section on types of private insurance offered the elderly as supplementary to medicare examines true supplementary policies, indemnity policies paying fixed amounts for hospital stays, and limited policies covering certain types of catastrophic illnesses. Problems with these policies and their insurers include lack of standardization, duplicate or excessive
1-264
coverage, abstruse language:, poor return for premium dollars, and marketing abuses. Delineation of a model of State health insurance regulations includes adherence to unfair trade and advertising regulations, more efficient handling of consumer complaints, premium price controls, and minimum standards requirements. Regulations :recommended for medicare supplements are outlined, including disclosure of and standards for benefits, and regulation of preexisting conditions limitations. In a survey of State insurance departments, officials cite marketing, documenting, and prosecuting abuses as serious problems but do not recommend new State or Federal legislation. Final sections recommend areas for State action, such as consumer information disclosure and requirements, and cover _urrent and suggested Federal government activity. Tables, 49 references, and illustrations are included.
Descdptor(s): Non-employment related plans, Limitations on coverage, Exclusions from coverage, Policy in,datives, Comparisons of health care programs, Medicare.
584. Mental Disorder and Primary Medical Care. An Analytical Review of the Literature.
Janet Hankin and Julianne S. Oktay. Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD 20857 DHEW/PUB/ADM-78-661 National Inst. of Mental Health, Rockville, MD. Applied Biometrics Research Branch. 1979, 204 pp. A vailability: Superintendent of Documents, Government Printing Office, Washington, DC, order number 017-02400919-9.
This report presents an overview of research regarding the diagnosis and care of patients with psychiatric illness by the primary care physician, as well as 354 annotated references. Relevant papers were selected from a literature search of all English language books and articles cm mental illness in general practice published between 1959 and 1975. An introduction comments on the primary medical care system in the United States, the delivery of mental health services, and the integration of health and mental health services. The summary of the articles annotated in the bibliography first addresses the identification of psyehiatrie morbidity in primary medical care settings and covers diagnosis of mental illnesses, reported rates of psychiatric morbidity, and research based on several types of general practices in Great Britain and the United States. Studies concerning the use of health services by primary care patients with mental
Health
Care Programs
health problems are then reviewed, followed by a summary of articles which explore management of this patient population, Referrals to specialized services, types of treatment provided by primary care physicians, and psychiatric training for general practitioners are considered. The overview concludes that a substantial number of primary care patients suffer from mental disorders but do not receive specialized care. The annotated bibliography is arranged in alphabetical order by author and describes the problem studied, methodology, and major findings for each entry. References which were cited in the overview but not included in the bibliography are listed separately. Indices are provided for both sections of the report. The appendices contain additional references on historical works, psychosomatic medicine, consultation psychiatry, training manuals, and other articles published in 1975 and 1976. National
Inst. on Mental Health,
Series D, No. 5.
Descriptor(s): Mental health services, Demand/utilization of health care programs, Trends in health status, Outpatient facilities, Physicians, Comparisons regarding foreign health policies.
585. Mental Health Services for Medicaid Enrollees in a Prepaid Group Practice Plan.
sixth visit, of those who stayed until the sixth visit medicaid patients attended more sessions than the other two groups. Therapeutic orientation was strongly influenced by community mental health principles and techniques. There was emphasis on promotion of functional competence rather than self-actualization, with an adherence to a multidetermined view of etiology -psychological, social, biologic, genetic, and educational. There was also evidence that psychiatric treatment reduced the use of other physician services, especially x-ray and laboratory services. While the poor require as many or more mental health services as do middle-income groups, the cost for these services may be somewhat reduced by less use of other services following psychotherapy. Ten years of experience in providing mental health care to the medicaid population in a prepaid medical group practice setting demonstrates that this is a feasible method of delivering mental health care to a low-income group. However, the substantial attrition rate of medicaid enrollees from the medical plan itself remains a problem of some magnitude and requires determining the causes to reverse the trend. Ten references axe provided. (Author abstract modified)
Presented at the 131st annual meeting of the American tric Association, Atlanta, GA, May 8-12, 1978.
Psychia-
Descriptor(s): Medicaid, Mental health services, Prepaid plans, Demand/utilization of health care programs, Participants in health care programs.
Sidney S. Goldensohn and Raymond Fink. National Inst. of Mental Health, Rockville, MD. 1978, 5 pp. Availability: Feb 79.
American
Jnl. of Psychiatry
v136 n2 p160-164
In the prepaid group practice setting of the Health Insurance Plan of Greater New York, the low-income members increased their use of mental health services. This study indicates that, initially, medicaid enrollees used the mental health services less than the other two major member groups, Federal employees and New York State employees; however, over a 6-year period, low-income members increased their use of the services, and by 1976 exceeded the rate for the other two groups. Increases in use occurred both in the rate of those entering the treatment system through initial consultation and in the average number of services per treated patient, despite the declining medicaid enrollment during that period. Studies have shown that those with little education tend to use fewer mental health services, and as medicaid enrollees tend to be less educated than the other two subscriber groups, these study f'mdings are interesting. It is also commonly believed that the low-income person has a greater tendency to drop out of treatment early. Although medicaid patients were more likely than others to end therapy before the
586. Mental Health Services. Utilization
by Low Income Ea-
toffees in a Prepaid Group Practice Plan and in an Independent Practice Plan.
Stephen J. Williams, Paula K. Diehr, William L. Drucker and William C. Richardson. National Center for Health Services Research, Hyattsville, MD. 1978, 13 pp. AvMlabib'ty:MedicalCarev17n2p139-151
Feb 79.
This study examines utilization and certain costs for mental health services provided to a low-income population enrolled in two comprehensive benefit plans. Mental health services were included in both the prepaid group practice plan (P(3P) and in an independent practice plan (IPP) under the Seattle Prepaid Health Care Project in Seattle, Wash. There were no direct costs to enrollees. Utilization of services was studied for 4 years under conditions that might simulate universal entitlement. "I_e analyses indicated that females used substantially more mental health services than males, and enrollees aged 20 to 44 used more
1-265
services than those in other age groups. The PGP generally experienced higher utilization than the prepaid IPP. Significant racial differences were evident, with whites using more services than blacks and black males using strikingly few services. The IPP was oriented toward physician providers and emphasized individual psychotherapy, while the PGP employed a diversity of practitioners and therapeutic modalities. The data indicated that the percent of enrollees using any mental health service was twice as great in the PGP as in the IPP. Inpatient services were also examined. A significantly higher proportion of IPP enrollees were admitted for inpatient care as compared to PGP enrollees. The cost of mental health services was less than 10 percent of total health service costs in both plans. Eight tables and 36 references arc included in the article. (Author abstract modified)
Also See "Relationship Between Uttlization of Mental Health and Somatic Health Services Among Low Income Enrollees in two Provider Plans. '" Descriptor(s): Participants in health care programs, Demand, / utilization of health care programs, Prepaid plans, Mental health services, Comparisons of health care programs, Heait;h care costs.
mental health insurance, compensation for tile mentally irapaired worker, and the cost of private practice psychiatry under National Health Insurance. A final section gives specific recommendations for expanded services and insurance benefits and outlines the structure and fimctions of a proposed congressionally chartered non-profit national center for mental wellness in the work setting. Footnotes and tabular data are included. A list of conference participants quoted is appended. Springer Series on Industry
Descriptor(s): Cost/benefit analyses, Mental health services, Prepaid plans, Allied health professionals, Voluntary initiatives.
588. Methodology Used to Measure Health Care Consumption During the First Year of the Health Insurance Experiment. Kent H. Marquis. Rand Corp., Santa Monica, CA 90406 Rand/R-2126-HEW Department DC.
587. Mental
Wellness Programs
for Employees.
Richard H Egdahl and Diana Chapman Walsh. Boston Univ. Health Policy Inst., Boston, MA 02215 1980, 230 pp. Availability: Springer-Verlag,
New York, NY 10010.
This volume represents the outcome of a conference on Employee Mental Wellness Programs held in 1978. The conference was intended to bring together experts inside and outside industry to discuss industry's current and potential roles in delivering mental health services. Two introductory papers cover the industrial cost of severe mental distress, alcoholism, and drug dependence arid results of the final survey of employee mental wellness programs by the Washington Business Group on Health. Program models and directions are explored through papers presenting case studies in mental wellness programming, guidelines for employee assistance program development, labor and employee assistance programs, promotion of an employee assistance program in a health maintenance organization (HMO), and ethics in industrial mental health programs. One section is devotcd to experiences with staffing and organization; these papers examine statfing in an employee counseling service, a corporate emotional health program, and employee assistance programs, Financial considerations are analyzed in papers on corporate
t-2tJ'.,
and Health Care, No. 9.
of Health, Education,
and Welfare, Washington,
Aug 1977, 77 pp. A vailability: Rand Corp., Santa Monica, CA 90406. The research design of the Health Insurance Study addresses questions about the demand for health care. Constructs specified by economic theory are measured to observe relationships between consumption of medical services and the prices for those services faced by consumers. An important goal of the research is to generate unbiased results that apply to a variety of financing and coverage possibilities. These theoretical and applied objectives shape the measurement requirements for the research. The demand estimation goals ,of the experiment require measurements to observe a broad range of health care services, to infer demand for specific services, to obtain details of each health service used, to scale each ilem consumed in ratio units, to assign each observed service to a l:_int in time and an episode of illness, and to minimize measurement effects. Measurement biases correlated with the experimental treatments of "true" utilization can distort estimates of the price effects. The most probable measurement bias would be a failure to detect all health care consumption because of reliance on only insurance claims to measure utilization. Therefi_re, a supplementary reporting mechanism was established. A small scale pretest was conducted on a pilot sample to compare the effect of weekly and monthly supplementary reporting on the amount of outpatient consumption detected within each of two extreme experimental financing
Health
Care Program_
treatments: one in which all outpatient care was free and another in which families paid the entire cost of care until a large deductible requirement was met. Results suggested that a measurement
590. Metrolmlitan Comprehensive Care Program. A Health Systems Organization Demonstration.
system using only insurance claims could result in a 20-percent underestimate of overall utilization. Measurement effects were correlated with the experimental insurance plan treatments. The group submitting weekly reports reported significantly more consumption than the monthly report group within a deductible treatment. No significant effects of supplementary reporting were found in a plan in which service was free. The pretest also indicated that providers (doctors, pharmacies, etc.) did not al-
New York State Dept. of Health Office of Health Systems Management, Albany, NY 12237 New York State Dept. of Social Services, Albany, NY 12237 Health Care Financing Administration, Washington, DC. Jul 1980, 168 pp. Availability: New York State Dept. of Health, Office of Health Systems Management, Albany, NY 12237.
ways furnish complete information and that provider nonresponse was correlated with the experimental insurance treatments. Tables, footnotes, and approximately 35 references are included. (Author abstract modified)
A demonstration project designed to minimize barriers to the effieient delivery ofhealth care services to the East Harlem (New York City) community is presented. Components essential to the implementation of the project are (1) administration of the Citye.aid program, (2) improved and simplified medicaid eligibility
Descriptor(s): Impact of third-party coverage, Deductible/coinsurance, Reimbursement, Demand/utilization of health care programs, Medical/surgical services,
determination, (3) maximization of third-party payments through development of a patient screening system, (4) improved management at Metropolitan Hospital, (5) development of a case management system and a process for program enrollment and (6) the development of a health maintenance organization (HMO) at Metropolitan Hospital. These program components are intended to provide the f'mancing of comprehensive and coordinated health services at Metropolitan Hospital to a maximum of 17,100 persons who previously did not have adequate health care coverage, to ensure that medicaid coverage is extended to all East Harlem residents who are eligible, and to provide maximization of third party coverage for Metropolitan Hospital. The project is also designed to address key research issues. The project's impact on residents' health status, health services delivery, facility financing and management, and efficiency will be evaluated. General areas treated in the project presentation are the project title and objectives, the background and importance of the project, the demonstration methodology, evaluation, work
589. Methods for Setting Priorities in Areawide Health Care Planning. An Annotat_ Bibliography.
Young (Arthur) and Co., Washington, De 20036 National Health Planning Information Center, RockviUe, MD. Apr 1978, 109 pp. A vai/ability: National Technical Information Service, Springfield, VA 22166, HRP-0300801. This bibliography is an aid to health planners involved in developing areawide plans for health care. It provides 79 subjectclassified entries. These major classes include concepts and methods relating to analytical approaches and concepts and methods under goal-harmonizing approaches. Within these subject areas, entries are arranged alphabetically according to the author's last name. Each entry provides the author, title of the work, title and volume of the source publication, date, and page numbers (where applicable). Each entry is followed by an ab. stract of the work. Books, articles, studies, reports, and papers are included in the bibliography. Most were published from the mid-1960's through the early 1970's. An additional 58 references are listed but not abstracted in the bibliography.
Health Planning
Bibliography
$etqes, No. 8.
Descriptor(_9: Characteristics of U.S. health care system, Health care costs.
plan, project staff, and implementation potential. The agreement between New York State, New York City, and the Department of Health and Human Services to conduct the project is appended' al°ng with maps °fn°rthern Manhattan" Tabular and graph" ic data are provided. Descxiptor(s): Prepaid plans, Medicaid, Health care/services, Inpatient facilities, Funding/financing of health care programs, Supply/availability of services, Publicly sponsored/mandated health plans.
$91. Minimal Care Units. Mechanisms Containment. Alice L. Glass and Leon J. Warshaw. 1978, 9 pp. Availability: Health Care Management
for Hospital Cost
Review v3 n2 p33-41
1-207
Spring 1978.
(PSRO) period to see if they reveal any presumption for applying the PSRO strategy to private patients as well. PSRO's mandated
Minimal care units can reduce the cost of a day in the hospital for some patients. Minimal care has always been part of the acute hospital care. Hospital personnel are deployed so that the sickest patients are adequately attended to while services for the rest are scaled down. Transferring patients to less expensive minimal care units when the need for acute bed care no longer exists may reduce the cost of the hospital stay. Although some hospitals have established minimal care units, since 1970 the number of units has declined. Attention to the lower end of the care spectrum has largely been preemptd by the explosive increase in extended care facilities and long-term nursing homes. To be successful, minimal care unit occupancy must be rigidly limited to those patients who need hospitalization, such as those patients with chronic illnesses like diabetes or hypertension. The cost containment potential of the minimal care unit will not be realized if it is used to house patients who really belong in an extend-
by the Social Security Act, aim to monitor and control hospital use by publicly funded patients, particularly medicare and medicaid patients. Data are presented from the Chicago Hospital Discharge Study which was conducted in February 1970, before PSRO activities were undertaken. The study compares the lengths of stay of patients irkfive payment categories: Blue Cross,
ed care facility or to house patients who do not really require hospitalization. Third-party reimbursement policies have deftnitely discouraged the development of minimal care units. Reimbursement for minimal care patients occupying acute care beds is virtually automatic, but not when the same patients are transferred to minimal care units, and in some cases, retroactive disallowances have occurred. However, those involved in minimal care units feel that these problems can be overcome with careful planning, and the advantages far outweigh the disadvantages. The minimal care unit should represent a reorganization
Descriptor(s): Cost containment efforts, Hospital services, Present legislation/regulations, Medicaid, Methods of payment determination.
of existing bed capacity, not an expansion, and the ultimate success of the unit will depend upon the support of the entire staff, especially physicians. The potential for generating financial savings with a minimal care unit is an especially attractive addi-
Massachusetts Dept. of PuLblic Health Office of State Health Planning, Boston, MA 02111 National Center for Health Services Research, Hyattsville, MD.
tion to the current urgent efforts to control escalating hospital costs. Five references, 16 suggested readings and 1 table are provided.
May 1980, 224 pp. Availability: Office of State Health Planning, Massachusetts Dept. of Public Health, Boston, MA 02111.
Descriptor(s): Cost containment efforts, Inpatient facilities, Impact of third-party coverage, Limitations on coverage, Hospital services,
A model which provides a first step toward long-run incremental
592. Mode of Payment and Length of Stay in the Hospital. More Work for PSROs. Stephen
M. Davidson.
1977, 11 pp. Availab_Tity: Medical Care v15 n6 p515-525 Jun 77. This paper compares the lengths of stays for medicaid patients with a pre-Professional Standards Review Organizations
1-268
medicaid, commercial insurance plans, direct payment out-ofpocket, and a residual group. The data showed that average length of stay for medicaid patients was not consistently different from that for patients who paid by other means. It is therefore argued that if the PSRO technique proves successful as applied to medicaid patients, it might also benefit private third parties who wish to monitor and control the stays of their patients. Footnotes, 4 tables, and 22 references are given. (Author abstract modified)
593. Model for Assessing and Effecting Hospital Closure. Final Report.
cost analysis of hospital cJLosures is provided. Specifically, the report (1) establishes one method to identify those hospitals which may be likely closure candidates, (2) explores possible ways to mitigate undesirable economic effects of closure, (3) develops a method for allocating patients and units of service from the closure candidate to the receiving hospitals, (4) develops a methodology to estimate the costs of treating the additional patients at the receiving hospitals, and (5) evaluates the operating savings over time of the decision to close a hospital. Methods used in the model are designed to make use of publicly available information which has been reported by the hospitals to various agencies. The model was tested by applying it to a potential closure situation. The hospitals selected for analysis possessed many of the characteristics identified as useful for identifying potential closure candidates and receiving hospitals.
Health Care Programs
Some of these characteristics are small size, investor-owned status, largely depreciated physical plant, financial problems, and the lack of a critical mass of beds to provide a broad range of services. The model showed that the savings in closing a hospital depend upon the incremental cost of treating patients at the receiving hospitals. Through the use of hospital financial reporting systems, the incremental costs at the receiving institutions are determined. Systems savings over time are analyzed by the application of present value analysis. Several ways of applying portions of the system savings to alleviate some of the undesirable economic effects of closure on employees, the local community, and local financing behavior are also discussed, Tabular and graphic data are appended.
Descriptor(s): Supply/availability of services, Demand/utilization of health care programs, Inpatient facilities.
594. Modelling the Effects of National Health Insurance in the United States.
Gall R. Wilensky and Louis F. Rossiter. Jun 1979, 12 pp. A vailability: National Center for Health Services Research, Hyattsville, MD 20782.
A research project aimed at the development of models capable of analyzing the effects of alternative national health insurance proposals is described. Such models will require a series.of eomponent analyses, including the demand for medical care, the supply of medical care, the effects of alternative income tax treatments on the demand for medical care, and the effect of existing public programs, such as medicare and medicaid, on the use and costs of personal health care. Historically, these types of analyses have been severely hampered by the lack of appropriate data. In an attempt to remedy this situation, the National Center for Health Services Research funded a major data collection effort, the National Medical Care Expenditure Survey (NMCES). The data collection has been in progress since 1976 and will continue until the end of 1979. Analyses based on the data are expected to require 5 years beyond the data collection period. NMCES consists of three major surveys: (1) a survey of 13,500 randomly selected households, each interviewed 6 times over a 15-month period during 1977 to 1978; (2) a survey of the physicians and hospitals that provided care to household respondents during 1977; and (3) a survey of insurance companies and employers responsible for the private insurance coverage of the household respondents. The data encompassed by the NMCES surveys are capable of supporting a series of analyses ranging in complexity from descriptive reports of insurance eov-
erage and health care use to multivariate analyses of demand and supply integrated into a dynamic microsimuiation model of alternative national health insurance proposals. The denmnd and supply equations of the model being developed are outlined. Presented at Health Care System Modelling Workshop International Institute of Applied Systems Analysis, Laxenburg, Austria, June, 1979.
Descriptor(s): National health insurance (NHI), Comparisons health care programs, Health information/data systems.
of
595. Modifying Medicaid Eligibility and Benefits. Bruce Spitz and John Holahan. Urban Inst., Washington, DC 20037 UI-986/13 National Center for Health Services Research, Hyattsville, MD. Ford Foundation, New York, NY. Jun 1977, 93 pp. Avnilabib'ty: Urban Inst., Washington,
DC 20037.
This paper is the first of a four-part series on alternative strategies for controlling the costs of State medicaid programs. The series is a systematic examination of State options which are permitted by Federal regulations and those which would iraprove the efficiency of the programs. Cost containment issues and options regarding medicaid eligibility, benefits, provider reimbursement, and utilization controls are set forth. Possible changes in Federal regulations and financing mechanisms which might improve State management of medicaid are then addressed. This paper begins with a disenssion of the States' choices with respect to placing limitations on eligibility. It is generally concluded that programs are unlikely to find a resolution to medicaid f'meal problems through either manipulation of eligibility criteria or increased quality control efforts. The options are either politically unpalatable, insignificantly cost effective, too costly to implement, or will not provide immediate aid. Reducing the number of ineligibles (i.e., those appropriately determined to be eligible), and the amount of client fi'aud has more political appeal. However, identification of ineligible persons and fraudulent users of services requires sophisticated data processing systems and a high degree of coordination among State agencies. There is a point where the costs of additional monitoring exceed the savings from successful discoveries. The paper then moves to an examination of the choices States have in reducing program costs through limitations on benefit packages. Elimination of or limitation on covered benefits has been
1-269
the most frequently employed means used by States in an effort to contain costs of medicaid programs. This paper analyzes the implications of such actions with regard to several services and concludes that it is not an effective cost containment strategy. Seven tables and 93 reference notes are included. (Author ab-. stract modified) Descriptor(s): Cost containment efforts, Medicaid, Eligibility requirements, Exclusions from coverage, Mandated benefits:, Policy initiatives, Reimbursement.
596. Multilevel Care. A Veterans Administration Health Care Cost Control.
Initiative in
John Mulhearn and Karl Eurenius. l979, 3 pp. Availability: Jnl. of the American Medical Association v242 n12 p1285-1287 21 Sep 79.
This article describes efforts by the Veterans Administration's (VA) Department of Medicine and Surgery, the largest of the civilian Federal health care systems, to develop a new system of resource allocation and financial management. In response to pressures to provide greater accountability for its $5 billion-plus annual budget, the VA is currently testing the new system, known as multilevel care, in 10 of the 172 VA medical centers, The system is designed to match patients' variable medical needs with different levels of health care resources, including personnel, equipment, space, and beds. Care levels range from the continuous monitoring of critically ill patients at the intensive care level minimal or maintenance level of care such as for patients undergoing diagnostic studies. The multilevel care systern comprises two subsystems: the patient care subsystem and the fmancial management subsystem. The eight major components of the patient care subsystem help determine the level of care needed and the resources consumed. Among these levels, the extended hospital level has the most implications for resource allocation and consumption, since the veteran population will experience more frequent extended episodes of care. The financial management subsystem includes a new cost-monitoring and budgetary mechanism and will prepare cost statements for third-party insurance reimbursement, based on aggregate billing
597. Multiple Health Insurance Coverage. The Overlap of Dread Disease and Extra Cash Policies With Other Types of Coverage. Daniel C. Walden, Gail R. Wilensky and Judith A. Kasper. Aug 1980, 14 pp. Availability: National Center for Health Services Research, Hyattsville, MD 20782. National estimates on the :prevalence of multiple health insurance covearge with respect to dread disease and extra cash policies are presented. Particular emphasis is given to the characteristics of the population covered by dread disease and extra cash policies as well as by the medicare or medicaid programs, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) or Civilian Health and Medical Program of the Veterans Administration (CHAMPVA), or private health insurance. The data reported are based on information provided by 13,500 respondents during the fifth interview of the National Health C_tre Expenditures Study, which was conducted from early December 1977 to early April 1978. Preliminary findings showed that about 7.5 percent of the civilian noninstitutionalized pc,pulation (15,961,000) were covered by dread disease or extra cash health insurance in December 1977; 5.5 percent were covered by a dread disease policy and 2.5 percent were covered by an extra cash policy. Age, color, census region and division, and place of residence were associated with differences in the percent covered by dread disease or extra cash policies. According to age, the range of coverage was from 3.5 percent for those less than 6 years old to over 12 percent for those over 55 years old. About twice as many whites as those in the other color group were covered, and persons living in the South and North Central regions were more likely to have coverage than those living in the Northeast or West regions. Among the approximately 23 million persons covered by medicare, 12.8 percent also had dread disease or extra cash policies, while only 2 percent of the 13.8 million medicaid beneficiaries and about 5 percent of the 6.5 million CHAMPUS/CHAMPVA beneficiaries had purchased dread disease or extra cash coverage. Differences in the percent of the population covered by both medicare and dread disease or extra cash policies were found according to demographic characteristics. Persons covered by private health insurance and dread disease, or extra cash policies, showed differences according to age, color, perceived health status, and residence variables. Tabular data are provided.
and level of care costs. The article concludes that through such programs as multilevel care, the VA can demonstrate its potential as a national laboratory for the evaluation of health system
Presented at the 1980 Ann,,zal Meeting of the American cal Association, Houston, TX, August 12, 1980.
models. Nine references are included.
Descriptor(s): Participants in health care programs, Non-participants in health care programs, Medicare, Medicaid, Publicly sponsored/mandated health plans, Non-employment related plans, Private health care plans.
Descriptor(s): Cost containment Voluntary initiatives,
1-270
efforts,
Inpatient
facilities,
Statisti-
Health Care Programs
598. National Ambulatory Madical Care Survey. 1977 Summary. United States, Janmwy-Decemlmr 1977.
ery of health care more cost effective. Recommendations deal with economic incentives in purchasing insurance and health plans, consumer cost sharing, fair market health plan competi-
National Center for Health Statistics, Hyattsville, MD, 20782 DHEW/PUB/PHS-80/1795 Apr 1980, 61 pp. Availability: National Center for Health Statistics, Hyattsville, MD 20782.
tion, alternative financing arrangements, regional physician and hospital directories, information on alternative health care plan benefits, regulation of insurance carriers and health plans, and assessment and assurance of quality. Recommendations regarding private sector cost containment initiatives bear upon reimbursement levels for providers, voluntary cost containment programs, reimbursement restrictions, prospective rate setting for hospitals, incentives to limit bed capacity, incentives to provide appropriate care, and service use in appropriate settings. Recommendations regarding guidelines for regulation deal with evaluating public utility regulation and exemptions from it, a review of the regulatory process, planning, certificate-of-need, decertification, supply guidelines, placement review criteria, regional centers, capital expenditure limits, and criteria and use of practice evaluation techniques. Recommendations are .also of_ fered in the general areas of cost-containment measures within medical practice, supply and distribution of health care providers, research guidelines, and consumer and patient education. The task force reports on the topics of marketplace, demand, supply, and technology are also presented, along with comment and dissent and a future research agenda. Chapter references, an index, and tabular data are provided.
Based on data obtained from a national sample of office-based physicians, statistics are presented on the provision and use of ambulatory medical care in physicians' offices during 1977. Use patterns are described in terms of patient characteristics, visit characteristics, and physician and practice characteristics. The basic sampling unit for the study was the physician-patient visit; the study scope was all office visits made in the conterminous United States by ambulatory patients to nonfederally employed office-based physicians, as classified by the American Medical Association or the American Osteopathic Association. Estimates presented are based on information obtained through a sample of patient records for visits to a national probability sample of office-based physicians (1,932). Physicians who participated maintained a list of all office visits during a randomly assigned 7-day reporting period. Appendix I contains a general description of the survey methods, the sample design, and the data collection and processing procedures, along with methods of estimation and imputation. Def'mitions of terms used in the report and the survey are presented in Appendix II, and Appendix III contains facsimiles of survey materials, including the introductory letter, patient record form, and induction interview form. Tabular and graphic data and refgzences are presented, Vital and Health Statistics
Descriptor(s): Cost containment efforts, Supply/availability of services, Medical technology impacts, Private health care plans, Plan desigu/program provisions (under health plans), Funding/ financing of health care programs, Providers of health care setvices, Policy/changes re health care, Third-party payors.
Series 13, No. 44.
Descriptor(s): Demand/utilization of health care programs, Outpatient facilities, Physicians, Medical/surgical services.
600. National Commission on the Cost of Medical Care. 1976-1977. Volume 2. Collected Papers.
599. National Conunisaion on the Cost of Medical Care. 1976-1977. Volume 1. Commission Recommendations Task
American Medical Association, Monroe, WI 53566 1978, 208 pp. A vailabib'ty: American Medical Association, Monroe, WI 53566.
Force Reports Research Agenda.
American Medical Association, Monroe., WI 53566 1978, 153 pp. Availability: American Medical Association, Monroe, WI 53566. The American Medical Association's Commission on the Cost of Medical Care presents recommendations on what providers, consumers, insurers, and regulators should do to make the deliv-
Papers presented to the American Medical Association's Cornmission on the Cost of Medical Care are provided. Articles treating the nature and extent of health care costs examine trends in health care costs and prices, population trends and the cost of medical care, medical practice expenses, rising hospital costs, and dental care costs. Aspects of the medical marketplace are analyzed in a discussion of health policy formulation that considers economic structure and factors influencing demand for health care. Factors contributing to the high cost of medical care
1-271
are examined
in papers
cal technology
and
care
as a right.
from
a cost-containment
bulatory
on making
Health
medical
rational
on multiphasic
care
care
delivery
abo:.t
testing
and
approaches
perspective delivery
decisioas
health
group
md
the
health care alliance (a specified set of providers se!..:c',ed by an underwriter to serve as an economic unit in delivcdn;_ health care benefits to consumers who have chos--n to ettrol[ in the alliance). and
Other
cost-contaimnent
availability
programs, insurance, care
market.
References
l)c._crtpt,,rcO: services,
Cost
Medical
Publicly
second
accompany frequently
containment
efforts,
technoiog?_
impact,,,
care costs,
mrgical
services,
Policy/changes
National
1976-1977.
re health
Commission
Volume
anti
!npalient
tbov_ders
,_1
cale
phti_s.
Medical
Association,
1978, 101 pp. A v:_ilabiL,O': American 53500
Medical
Data
W[
Association
tion's
with
Commission
views on technology
the work
_ices_ tiealth
Bases,
umt
of variable-,,
porch-
of
health
care
programs,
services, Medical technology systems, Providers of health Health
care
impacts, care ,or
costs.
ltealth
Care
in Great
Britain.
Lessons
|or the
I !SA,
analysis
hlsti!ute,
of the British
that any health
care system
Health
would
Service The
Dallas,
National
Health
modeled
after the British
promise
study
examines
m Britain
that
"[X 75240.
Service
very few benefits
the
historical
origins
of socialized
Monroe<
Care,
Associa
literature
t_y cc,.momic
bec or these concept
re-
of the medical marto strengther_ marke_
prin.=it)les
principles
of economic
to analyze inciudmg
with
National
and very high
Law in 1601 and reviews lhe administrative structure and budgeiary co_';ts of the British National Health Service. Suggesting that many of the characteristics of the British system can be ex-
i_'l
began
concludes
mcdicinc
marketplace, demand, sup?iy, and Fopics discussed in re!_tioa to ',h::
heahh care marketplace are characteristics ketplace, market shortcomings, proposals
to titlc/sourcc,
size, description
care/services,
602. National
This
Care,
medical
of Medical
according
n_edt,cal
d_t!;.l,t),as¢_ l\)r
53566
of the Amel'ican
on the Cost
the health care are summarized.
costs
Denland/atilization
Supply/availability of [_!ealth [nfc, rmation/data
piaiued In connection
care
m,z_hod/samFle
John C Goodman. 1_480. 214 pp. A_'allab,lio': [:isher
Monroe,
of
is a table of secondary
car__
care
Reviews
xcga_ d_ng Lhe u-_c
c_atuanon
tiai uses, :rod availability _,nd costs. Chapter references and footnotes are lisle.d, and subject and author indice_ arc provided
costs. American
of health
of'thai)sis,
and
l:citities
of hea!th
on the Cost of Medical
3. Literature
the analysis
rcspo,*._es
to ,upporl
Su0ply/avai!a_tlity
plans
payors,
Also provided
Descrqwor(_):
!_eaitb h_.a_th
presentation,
l,_ovided
tb'i_at<- health
health
Third-party
policy
dev,:lopment,
are the supply opinion
each
are
sponsored/mandated
Health
discussed
services,
public expectations for n'_.cdical ,are, national and the role of the Federal Government mth,:
tabular and graphic data na_r:tti_c d isc us,,i__n_,.
601.
issues
of physician
techm_logies;
research,
tcctmologies.
of an am _
practice,
ttse of medical is:_uc; and
ale _:mlyzed
in evaluations
systeln,
ntcdimedical
alone,
including efficiency.
the various
sectors
Nz:tmnal Hea!':l-; Services ma.ecuticai; and the trend
of the Poor
the text introduces
the
a num-
law of demand
These
principles
of the
_he role and financial
e_s; !he s_._p,)ly aad quali!y
the enactment
are then
National
incentives
of hospital
Health
of general
care;
and
the used
Service
practition-
the quality
of other
such as ophthalmic, dental, and phartoward private care. Geographical and
incentive,;, and the application of public utility reguh,fion heahh care. The litcratui-e leview on heaM_ care demand
u: i!_
s:)cia[ class inequities in the provision of health care are examiued and other charactecstics of the National Health Service are
divided
ot
asse.,.sed
health
into the broad
areas ot'socioh_gicai/b::havioral
care use and empirical
for health medical
services. services
literature
The
of patients
on the supply
n:odels
literature
role of the physician
on behalf
review
economic
on. the :_emand as a demander
is also
o1 medical
examined.
services
of "rhe
discusses
the
supply of physician and hospital services, m_d tt_e orga,fization of mcdic;.tl c,de deliver_ with references to o-ohon;ie:, of some and
t)hysicmn
review
of health
health
care
resp_msea
| 272
productivity.
Topics
care technology
costs; regarding
the acquisition the acquisition
discussed
in the
are the impact of medical
_ased
service
concluded States
choice
that the adoption
would
Tabular
on public characteristics
theory,
are
given,
attempts
to ex-
of public
choices.
of socialized
medicine
in the United
resuh in a lower quantity
data
which
as a result
and
footnotes
and quality are
of health
provided
It is care.
for each
,_hapter.
t_terature
of techm,logy
technologies;
of medical
plain
technologies:
on
policy _he
Des'ct4ptcw(s): garding care
foreign
Supply/availability health
policies,
of services,
Comparisons
Demand/utilization
programs.
Health
re-
of health
Care
P_t,g_m.
603. National Health Expenditures. Long-Term Projections.
Short-Term Outlook and
Mark S. Freeland and Carol Ellen Schendler. 1981, 42 pp. Availability: Health Care Financing Review v2 n3 p97-138 Winter 1981.
This paper presents projections of national health expenditures by type of expenditure and source of funds for 1981, 1985, and 1990. Rapid growth in national health expenditures is projected to continue through 1990. National health expenditures increased 400 percent between 1965 and 1979, reaching $212 billion in 1979. As a proportion of the gross national product, health expenditures rose from 6.1 percent to 9.0 percent between 1965 and 1979. They are expected to continue to rise, reaching 10.8 percent by 1990. This study projects that, under current legislation, national health expenditures will reach $279 billion in 1981, $462 billion in 1985, and $821 billion in 1990. Sources of payments for these expenditures are shifting. From 1965 to 1979, the percentage of total health expenditures financed by public funds increased 17 percentage points -- from 26 to 43 percent. The Federal share of public funds during this same period grew rapidly, from 51 percent in 1965 to 67 percent in 1979. This study projects that in 1985 approximately 45 percent of total health spending will be financed from public funds, of which 68 percent will be paid by the Federal Government. Public funds will account for 46 percent of total national health expenditures by 1990. Footnotes and tabular material are supplied, (Author abstract modified) Descn'ptor(s): Health care cost trends/projections, Funding/financing of health care programs, Source of premium payment.
604. National Health Expenditures,
1979.
Robert M. Gibson. 1980, 36 pp. Availability: Health Care Financing
Review v2 nl pl-36
Summer
1980.
This compilation of the dollars spent for health care in the United States during 1979 is a continuation of the series of annual reports now developed by the Office of Research, Demonstrations, and Statistics of the Health Care Financing Administration. Reports for fiscal years through 1977 were developed by the Social Security Administration and published in the Social Security Bulletin. Detailed estimates of health care spending by type of service and method of financing are provided
for 1979. The Nation spent an estimated $212.2 billion for health care in 1979, an amount equal to 9 percent of the gross national product. Health care expenditures amounted to $943 per person in 1979, with 43 percent of that amount being public spending. Health spending in 1979 increased 12.5 percent from 1978, up from the 11 percent change seen in 1978. Expenditures included $54.4 billion in premiums to private health insurance, $60.9 billion in Federal payments, and $30.5 billion in State and local government funds. The bill for hospital care was 40 percent of total health care spending in 1979, an increase of 12.5 percent from 1978. Spending for physician services increase 13.4 percent to $40.6 billion, 19 percent of all health care spending. All third parties combined -- private health insurers, governments,,philanthropies, and industries -- financed 68 percent of the $188.6 billion in personal health care in 1979, ranging from 92 percent of hospital care services to 64 percent of physicians' services and 39 percent of the remainder. Direct payments by consumers reached $60 billion, 32 percent of all personal health care expenses. Outlays for health care benefits by the medicare and medicaid programs amounted to $29.3 billion and $21.'1 billion respectively, combining to pay for 27 percent of all personal health care in the Nation. Hospital care benefits paid by the two programs amounted to $29.7 billion. Tabular and graphic data and eight references are provided. (Author abstract modified)
Descriptor(s): Health care costs, Health care/services, Fllnding/ financing of health care programs, Private health car_e plans, Publicly sponsored/mandated health plans, Health care cost trends/projections, Source of premium payment.
605. National Health Insurance.
Raymond D. Goodman. Health Resources Administration, RockviUe, MD. Div. of Regional Medical Programs. Jall 1976, 137 pp. A vailabih'ty: University of California Extension, Los Angeles, CA 90024. This monograph contains the proceedings of an educational symposium on national health insurance held under the auspices of the University of California. Included are papers representing the major proposals for a national health insurance (NHI) systern currently under consideration and texts of panel discussions on questions submitted by "the audience. The opening paper sumrnarizes the evolution of national health insurance in America from the beginnings of the voluntary health insurance movement through the New Deal, social security, and medicare to tlae NHI proposals of the 1970's. The Kennedy-Corman bill is then de-
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fended by Corman, compared with other proposals, and justified in terms of the needs of the elderly and the poor. The American Medical Association's proposal is examined for its features of adaptability, administration, and accountability; emphasis is placed on the medical profession's rather than the Governmenfs responsibility for decisions affecting patients. The paper presenting the perspective of hospitals in relation to NHI focuses on proposed changes in the health delivery system regarding regionalization, budget constraints, public accountability, comprehensiveness of care, service specialization, and social values and ethics. The exposition of the Ford administration proposal outlines its basic principles, including universal and voluntary access to health insurance, comprehensive and uniform coverage, the private health care financing system's preservation, and the partnership of private and public sectors in implementation, Topics of the three final papers are concerned with the role of the private insurance carrier, professional liability and contidentiality, and the patient as consumer under NHI. The appendix contains detailed information on each of the major proposals represented at the conference,
De_riptor(s): National health insurance (NHI), Publicly sponsored/mandated health plans, Providers of health care services, Private health care plans, Participation in health care programs.
606. National
trophic approach is most prominently represented by the LongRibicoff bill, which provides coverage for the entire population for expenses above $2,000 per person per year and for federalization of medicaid, to be financed through general revenues. Intermediate approaches are characterized by the 1974 Administration bill and the Kennedy-Mills compromise bill, which also protect against catastrophic illness. They provide for generally smaller out-of-pocket payments than do catastrophic approaches and so rely less upon market incentives to keep the health industry efficient. "ltle full-coverage approach is typified by the Kennedy-Corman bill, which recognizes that there is no basis for price competition with full coverage and uses certain mechanisms to promote an efficient medical care sector. Budgets would be negotiated with each hospital by a public agency, and a fixed sum of money would be set aside to reimburse physicians. Although all of the plans attempt to protect against catastrophic illness, they vary in their definition of catastrophic and vary considerably with respect to amount of income redistribution. All of the proposed plans hold some promise of making the medical care system more efficient, depending upon how they are implemented. Footnotes and a bibliography of about 20 references are provided.
Descriptor(s): National h_dth insurance (NHI), Comparisons health care programs.
of
Health Insurance. 607. National Health Insurance.
Joseph P. Newhouse. Rand Corp., Santa Monica, CA 90406 RAND/P-5920 Jul 1977, 13 pp. Availability: Rand Corp., Santa Monica,
CA 90406.
Various groups view national health insurance (NHI) as a means of achieving different, and sometimes conflicting, objectives. These objectives include improving health, protecting Americans against financial devastation from illness, reducing inequality in the distribution of income, protecting social cohesion by making health services available to all, and making the health care delivery system more efficient and less costly. However, due to several reasons, the goal of improving health is unlikely to be attained by any plan. The proposed NHI plans differ in their ability to accomplish the other objectives. Four critical issues are examined to appraise the plans in terms of these objectives: (1) the extent of coverage, (2) the reimbursement of providers and the nature of the delivery system, (3) financing, and (4) administration. Following this detailed analysis, the report appraises three approaches to NHI: the catastrophic approach, the intermediate approach, and the full-coverage approach. The catas-
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Edward Klebe. Congressional Research Service, Washington, DC 20540 Apr 1980, 10 pp. Availability: Congression_d Research Service, Major Issues System, Washington, DC 20540.
Issues bearing upon the development of a national health insurance (NHI) program are discussed, and related proposals likely to be considered by the 96th Congress are presented. The widespread desire for some form of NHI program stems from the public's discontent with the present status of tlie country's health system. Major sources of this apparent dissatisfaction are sharply escalating medical care prices, incomplete and partial protection against medical care expenses paid for by private health insurance, and inadequate protection against the costs of care associated with catastropl_dc illness or disease. Additional problems include the uneven distribution of health resources and services and the absence within the health industry of incentives to improve the efficiency and effectiveness of scarce health resources. Major policy issues associated with the development of an NHI program are the proper role of the Federal Government
Health Care Programs
in financing and administering health insurance, whether the program should be financed through multiple public and private sources or through a single channeling of funds through the public sector, the nature and scope of benefits to be insured, the extent of private health insurance industry involvement in the program, and the potential effect of the program on the organization and delivery of health service throughout the country, Proposals likely to be considered by the 96th Congress are measures that would (1) entitle all citizens to federally financed and administered, comprehensive health benefits; (2) make the Government responsible for financing health care only for the high risks in society; (3) provide federally financed economic incentives toward the purchase of private health insurance plans; and (4) mandate employers to purchase adequate private health insurance plans for employee groups. Congressional events and publications related to the NHI issue are listed, along with additional reference sources.
trolled through price controls -- a method which has failed again and again. The solution to the problem is to allow the private marketplace increased freedom to discover cost-controUing reimbursement techniques. Unlike Federal programs, private insurance providers have a strong interest in controlling cost and lowering premiums for the sake of competition. Innovative costcontaining reimbursement procedures include (1) greater reimbursement percentage for low-cost hospitals, (2) group health insurance plans, and (3) the health maintenance organization (HMO). The article includes bibliographical footnotes.
Descriptor(s): National health insurance (NHI), ment efforts, Third-party payors.
Cost contain-
609. National Health Insurance and Corporate Benefit Plans. Issue Brief No. IB73015. David A. Weeks. Descriptor(s): Health care cost trends/projections, Economic/ commercial influences, National health insurance (NHI), Funding/financing of health care programs.
608. National
Health Insurance. A Social Placebo.
Keith B. Leffler. Rochester Univ., Rochester,
NY. Center for Research
Government Policy and Business. 1977, 7 pp. AvMlability: Current History v73 n428 p17-21,35-36 77.
in
Jul/Aug
The article argues that national health insurance (NHI) is an ineffective response to the alleged health care crisis in the United States. The case for NHI must rest on at least one of the following conclusions about private markets: that they supply an inappropriate level of care; that the care provided is inappropriately distributed; that the costs are inappropriately distributed; or that the level of costs is too high. Research indicates that the average American receives adequate health care and that, due to medicaid and medicare, income is no longer a major factor in obtaining health care. Though complaints have been made of the disparity of medicaid subsidies across the States, it can be argued that the transfer of wealth to the poor should be determined by the citizens in the individual States. Most important, the federalization of the payment for medical care will not control care costs, since the NHI plan will cause a considerable increase in the demand for medical care. The increase could only be con-
Conference Board, Inc., New York, NY 10022 1974, 45 pp. Availability: Conference Board, Inc., New York, NY 1(1022.
This study examines the provisions of 10 national health insurance (NHI) legislative proposals -- including the Kennedy-Mills and Nixon Administration bills -- and compares them point-bypoint with typical existing company coverages for employees and retirees. Information for this comparison was obtained from 1,794 companies of all sizes in manufacturing, banking, insurance, public utilities, transportation, construction, retail, and wholesale trade. The report includes summaries of the major eligibility rules, benefit provisions, and financing schemes now under consideration, as well as a discussion of current union attitudes and actions in health-benefit bargaining. The major conclusions support the contention that a substantive intervention by the Federal Government would have a major impact upon benefit planning, cost-sharing, and bargaining, but little direct effect on the benefit coverages to be provided to workers. Benefits to low-wage workers and the unemployed would increase greatly. The proposed legislation would have five definite effects on the corporate benefit system: (1) new minimum benefit standards for health insurance would be established for workers and nonworkers under a Federal plan; (2) preventive medicine, ambulatory, and outpatient care would be stressed to discourage hospitalization; (3) current trends would accelerate toward major medical full-care coverage in many industries and in small companies; (4) costs would rise regardless of the financing choseta because of anticipated benefit supplements, employer contributions for employee premiums, and shifts in bargaining; and (5) benefits from in-company health programs and experience-rating schemes may be lost in a national plan, even one adminis-
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tered at the State level. Four tables, eight charts, and an exhibit comparing corporate health insurance benefits with provisions of proposed national health insurance legislation are given. (Author abstract modified) ConFerence Board Report No. 633.
Descriptor(s): Private health care plans, Health care/services, Plan design/program provisions (under health plans), Deductihle/coinsurance, Funding/financing of health care programs, National health insurance (NHI), Comparisons of health care programs, Eligibility requirements,
610. National European
Health Insurance and Health Resources. The
Experience.
Jan Blanpain, Luc Delesie and Herman Nys. Health Resources Administration, Hyattsville, MD. Div. of Legislation. 1978, 294 pp. Availability: Harvard University, Press, Cambridge, MA 02138. The impact of government intervention in medical care systems is examined for West Germany, England and Wales, France, the Netherlands, and Sweden. The issues considered for each country are why and how resources development took place, what forces and issues were operative, how interested parties participated and interacted, and what role government played. The common frame of reference to which health resources development in each country is related is the national health program, Compulsory health insurance is examined as an effort to provide every citizen with equal access to a physician's services. The text also examines the the shift in Government policy in all five countries, to the development of hospitals and the proliferation of specialized institutions for the aged, mentally ill, and the mentally retarded. Each country is shown to have learned that unlimited health care does not guarantee unlimited health, so that emphasis must be given to preventive medicine, education, and the reduction of environmental causes of disease. Throughout the study, the roles played by physicians, insurance companies, labor unions, and legislators in the development of health policy are described. Tabular data, a bibliography, and an index are provided. Desc_ptor(s): Publicly sponsored/mandated health plans, Health care/services, Plan design/program provisions (under health plans), Comparisons regarding foreign health policies, Facilities providing health care.
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611. National Health Insurance and Income Distribution. Rita M Keintz. 1976, 218 pp. Availability: D.C. Heath and Co., Lexington,
MA 02173.
This book weighs the alternatives of health care financing and the cost and benefit "tradeoffs" inherent in the choice of any one national health insurance (NHI) plan. It also analyzes the various NHI proposals (Young, Corman-Kennedy, Ullman, Burleson-McIntyre, Fulton-Duncan, and Long-Ribicoff Bills) presently before Congres:_ in terms of the redistributive effects across income groups. The analysis relies on (1) knowledge regarding the current utilization and expenditure patterns for personal health services by family income groups and (2) on the evidence regarding the distribution of program cost burdens among these same group.s through premiums, coinsurance and deductibles, certain types of taxes, and Federal subsidies. Specific provisions are recommended by order of priority that must be included in any NHI proposal to eliminate potentital distributional effects from the plan's cost and benefit structures. Thus, a progressive cost structure should be established for the financing of the plan, whether through a graduated tax on personal income, on corporate or business income, and on estates and gifts, or in combination. The plan should provide for universal coverage with all persons eligible for the same benefits or covered services. In addition, there should be no requirement for cost sharing by the consumer in the form of deductibles, eoinsurance payments, or copayments. The complete range of comprehensive benefits should include all covered services, without limitations or cost sharing for intermediate long-term nursing home care, mental health services, adult dental care, all preventive and rehabilitative services, health-related social services transportation, and child care. Furthermore, all services provided by nonphysician personnel should be covered. Finally, medicare (and its payroll tax) and medicaid programs should be eliminated, together with the present medical deduction under current personal income tax laws. Notes, figures, footnotes, an index, and a selected bibliography of approximately 110 references are provided. Descriptor(s): National health insurance (NHI), Comparisons of health care programs, Funding/financing of health care programs, Source of premium payment, Health care/services.
612. National Health Insurance and Primary Medical Care for Children. John A. Buffer. 1976, 290 pp. Availability: University Microfilms International, Ann Arbor,
Health Care Programs
MI 48106.
per year. The results and conclusions of this paper derive from predictions for the Nation based on the behavior of 5 million
In principle, primary care for children should not be difficult to deliver. It is therefore surprising that American children often receive inadequate primary care. This study addresses the re.asons why the Nation does not do a better job of delivering primary care to children. Specifically, it seeks to determine if a reduction in financial barriers to access will result in substantial improvements in children's patterns of primary care use. Discussion topics include patterns in the use of primary care among children, public expenditures for children's care, national health insurance proposals and their likely effects, prepayment and capitation, and areas of focus for future research. Two basic propositions are argued. First, any but a comprehensive care package of the sort proposed in the Kennedy-Griffiths or Kennedy-Corman bills is apt to have minimal impact on the level of medical services provided for most children and may even reduce the comparative advantage of children over other age groups in gaining a fair share of the public medical care dollar.
Federal employees and their families under an insurance package similar to some proposed NHI bills. It is presumed that demand equaled supply in 1973. Price and utilization for that year then revealed a common point on both schedules. A second point on the demand curve is obtained by extrapolating the behavior of 5 million persons covered by the Federal Employees Health Benefit (FEHB) Plan. All prices are in 1973 dollars. The study concludes that subsidizing demand with NHI as modeled on the FEHB high option plan would lead to a dramatic increase in the price for private office psychiatric care and to a large tax bill for this portion of NHI. Alternative proposals include omitting private office psychiatric treatment from coverage under NHI altogether, setting up a system of triage or screening for treatment of mental illness, and instituting price controls and review boards. Five tables, 9 references, and 12 footnotes are included.
Second, even a comprehensive care package is not sufficient to assure that children of various incomes and residential areas will enjoy equal access to services. A successful financing scheme must be accompanied by efforts to alter the organization of children's medical services, to change the distribution presently in effect, and to assure the presence of primary care arrangements in areas of provider scarcity. Footnotes, tables, reference materials and appendices are provided.
Discussion Paper No. 4.
Submitted in partial fulfillment of the requirements for the degree of Doctor of Education to Harvard Univ., 1976.
614. National Health Insurance as an Agent for Containing Health-Care Costs.
Descriptor(s): National health insurance (NHI), Preventive services, Supply/availability of services.
Milton I. Roemer. 1977, 11 pp. Availability: Bulletin of the New York Academy v54 nl p102-112 Jan 78.
613. National Health Insurance and the Market Psychiatric Services. Thomas
for Private
G. McGuire.
Boston Univ. Dept. of Economics, Boston, MA 02135 1976, 16 pp. Availability: Boston Univ., Dept. of Economies, Boston, MA 02135. This paper roughly calculates the demand for psychiatric care in order to assess the likely effects of national health insurance (NHI) on price, utilization, and cost of such care to the Federal Government. Two models of NHI are considered, each with a 20 percent coinsurance charge to patients. The first version of NHI does not limit visits; the second limits coverage to 20 visits
Descriptor(s): Government employee plans, Mental health services, National health insurance (NHI), Plan design/program provisions (under health plans).
of Medicine
A national health insurance (NHI) plan is proposed as the best means to constrain or eliminate medical care expenditures that are not beneficial to health or not beneficial enough to justify the costs. NHI increases rates of provision of health services largely by increasing access of patients to the physicians who order the hospitalizations, tests, operations, drugs, and other components of comprehensive health care. This inevitably memas greater expenditures, but the same process occurs under voluntary health insurance, and even without any insurance for persons who can afford the costs. The purpose of NHI is to channel more spending through the public sector where it can be reasonably controlled. Cost-containment interventions used by NHI programs have included constraint on the patient (cost sharing), and constraint on the doctors (monitoring by physicians) prior approval for elective surgery -- Holland (authorization of hospital stays beyond 7 days) -- Belgium, and modification of fee-for-
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service remuneration for general practitioner services--Great Britain. NHI strategies to reduce hospitalization costs include controls over hospital construction, extension of the regionalization concept, and prospective budgeting. Drug expeditures are controlled through prescription monitoring, approved lists of drugs, and bulk purchase. In today's world, health care is regarded as a human right, and it is pointless to decry social financing of some sort to achieve equity in the provision of services. The task is to prevent extravagance or corruption in the use of public money. References are provided. (Author abstract modified)
change process is premised on deliberate, long-term action through a series of coordinated reforms. Aspects of the KHSA are analyzed using Gorz's criteria for policy analysis. It is coneluded that the KHSA does represent a significant change from both the concept of health ma:mtenance as individual responsibility and the traditional provision of health services through the market system with noninterf_'rence from both State and Federal Governments, except in cases of extreme poverty. The bill is criticized for not proposing ;t significant alternative to current patterns of resource control and distribution and for not thailenging current premises and ideologies that support these patterns. The study concludes with a discussion of policy and
This article was presented in a panel as part of the 1977 Annum Health Conference of the New York Academy of Medicine held on April 28 and 29, 1977.
strategy issues and suggested modifications to the KHSA. It is suggested that increased participatory democracy in the health sector is the key component for major redistribution and reorganization of health resources. Ten tables, nine figures, footnotes, an extensive bibliography, and an appendix are included.
Descriptor(s): Cost containment efforts, Economic/commercial influences, National health insurance (NHI), Comparisons regarding foreign health policies.
615. National Health Insurance as an Issue in Political Economy. The Implications of the Kennedy Health Security Act for Developing a Strategy to Effect Major Reorganization of Health Care Delivery in America. Susan R. Windham. 1976, 248 pp. Availability: University Microfilms International, MI 48106.
Submitted in pat-tiM fulfdlmcnt of the requirements for the degree of Doctor of Ptu'losoph'y to Brandeis Univ., 1976. D_criptor(s): Health insurance industry, Policy/changes re health care, National economic conditions, National health insurance (NHI).
616. National Health Insurance. Benefits, Costs, and Consequenees. Ann Arbor, Karen Davis. Brookings Inst., Washington,
This study examines the Kennedy Health Security Act (KHSA) and its potential impact on equalizing access to health care services in light of the American political economy. It is suggested that the development of a health policy that promotes equal access to health care can only be achieved by understanding and actively addressing broader sociopolitical issues. To support this thesis, the study combines existing theoretical material and original analysis in several ways. First, the study examines power elite behavior in the health sector, focusing on organized medicine through the American Medical Association (AMA) and on Blue Cross. Next, the roots of current political strategies to implement national health insurance are traced through the medicare struggle, emphasizing the AMA's influence on health policy. The role of Blue Cross in shaping medicare and national health insurance is also analyzed. The analytical framework used to evaluate the provisions of the KHSA bill is based on Gorz's concept of nonreformist policy development, which stems from the question of how to promote fundamental change in a capitalistic society short of physical revolution. Gorz's conception of the social
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DC 20036
Carnegie Corp., New York, NY. Richard King Mellon Foundation, Pittsburgh, PA. Robert Wood Johnson Foundation, Princeton, NJ. M_iy 1975, 182 pp. Availability: Brookings Inst., Washington, DC 20036.
The benefits and costs assoc:iated with major proposals for national health insurance are e_amined, and a plan is outlined that would meet the goals of national health insurance -- ensuring access to medical care for all Americans, reducing the fmancial hardship of medical bills, and containing health care costs. Major health insurance issues a:re summarized, and the shortcomings of the private health cm-e market are discussed, as well as its impact on Government policy. The current combination of private insurance and public insurance programs is also assessed. Criteria are developed for a national insurance plan, concerning who should be covered, what services should be included, and the role of patients' direct payments. These considerations are then applied to seven propcsals that have been introduced in
Health Care Programs
Congress during the past few years: Medicredit, the 1973 LongRibicoff bill, the 1974 Ford administration plan, the American Hospital Association plan, the Health Insurance Association of America plan or the Burleson bill, the Kennedy-Mills bill, and the Health Security Act or the Kennedy-Griffiths bill. Tables summarize data on coverage, benefits, methods of administration and financing, standards and reimbursement of providers of services, and any provisions relating to the delivery, organization, or development of health resources for each plan. Costs benefits and consequences of these proposals are then analyzed. A final summary outlines the principal similarities of the major national health insurance proposals and their impacts on beneficiaries, service delivery, direct patient payments, costs, employers, private insurance companies, and State governments, Using ideas from each plan, features that should be included in a national program are recommended. Footnotes, tables, and an index are provided. Twelfth Series.
Volume in the Brookings
Studies in Social Economics
Descriptor(s): National health insurance (NHI), Cost/benefit analyses, Comparisons of health care programs, Present legislation/regulations.
617. National da.
administration and accountability are the basic principles of the Canadian program. A history of the Canadian health care system and its structure is presented, including detailed descriptions of early developments and characteristics of program components and effects. The book examines problems of program iraplementation in the provincial system of Quebec, analyzes impacts of the system upon the national economy, and discusses the divergence of public and medical interests in terms of quality of care and its regulation. The book outlines implications of the Canadian national health insurance plan based on access to and patterns of care, quality of care and relationships, costs of medical care, and administration and operation. Although there uppears to be substantial unanimity among Canadians concerning the necessity and desirability of health insurance, problems such as geographic maldistribution, physician overspecialization, and pressures to increase coverage of health insurance plans remain. Tabular material and an index are supplied, as is an appendix on the Sun Valley Forum. A volume on current health care issues from Forum on National Health, Inc. P_gs 1974 Symposium. A Wiley Biomedical-Health
The Sun Valley of the Forum Publication.
Descriptor(s): Comparisons regarding foreign health policies, Economic/commercial influences.
Health Insurance. Can We Learn From Cana.
Spyros Andreopoules. 1975, 273 pp. Avallability: John Wiley and Sons, New York, NY 10016.
This volume contains the papers and discussions of a 1974 symposium of the Sun Valley Forum on National Health that focused on the Canadian experience with national health insurance and considered possible implications for the United States. The comparison with Canada was felt to be especially valid because of significant characteristics shared by both countries, Among these are an independent and self-regulating medical profession; locally controlled, nonprofit hospitals; the rising costs of physician and hospital services, the difficulties of d_ming and regulating the quality of medical services; and the gcographic and specialty maldistribution of physicians that causes problems of access to primary medical care. Among the diffcxences are the greater trust of Canadians in their government, a better balance of power between the national and provincial Canadian authorities, and the clarity of policy goals defining the Canadian national health insurance program. Universal coverage, comprehensive benefits, portability of benefits, and public
618. National Health Insurance. Canada's Path, America's Choices.
Theodore R. Marmor and Edward Tenner. Chicago Univ. Center for Health Administration Studies, Chicago, IL 60637 Robert Wood Johnson Foundation, Princeton, NJ. 1977, 9 pp. Availability:
Challenge v20 n2 p13-21 May/Jun
77.
This article suggests that the United States can learn valuable lessons from Canada about access to care and control of costs under national health insurance (NHI). The article notes some similarities and some differences in the Canadian and American health care systems. It further notes that Canadian and American costs have been strikingly parallel. However, the requiremcnt that patients pay deductibles or coinsurance has proved politically unpopular in Canada; in the United States, almost all of the current major proposals rely on copayment for family health expenditures. In addition, the use of line-by-line and glohal budget techniques and substitutes for hospitalization as devices to control Canadian inflation has not successfully checked hospital expenditures. The article also states that, under NHI,
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Canadian fee-for-service reimbursement has raised physician incomes in two main ways: through the reduction of bad debts and collection expenses and through the leveling-up of fees. Further, the strategy of training more physicians to improve their geographical distribution and to increase fee competition has largely failed in Canada. Canadian studies concerning access to care show relatively modest changes in the overall use of hospitals and physicians by lower-income groups. Finally, the article suggests that although NHI can abolish the fear of destitution, control of environmental factors may be a key to better national health and cost containment. Five figures and two tables are included,
Payment and regulatory policies must apply uniformly to all purchasers of medical care, private as well as public, or providers will be encouraged to discriminate against patients for whom payments are lower or regulations are more burdensome. Various plans proposed in this country are used for examples of approaches to particular issues. Drawing on American experience with medicare and medicaid and in Canada and the United Kingdom, descriptions of the programs that would result from the different proposals before Congress are provided. Tabular data, footnotes and about 400 references are provided. Several national health care plans, are appended. (Author abstract modifled)
An earlier version of this paper appeared in Policy Sciences, v6 n4 Dec 75. This article is part of an ongoing study of national health insurance,
Descriptor(s): National health insurance (NHI), Comparisons regarding foreign health policies, Cost containment efforts, Pollcy/changes re health care.,,Cost/benefit analyses, Publicly sponsored/mandated health plans.
Descriptor(s): Cost containment efforts, Deductible/coinsurance, Physicians, Comparisons regarding foreign health policies. 620. National Health Insurance in Canada.
619. National Health Insurance. Conflicting Goals and Policy
Theodore
Choices.
1979, 10 pp. Availability: Employee l:tenefits Jnl. v4 nl p20-29 Winter 1979_
Judith Feder, John Holahan and Theodore R. Marmor. Urban Inst., Washington, DC 20037 Ford Foundation, New York, NY. 1980, 721 pp. Availability: Urban Inst., Washington,
DC 20037.
Issues considered instrumental to the success of any national health insurance (NHI) program are discussed. The analysis is based on a 3-year study by a team of 13 economists, political scientists, and public policy analysts. The most neglected part of the NHI policy debate and policy research in general is program implementation. The most important policy issue to be considered is how the Federal Government can afford an NHI program. The issue will be decided on the basis of how policymakers handle the payment and regulatory mechanisms which medicare and medicaid exposed as mainsprings of inflation in health care costs. Necessarily, reform of payment and regulatory mechanisms will require difficult trade-offs wherever the constituencies of a working program polarize into interest groups. To meet apparently conflicting goals of controlling costs and expanding people's access to health care, the Government must assume responsibility for setting limits on its expenditures and for allocating resources. In making public spending decisions, policymakers must evaluate medical services' worth relative to other goods and services. Policy options are developed for administration reimbursement, regulation, and range of insurance benefits,
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Allison.
This paper describes the operation of national health insurance (NHI) in Canada and measures its performance with the health care system in the United States. NHI in Canada refers to two separate government programs: one provides for prepaid hospital care and the other for prepaid physicians' services. Both programs are financed jointly by the Federal and Provincial governments. To qualify for Federal contributions, each province must meet Federal sl_andards for basic hospital and medical services. Thus, there are 10 provincial and 2 territorial hospital and medical care insurance programs, and they differ in benefits, financing arrangements, and administration. None of the various benefit packages covers all needed services. Hospital coverage is at the ward level, so ps.tients desiring semiprivate or private rooms must pay for them. Most of the programs also do not cover or cover for only certain classes of people, dental care, outpatient prescription drugs, nursing home care, eyeglasses, hearing aids, and medical appliances. Although there is no direct copayment for physician,.;' services in the plans, some physicians bill patients directly for t.he difference between their fee and the authorized reimbursement from the provincial plan, thus introducing an element of co,;t sharing. In addition, more than one of every two Canadians has private health insurance to supplement the government plazas. Problems associated with the NHI plans include increased health care costs, the creation of excess
Health Care Programs
hospital facilities, high utilization of services, and overspecialization and maldistribution of physicians. Tables and reference notes are provided,
Descriptor(s): Comparisons regarding foreign health policies, Publicly sponsored/mandated health plans, Plan design/program provisions (under health plans), Funding/financing of health care programs.
Descriptor(s): Health care/services, Physicians, Funding/financing of health care programs, Comparisons regarding foreign health policies. 622. National Health Insurance Issues. The Adequacy of Coverage.
621. National Health Insurance in the Federal Republic of Germany and its Implications for U.S. Consumers.
Gordon K. MacLeod. Ford Foundation, New York, NY. 1976, 6 pp. Availability: 76.
Public Health Reports
v91 n4 p343/348
Jul-Aug
The ongoing debate in the United States about national health insurance issues warrants systematic investigation of the health care systems in other countries with long experience in publicly mandated financing. This article focuses on the Federal Republic of Germany which, like the United States, has a Federal-State form of government. Germany was also the fhst industrialized nation in the world to adopt a compulsory health insurance program in 1883. Even though the West German government does not operate its health insurance system, it has had nearly a century of experience in grappling with problems related to health care delivery and financing in the private sector. Specifically, it is responsible for setting national policy, regulating the basic and supplementary levels of benefits, and overseeing the fiscal operations of local sickness funds. Data for this article were collected in 1973 and 1974 through personal interviews with spokesmen for the Federal Republic of Germany, a national consumer organization, trade unions, employers' associations, physicians' associations, local sickness funds, and the private insurance industry. Questions concerned financing, planning, organizing, and delivering health care services, and the consumers' avenues of recourse if dissatisfied with the acceptability of service or with the technical quality of care. Information on the historical development of national health insurance in Germany is followed by discussions that focus on cash sickness benefits, consumer satisfaction, health care providers, professional organizations, administration of local sickness funds, and private health insurance. In conclusion, the current escalation of health care costs and the attendant political reactions in Germany are discussed, and the lessons that America can derive from the comparison are delineated. One graph and 18 references are given.
Stephen G. Sudovar and Patrice H. Feinstein. Health Issues, New York, NY 10019 Roche Lab., Nutley, NJ. 1979, 39 pp. Availability: Health Issues, New York, NY 10019.
This report outlines an adequacy standard for health insurance and examines the health insurance protection of the U.S. population, to aid in developing a national health insurance (NHI) structure. NHI proposals have included a wide variety of finan¢ing arrangements, administrative mechanisms, and benefits. However, agreement on these proposals is lacking because of uncertainty about which groups lack adequate protection. This, in turn, is a result of a lack of adequacy standards for measuring current health care protection. The lack of consensus argues for an incremental approach, or series of extensions of health care benefits to the various groups identified as needing protection, until a minimum amount of protection is achieved for the entire population. Nevertheless, no body of data exists to reliably describe the extent of underprotection. An interdisciplinary advisory panel has recommended the following minimum adequate expense protection standard: (1) covering 80 percent of the costs of medically necessary inpatient and outpatient care; (2) covering some psychiatric care; and (3) covering 100 percent of the costs of medically necessary health care in excess of 10 to 30 percent of individual income. To evaluate protection, the population was divided into coverage type (private insurance, medicare, and others), and each coverage type was compared with the adequacy standard. Data on uncovered groups were obtained from a U.S. Census Bureau survey. Research findings showed that over 90 percent of the protected population has adequate inpatient hospital and psychiatric care and inpatient laboratory and X-ray services. Nearly 66 percent has adequate protection for maternity and inpatient physician visits, but less than 33 percent has an adequate out-of-pocket limit. The report coneludes that although underprotection remains a problem, the access of the American population to programs of health expense protection has increased dramatically in the last decade. Two appendices containing biographical profiles of tlie advisory panel and related study data, tables, and 33 references are provided. (Author abstract modified)
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Descriptor(s): National health insurance (NHI), Private health care plans, Publicly sponsored/mandated health plans, Health care/services, Participants in health care programs, Non-participants in health care programs, Plan design/program provisions (under health plans),
623. National Health Insurance Issues. The Cost of a National Prescription Program.
Gordon R Trapnell. Roche Lab., Nutley, NJ. 1979, 105 pp. Availability: Health Issues, Radio City Station, NY 10019.
The primary purpose of this report is to supply the basic actuanal data and techinques needed to provide a basis on which to evaluate alternative ways to fmance prescriptions. An additional objective is to compare the relative cost of several specific alternative approaches to coverage of prescription drugs. Those examined differ by population groups eligible, types of health conditions for which drugs are covered, and the cost-sharing specified. Base-line actuarial data estimates presented show that outlays for prescriptions are substantially higher than the official government figures. Total spending for outpatient legend drugs and insulin in 1978 amounted to $10.5 billion as compared to $6.8 billion in 1972. Most of this increase was due to inflation, demographic factors, and an increase in the average prescription size. In the absence of a national prescription program, expenditures for prescription drugs are estimated to rise to $16.8 billion by 1983. This study focuses on three concepts of a national prescription program: the cost to the country, or how much more will be spent to produce and distribute prescription drugs; the outlays of the new program, or how many dollars will flow through the program; and the new taxes or mandatory premiums that will be necessary to pay for the program. The most important aspects of the cost of a national prescription program axe its impact on total national spending for prescriptions and the increased tax burden. The relative magnitude of total spending for prescription drugs in 1983 under eight alternative plans is cornpared to the projected spending without such new plans. Total national spending under a comprehensive program for the entire population wouM be $24.9 billion in 1983, an increase of $7.5 billion over what would have been spent in the absence of a new program. This program would require $18.3 billion of new taxes if it is financed by the Federal Government. In addition, three criteria must be considered if funds for a social insurance program are limited and benefits are targeted to those most in need: the financial burden of paying for prescriptions, the resources that a household may have to draw on in meeting these costs,
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and the social waste involved in additional administrative costs. Data in this report confirm that the aged and chronically ill have the highest frequency of large expenditures for drugs and the lowest incomes. Thus, if total funds are to be limited, the incomerelated family deductible approach maximizes the protection delivered to those in need. Tables, charts, and graphs are provided, along with appendices of technical material. (Author abstract modified)
Descriptor(s): Health infc,rmation/data systems, Health care cost trends/projections, Cost/benefit analyses, Pharmaceutical services, Plan design/prog.ram provisions (under health plans), Comparisons of health care programs, National health insurance (NHI), Funding/financing of health care programs.
624. National Health Insurance Issues. The Unprotected Population. Stephen G. Sudovar Health Issues, New Roche Lab., Nutley, 1977, 24 pp. Availability: Health
and Kathleen Sullivan. York, NY 10019 NJ. Issues, New York, NY 10019.
Though the national heahlh insurance (NHI) concept has been debated for over half a century, the Nation has yet to achieve consensus on the fundamental elements of a unified national health policy. The major inflationary pressures in the health system today derive from past initiatives to improve the quality of health care and extend access to care across a broad spectrum of the population. This exp;msion has been achieved at enormous and steadily increasing costs. The existing system is basically sound despite the high costs of care, the misutilization and misallocation of resources, and inadequate availability of health services to some segments of the population. The division of effort between the public and pEivate sectors is natural and appropriate. Those who can afford to pay do so, and those who cannot are collectively assisted by society through government plans. The unprotected population, unable to afford private coverage but earning too much to qualify for public assistance, falls into the gap between. Assistance can be extended to the "gap" population without fundamentally changing the existing health care system. Such a policy must build incrementally toward guaranteeing that 100 percent of the population has adequate protection against the expenses of nex_mary health care service. Presently, over 50 percent of the unprotected population earns less than $10,000 annually. Extending a program of protection to this identifiable group is an achievable objective within the framework of tile existing health care system and a logical initial
Health
Care Programs
increment of NHI. Fi_qeen tables and three figures comparing data about the "gap" segment ofthe population are provided, in addition to 46 annotated footnotes. (Author abstract modified)
Descriptor(s):
Demographic
features of population,
health insurance (N-HI), Non-participants grams.
Descriptor(s): National health insurance (NHI), coinsurance, Source of premium payment.
Deductible/
National
in health care pro-
625. National Health Insurance Issues. Viability of the CostSharing Concept.
Surendra K. Mansinghka. Health Issues, New York, NY 10019 Roche Lab., Nutley, NJ. 1978, 28 pp. Availability: Health Issues, New York, NY 10019.
This pubfication discusses cost sharing as a means of financing national health insurance (NHI), studies two public health insurance plans employing cost sharing, and makes NHI recommendations. Five types of NHI coverage are currently being discussed: coverage by population group (medicare, medicaid), coverage by disease type, coverage by type of service Cnospitalization, etc.), and coverage for all of the preceding with or without cost sharing (direct financial participation by those covered), Based on multiple criteria developed to compare care quality, administrative feasibility, and equitability to the population in need, cost sharing will result in the best medical care at the lowest cost and reaching the most people. Although literature indicates that cost sharing will effect the amount and mix of services utilized, opinion diverges on the magnitude of this effect, Moreover, most studies conclude that the relationship between cost-sharing levels and demand for service will be negative. Nevertheless, the studies indicate no definitive conclusions about the relationship between income levels and various cost-sharing plans. Studies of the Rhode Island Catastrophic Health.Insurance Plan (RICHIP) and the Manitoba Pharmacare program in Canada are presented for their findings on administrative costs, The ICHIP, covering catastrophic illnesses and relating benefits to income and other third party coverage, produces high administrative costs but covers a wide range of populations and uses a simple administrative process. The Manitoba program, covering prescription drugs only, yields very low administrative costs. Recommendations include (1) incorporating cost-sharing provisions into any NHI legislation (2) requiring no consumer spending for medical expenditures over a certain amount, and (3) using a deductible as the means for applying the incomebased scale. Graphs, tables, and 101 references are included,
626. National Health Insurance Proposals. Provisions of Bills Introduced in the 94th Congress as of February 1976.
Saul Waldman. Social Security Administration
Office of Research and Statis-
tics, Washington, DC 20203 HEW/PUB/SSA-76/11920 Feb 1976, 209 pp. Av_lability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-070-00282-0.
This report offers detailed information on the provisions of all 18 national health insurance (NHI) bills introduced in the 94th Congress as of February 1976. For this report, a NHI program is defined as one which would at least (1) establish a plan by law or provide substantial incentives for its voluntary establishment, (2) use some type of insurance or tax mechanism, and (3) potentially affect all or most of the population. For comparative purposes, the plans have been grouped according to their general approach as follows: mixed public and private, mainly public, tax credit, and catastrophic protection. A table lists the bills by name, bill number, and first sponsor in the House and Senate and indicates any announced support by major national organizations. A comparison made of these bills with those introduced in the 93rd Congress indicates that most of them are identical to or are modifications of bills introduced in the last session. Of the bills supported by major national organizations, five have been reintroduced, all of them in modified form. To facilitate analysis and comparison, the provisions of all the bills have been presented in a manner which provides information on the following subjects: general concept and approach, coverage of the population, benefit structure, administration, relationship to other government programs, financing, standards for providers of services, reimbursement of providers of service, and delivery and resources. Many of the bills include provisions specifically designed to effect changes in the methods of delivery of health care services or to increase the supply of health resources. These provisions are included in the category of delivery and resources. Many of the plans have established the standards for providers of service to participate in the program by reference to the standards used in the medicare law. A description of these medicare standards is shown in the appendix. Summary charts describing the major features of the proposals, tables, and footnotes are provided. (Author abstract modified)
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Descriptor(s): National health insurance (NHI), Comparisons health care programs, Policy initiatives.
of
Rand Corp., Santa Monica, CA 90406 National Center for Health Services Research, MD. Department DC.
627. National Poor.
Health Insurance, Psychotherapy,
and the
Daniel W. Edwards, Les R. Greene, Stephen I. Abramowitz and Christine V. Davidson. 1979, 9 pp. A vailabib'ty: American Psychologist v34 n5 p411-419 May 79. Four pertinent hypotheses focusing on psychotherapy coverage for the Ix)or under national health insurance (NHI) were examined in a series of studies of patients in community mental health centers. Debate on psychotherapy coverage under NHI has centered around perceived inequitable service to different income groups. It has been argued that NHI coverage for psychotherapy would represent a subsidy to the affluent by poorer citizens. The hypotheses examined included the attraction hypothesis, which states that mental health professionals cannot create clinical settings that will attract the poor; the duration hypothesis, which argues that even if the Ix)or sought treatment, they would receive fewer sessions than would more affluent groups; the elitism hypothesis, which suggests that the poor would be treated by less qualified professionals; and the effectiveness hypothesis, which suggests that the poor would profit less from psychotherapy than would the affluent. Study data for testing these hypotheses were obtained from various sources, such as the National Center for Health Statistics and numerous private surveys. Data analysis indicates that none of the hypotheses was supported by available statistics. In developing a plan for NHI coverage, attention needs to be given to ways to ensure that the settings and services covered will be attractive, accessible, and helpful to the poor. Among the likely critical ingredients are location of clinics that are easily accessible, professional commitment, evaluation of effectiveness strategies, and establishment of fee structures that make NHI-supported psychotherapy financially feasible for both patients and taxpayers. One table, 6 reference notes, and approximately 35 references are included in the article. (Author abstract modified) Descriptor(s): Demographic features of population, health services, National health insurance (NHI).
628. National Health Insurance. Mandated Employee Coverage.
Some Costs and Effects of
Bridger M. Mitchell and Charles E. Phelps.
I-2_4
Mental
of Health, Education,
Hyattsville,
and Welfare, Washington,
1976, 19 pp. Availability: Jnl. of Political E_onomy v84 n3 p553-571 Jun 76. This paper assesses several economic consequences of financing a system of national health insurance (NHI) which mandates that employers provide insurance for their employees and dependents. Effects for 1975 are simulated using data from a 1970 health care survey. Findings show that employer premiums would rise between $5 an6 $21 billion for plans under congressional consideration. These premium increases would, in the short run and in the absence of offsetting subsidies, decrease the number of persons employed. For the proposals under consideration, the range of increase in the unemployment rate is between .4 and 1.4 percentage points, with significant variation by industry. Furthermore, as employer premium payments are shifted to employees, taxable income will fall, leading to additional tax expenditures of $1.3 to $5.9 billion. These tax expenditures are between 25 and 40 percent of the new direct Federal outlays for those NHI proposals. Although it is an "off-budget" financing mechanism, mandated insurance nevertheless has significant budgetary effects. The additional tax revenue not presently collected on existing employer group health insurance premiums and on personal income tax deduction of premiums amounted to about $6.4 billion in 1975. Combining this amount with new tax expenditures from a mandated NHI plan would result in total tax expenditures on health insurance premiums in 1975 of $8 to $12 billion, or about 4 to 6 percent of the Federal revenues from personal income and payroll taxes in 1975. Elimination of these indirect subsidies, no longer needed to encourage the purchase of insurance under a mandatory program, could provide a substantial increase in Federal revenues. Tables, footnotes, approximately 25 references, and an appendix giving an estimation of transitory unemployment effects are included. (Author abstract modified) Longer version of this paper has been published Corporation Report, R-1509-HEW (1975).
as a RAND
Descriptor(s): Source of premium payment, National health insurance (NHI), National 4w.onomic conditions.
629. National Health Insurance. What Now, What Later, What Never. Mark V. Pauly.
Health Care Programs
American Enterprise Inst. for Public Policy Research, Washington, DC 20036 1980, 381 pp. A vailability: American Enterprise Inst. for Public Policy Research, Washington, DC 20036.
a means of ensuring uniform essential medical care for all citizens at the lowest possible cost. Specific NHI Senate bills, notably S. 1812 and S. 1720, were critiqued by some of the witnesses, while others spoke generally of the features they preferred for a NHI plan. Witnesses spoke of the need for a NHI plan to provide incentives for cost containment while ensuring essential and
These proceedings of a conference on national health insurance (NHI) held in Washington, D.C., present 12 papers dealing with 4 major themes. Political and economic concerns relating to initiating an NHI program are discussed in papers focusing on the impact of NHI proposals on the Federal budget, taxation and the cost of NHI, and the effects of financing NHI through mandatory employee benefit payments. A section on solving the problem of underinsurance presents papers on rationales for government initiative in catastrophic health insurance; reforming national health programs for the poor;, and preventive care, care for children, and national health insurance. Next, solving the problem of overinsurance is considered in three papers focusing on conceptual issues, the tax treatment of health insurance premiums as a cause of overinsurance, Blue Cross and Blue Shield, and health care costs. The final section deals with longrun and short-run strategies for cost containment. It presents three proposed alternatives to NHI: greater reliance on health
quality health care. Some cost-containment recommendations were citizen-Government cost-sharing for medical services, a deductible amount to be paid by the user to discourage overuse
maintenance organizations, income-related cost sharing, and the use of regulation to promote the emergence of more competitive health care systems. Individual chapters have tables, footnotes, and references. Commentaries follow the papers in each section.
Descriptor(s):
Pr_.eedings
631. National Health Insm'anea. 96th Congress second session, Volume 2.
of a conference held in Washington,
DC.
Descriptor(s): National health insurance (NHI), Cost containment efforts, Health care cost trends/projections, Non-participants in health care programs,
630. National
Health Insursaea,
of medical services, controls on physician fees, an emphasis on preventive care, encouragement of the use of paraprofessionals who would perform outpatient and home services, and approaches that would encourage competition in fee setting and rate setting. There was disagreement about provision for catastrophic illnesses in a NHI program. Some felt such a provision would encourage the escalation of the number and cost of medical services, while others believe it to be necessary to prevent financial ruin for persons and faro/lies victimized by long-term illnesses. Written statements are provided in addition to the record of verbal testimony and subcommittee questioning. 96th Consress _rst session. National health insurance (N-HI).
Committee on Ways and Means (U.S. House) Subcommittee on Health, Washington, DC 20515 Feb 1980, 794 pp. A v_lablh'ty: Printed for the Committee on Ways and Means, serial 96-91..
1979.
Committee on Labor and Human Resources (U.S. Senate) Subcommittee on Health and Scientific Research, Washington, DC 20515 Nov 1979, 68 pp. Availability: Printed for the use of the Committee on Labor and Human Resources. Testimony regarding the need for a national health insurance plan (NHI) is presented before the Senate Subcommittee on Health and Scientific Research, with particular attention to New Jersey's health needs. Testimony from New Jersey public officials, private citizens, and representatives of the New Jersey medical community generally supported some form of NHI as
A series of public hearings on legislative proposals for national health insurance (NHI) and proposals to restructure incentives in the private health care sector were held in Washington, D.C., and a number of cities around the country during early 1980. Testimony covered (1) a comprehensive program of NHI, (2) expanded catastrophic health insurance protection, (3) strengthening and extending the protection offered under existing public programs like medicare and medicaid, and (4)improving the effectiveness and expanding the availability of private health insurance through the use of incentives to stimulate competition and greater cost consciousness in the private sector. Proponents of specific legislative proposals, recognized experts in the health care field, and representatives of national organizations as well as individual citizens spoke or had testimony submitted to the record. During the opening hearings in Washington, D.C., re-
1-285
presentatives of the following organizations were among those who testified: the American Conservative Union; American Nurses Association; American Psychiatric Association; the Health Insurance Association of America; the National Women's Health Network; the United Automobile, Aerospace, and Agricultural Implement Workers of America; and the Veterans of Foreign Wars. Related materials are appended. (Author abstract modified)
Descriptor(s): National health insurance (NHI), Cost contain. ment efforts, Private health care plans, Present legislation/regulations, Health care/services, Voluntary initiatives, Competition/interaction among third-party payors, Policy initiatives.
632. National Health Insurance. 96th Congress second session, Volume 3.
committee on Ways and Means (U.S. House) Subcommittee on Health, Washington, DC 20515 Apr 1980, 377 pp. Availability: Printed for the Committee on Ways and Means, serial 96-94..
A series of public hearings on legislative proposals for national health insurance (NHI) and proposals to restructure incentives in the private health care sector were held in Washington, D.C., and a number of cities around the country during early 1980. This document contains the testimony of field hearings held in Miami, Fla., and Honolulu, Hi. Testimony prehensive program of NHI, (2) expanded
covered (1) aeomcatastrophic health
insurance protection, (3) strengthening and extending the protection offered under existing public programs like medicare and medicaid, and (4) improving the effectiveness and expanding the availability of private health insurance through the use of incentires to stimulate competition and greater cost consciousness in the private sector. Proponents of specific legislative proposals, recognized experts in the health care field, and representatives of national organizations as well as individual citizens spoke or had testimony submitted to the record. During the Miami hearings, representatives from the Florida State Legislature, the Dade County Council of Senior Citizens, and the Southern Christian Leadership conference were among those who testifled. Those testifying during the Honolulu hearings included the Governor of Hawaii, and representatives of the Hawaii State Legislature, the Kaiser Permanente Medical Care Program, the International Longshoremen's and Warehousemen's Union, and the Hawaii Psychological Association. Related materials are appended,
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Descriptor(s): National health insurance (NHI), Cost containment efforts, Private health care plans, Present legislation/regulations, Policy initiatives, Competition/interaction among third-party payors.
633. National Health Program for Infants, Children and Youth.
Helen M. Wallace and C. Arden Miller. 1978, 12 pp. Availabih'ty: Health Care Management Review v3 n4 pl 1-22 Fall 1978.
With our current national concern for the increase in the cost of health care, children and youth represent a possible candidate population for early special coverage under a national health program. The plan should assure health care coverage for all mothers, infants, and youth up to 21 years of age. Primary health care should be covered by the plan without charge to the child or family and without deductible or coinsurance. Where primary support is provided by nonmedical personnel, backup support and advice should be readily available from qualified physicians. Preventive health services and prenatal and intrapartum care should be provided. Additional services which must be included are hospital inpatient care, laboratory services, dental services, and home health care. The quality of care offered may be improved through use of advisory groups, an effective grievance method for users, establishment of performance standards for agencies furnishing services, and development of a system requiring recertification and continuing education for health care providers. The national plan should also include support for programs that will train the providers and those who will plan, administer, monitor, and evaluate services. A regional approach will be needed to implement the plan, and it is suggested that the program for mothers and children be funded by Federal money only to assure uniformity of the level of care. Choices available for payment to providers are fee for service, salary, or capitation. It is anticipated that implementation of such a national plan would result in the need to expand primary health care services for the target population. In addition, measurable standards of performance must be established. Two tables and 10 references are included in the article.
Descriptor(s): Demographic features of population, health insurance (NHI), Policy initiatives.
Health
National
Care Programs
634. National HMO Census Survey, 1977. Summary. Group Health Association of America Inc, Washington, DC 20036 American Association of Foundations for Medical Care, Potomac, MD 20854 Blue Cross Association, Washington, DC 20006 Health Insurance Association of America, Washington, 20006
DC
National Association of Blue Shield Plans, Chicago, IL 60611 1977, 36 pp. A vailability: Group Health Association of America, Inc., Washington, DC 20036. Results are reported from a census of health maintenance organlzations (HMO's) covering February 1977 to August 1977. The primary purpose of the census was to bring consistency to the reporting of HMO facts and figures and to produce this information in one document. A total of 93 percent of all HMO plans, representing 97.5 percent of enrollment, responded to the census survey. The total membership for all HMO's was 6,330,676, making an increase of 314,233, or 5.2 percent, over the 1976 membership. HMO's with 100,000 or more members accounted for 71 percent of total membership. HMO's that had been operational 10 or more years acoaunted for 70.6 percent of total membership. When type of practice is considered, 65 percent of all plans, representing 90 percent of the total membership, are prepaid group practice plans. With respect to the plans that reported membership data in 1976 and 1977, an overall 14.7 percent increase in operational plans was found. Overall, the number of hospital days per 1,000 members is 488; however, in plans of 100,000 or more members, hospital days per 1,000 members average 408. All prepaid group practice plans, regardless of size, reported average use data of 458 hospital days per 1,000 members. The rate of physician use was found to be 3.8 total physician visits per member per year in all responding plans. The median family premium was $89 per month. Prepaid plans which have been operational 10 or more years have the lowest median family premium rate - $81 per month. Finally, there are 1.14 full-time equivalent physicians per 1,000 members in all prepaid plans. Tabular data are provided. (Author abstract modified)
DHHS/PUB/PHS-80-50159 Jun 1980, 42 pp. A vailabih'ty: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 01743004)0239-2.
This is an annual census of health maintenance organizations for the period from July 1, 1979 to June 30, 1980. A 3-page questionnaire was mailed to the 236 plans fisted by several sources as being in operation. A total of 200 questionnaires were returned, although not all questionnaires were filled out completely. Information was gathered on plan characteristics, such as model type, operational premium rate, and tax status; enrollment; and utilization data. The census reports 236 prepaid plans in the United States with a total enrollment of 9,099,858. Since 1974, the total number of prepaid plans reported by the census has increased by 66 percent, and total enrollment has increased by 72 percent. The seven Kaiser plans have all been operational for 7 or more years and make up 69 percent of the membership in the largest size category (i.e., with I00,000 or more members). The majority ofthe plans are less than 10 years old, and HMO's are distributed fairly evenly over the various model types. Of all plans, 26.7 percent are staffmodels, 32.2 percent are group models, and 41.1 percent are individual practice associations. Nearly 50 percent of the HMO's in the country are federally qualified and have 70 percent of the total membership. About 60 percent of the total membership, and 27 percent of all plans, are in the West; 18 percent of memberships, and 30 percent of plans, are in the North Central States; 17 percent of memberships, and 23 percent of all plans, are in the Northeast, and 7 percent of the total memberships, and 19 percent of the plans, are in the South. The average family premium per month for all plans reporting this information is $120.30 The overall inpatient utilization rate for all plans is 418 days per 1,000 members per year. Graphs and 26 tables are supplied.
Descriptor(s): grams.
Prepaid plans, Participation in health care pro-
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Hospital services, Medical/surgical services, Partici-
636. National HMO Development
pation in health care programs.
Department of Health, Education, and Welfare Office of Health Maintenance Organizations, Washington, DC 20852 DHEW/PUB/PHS-79-50111 Sep 1979, 39 pp. A vailability: Department of Health, Education, and Welfare, Office of Health Maintenance Organizations, Washington, DC 20852.
635. National HNIO Census 1980. Public Health Service Div. of Program Promotion, Rockville, MD 20857
Strategy Through 1988.
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This paper presents the Federal policy blueprint for health maintenance organization (HMO) development through 1988. The policies reflect certain underlying premises: (1) HMO's must provide quality health care on a cost-effective and fiscally responsible basis, (2) any Federal effort must be effectively managed and must build on past experience to the most efficient expenditure of public funds, and (3) every effort must ensure be made to encourage the private sector to duplicate and expand its past successes in developing well-managed HMO's. Goals for nationwide HMO growth are to increase the number of HMO's and thereby improve the public's access to comprehensive health services, to expand enrollment in existing HMO's so as to increase competition in the health care system, and to maximize the cost-savings potential of HMO's. To promote these goals, the Department of Health, Education, and Welfare (DHEW) has chosen a targeted community development strategy. Thus, DHEW will concentrate its resources on those communities that provide substantial opportunity to achieve the goals to promote HMO growth. DHEW's growth targets call for more than doubling the current number of HMO's nationwide and nearly tripling national enrollment by 1988. Using objective criteria based on development goals, DHEW developed a list of 61 priority communities. DHEW will develop a coordinated marketing and public affairs program for HMO's and will provide technical assistance. Private sector investment will be encouraged to the maximum extent possible. DHEW's development strategy articulates reasonable expectations for HMO development over the next decade and, for the first time, provides the department with the opportunity to organize the Federal program around a set of achievable policy objectives well within its capacity. Tables, footnotes, and a map showing the 61 targeted cities are included.
Descriptor(s):
ior and performance: finances, scope and composition of services, resource utilization, productivity, patient outcomes, organizational structure, and financial management. In addition, the study will examine both the accessability of hospital care to various socioeconomic groups and the overall structure of the hospital industry. The study assesses various programs that try to constrain the rate of increase in hospital costs by placing prospective limits on the reimbursements hospitals receive for their services. The programs selected for the study are operated by State agencies, hospital associations, and Blue Cross plans. The nine programs examined in this first part of the study are located in Arizona, Connecticut, Maryland, Massachusetts, Minnesota, New York, New Jersey, western Pennsylvania, and Washington. This volume presents a synthesis and analysis of the information obtained from the case studies of the nine programs. The report describes the characteristics of alternative generic approaches to prospective control of hospital reimbursement. It also describes the lessons provided by early program versions and gives a preliminary, qualitative assessment of the current programs. Individual chapters focus on adoption, implementation, and evolution of prospective rate-setting programs; current authority and organizational structure in the nine study programs; operational characteristics of prospective reimbursement programs; and the legal context ofrate-settingprograms. Tables, footnotes, and a bibliography of approximately 30 references are included. Legal cases cited are listed. Health
Care Financing
Grants and Contracts
Descriptor(s): Cost containment efforts, Methods of payment determination.
Inpatient
Series.
facilities,
Prepaid plans, Policy initiatives.
638. Nation's Use of Heallh Resources, 637. National Hospital Rate-Setting Study. A Comparative Review of Nine Prospective Rate-Setting Programs.
Diane Hamilton, Renee Walter, Jerry Cromwell, Eve Horowitz and Gilbey Kamens. Abt Associates, Inc., Cambridge, MA 02138 Health Care Financing Administration, Washington, DC. Aug 1980, 151 pp. Availability: Health Care Financing Administration, ORDS Publications Baltimore, MD 21235.
The National Hospital Rate-Setting Study is the most comprehensive study of hospitals undertaken to date. Data will be assembled on more than half of the short-term general hospitals in the U.S. in order to examine important aspects of hospital behav-
1-288
Reports
1979.
National Center for Health Statistics Div. of Health Resources Utilization Statistics, Hyattsville, MD 20782 DHEW/PUB/PHS-80/1240 1979, 169 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-022-00687-1.
The health service utilization patterns documented in this report are classified according to the three major settings in which they are provided: ambulatory, inpatient, and home care. Most of the data refer to 1974, 1975 or 1976. The major categories of services provided within the health care system are presented, as is the estimated number of persons served one time or more in a particular setting within each applicable year. Ambulatory care in
Health Care Programs
the practitioners' office and in ambulatory care facilities is outlined. Hospital ambulatory services include services provided in facilities such as emergency rooms and outpatient departments, Ambulatory care facilities not related to hospitals include health department clinics, neighborhood health centers, and public health service clinics. Inpatient care in hospitals, nursing homes, and other inpatient facilities are presented. These other inpatient facilities, "establishments with permanent facilities that include inpatient or resident beds and with health-related services that may include limited nursing services," include mental health facilities other than hospitals, and facilities for dependent children and orphans, the deaf, blind, unwed mothers, the physically handicapped, the neurologically handicapped, and other multiple purpose settings. Home health care services include either
hospice care. A third article cites some of the special financial problems that characterize a geriatrics practice and suggests ways they can be overcome, or compensated for, through the addition of laboratory, X-ray, and EKG facilities in the office and through the establishment of group practice. Summary resuits of a study on what the elderly think of doctors are included.
direct patient or telephone contact, hospital-administered programs, and State health agency (SILK) programs. Other services are diagnosis and treatment services, such as medications, tissue services, services provided by clinical and public health laboratories, and transport services; habilitation and rehabilitation services, such as the provision and use of prosthetic, optical, dental, and orthotic devices; and prevention and detection services for individuals, such as immunization and screening programs. Figures, tables, data sources, and an index are provided.
640. Negotiating Reimbursement Experience.
Descriptor(s): Demographic features of population, Demand/ utilization of health care programs, Health care/services, Facilities providing health care.
This article discusses Michigan's Blue Cross-Blue Shield experiment involving the use of the bargaining model to rate setting. The approach has in common with budget review methods the ability to tailor the result to individual hospital settings, and it creates the opportunity for both parties to adjust their aspirations through learning. Eleven hospitals participated in the experiment. Their selection was based on obtaining a predetermined mixture of size, geographic location, type of institution, and percentage of Blue Cross-Blue Shield utilization.
639. Needs of the Elderly. Robert N. Butler and Jack Kleh. 1978, 5 pp. Availability:
Internist v19 n7 p10-12,14,15
Sep 78.
Three articles on the needs of the elderly focus on Government and private-sector initiatives, needed changes in delivery systerns, and financial considerations in geriatrics practice. The first article describes the establishment of the National Institute on Aging 0NIA) and some of its work such as the recent conference to seek consensus on the detection, diagnosis, and evaluation of reversible brain syndromes. The article also suggests that physiclans, especially new ones, need to become better versed in geriatric medicine and that more geriatric residency programs like those of the City Hospital Center at Elmhurst in New York City and at the Long Island Jewish Institute for Geriatric Care are needed. A second article critiques some aspects of health delivery services for the elderly and suggests some needed changes in health insurance including incentives for ambulatory and home care, support for long-term facility care, and full coverage for
Descriptor(s): Publicly sponsored/mandated health plans, Reimbursement, Policy/changes re health care, Long te:rm care facilities, Providers of health care services.
Contracts. The Michigan
Fred C. Munson and Steven N. Williams. Social Security Administration, Washington, DC. 1977, 9 pp. Availability: Health Care Management Review v2 n4 p73-81 Fall 1977.
Each hospital's bargaining team included the administrator, an associate administrator, and a controller. The Blue Cross team included financial as well as administrative representation. Prior to negotiating, budget data were procured from all hospitals, and prenegotiation sessions were held to clarify financial information. Major bargaining issues did not significantly change over the life of the project. Primary areas of interest were productivity, volume projections, salary levels, staffing expectations, offset projections, inflation, and the mechanics of the prospective reimbursement project design. Discussions and arguments often centered on those areas where large percentage increases were forecast. Most contracts that were finalized developed in an ad hoc manner as a direct result of discussion in negotiating sessions, and in at least one case, Blue Cross settled at a percentage increase higher than the tentative outer limit which had been set prior to negotiations. All negotiations took place on an average of 3 months into the fiscal year for which the budget was being negotiated. Perhaps the most important risk-minimizing device was late negotiations. By negotiating a reimbursement contract as much as 6 months into the prospective year, it was fiir easier
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for Blue Cross and hospitals to select a total operating expense budget figure that would be close to actual cost. Four tables are included in the article, Descriptor(s):
Hospital services, Service benefit plans, Methods
of payment determination, Inpatient facilities, Outcome/evaluation of health administration,
641. Neighborhood
Health Centers. A Decade of Experience.
Milvoy S. Seacat. National Inst. of Health, Bethesda, MD. Div. of Research Resources. 1977, 15 pp. Availability: Jnl. of Community Health v3 n2 p156-170 Winter 1977. Using the team approach and gaining acceptance in the cornmunity, Neighborhood Health Centers (NHC's) have generally succeeded in delivering good, comprehensive health care, including preventive services and health supervision, to the poor. AIthough the recruitment of full-time salaried physicians has been difficult, and established health institutions have resisted NHC efforts, the future for NHC's looks encouraging. However, a stable source of funding is needed. It was thought that medicaid
1979, 12 pp. Availability: Transactions of the Society of Actuaries vXXXI p173-185 1979. This paper presents hospital utilization data concerning the proportion of total hospital days that is due to injury and the proportion of total hospital days that is spent in intensive care units. In addition, this paper presents data for hospitalizations, subdivided between injury and caases other than injury for both days spent in intensive care uni_ and total hospital days. The utilization proportions have been applied to claim costs underlying recently published tables of reserve factors for insured hospital benefits in order to obtmn corresponding reserve factors for special benefits involving only injury hospitalizations or intensive care treatment during hospitalization. For reasons given in the text, the continuation data have not been used to develop claim costs or reserves. Tables are included that show the utilization proportions, the resulting net annual claim costs, reserve factor comparisons, and hospital continuance. (Author abstract modified)
Descriptor(s): derwriting.
Hospital
services, Premium
determination/un-
would eventually cover the costs of NHC's, but many of the centers' patients are ineligible for benefits. Hospitals can obtain "ghetto medicine" grants for their outpatient department losses, but NHC's cannot. And since the majority of NHC patients are ambulatory, insurance payments do not cover a large share of NHC costs. Hence, NHC's have had to continually depend upon grants from the Office for Economic Opportunity (OEO) and later the Department of Health, Education and Welfare. Nonetheless, most studies indicate that the costs of providing comprehensive care by NHC's are reasonable compared to costs
643. New Directions in Public Health Care. A Prescription for the 1980s.
of other methods of providing care. The distinctive feature of all NHC's is their coordination of the full range of health care services for an entire community. The NHC structure should be seriously considered as a model for the delivery of health care services, not just to the poor, but to the entire community. Twenty-four references are provided,
Various proposals for national health insurance (NHI) and new approaches to the issue are presented in this third, revised edifion. The book consists of a collection of essays by various authors. An introduction to the public debate on NHI discusses the Nixon, Ford, and Carter proposals. Facts and assumptions concerning public health, access to care, and the reasons behind increased costs are reviewed. A discussion on medical care and
Descriptor(s): Outpatient facilities, Allied health professionals, Source of premium payment,
the pursuit of health describes the objectives of medical science, seven rules for good health, and the aim of national health policies -- economic equality. The Government's role and responsibility concerning the health of its citizens, the financial aspects of Government health programs, characteristics of health care insurance, incentives to lower insurance costs, and the problem of insuring the poor are highlighted. The experiences of some other countries with centralized health care are
642. Net Claim Costs and Reserves for Accident-Only Intensive-Care-Only Hospital Coverages. Robert
1-290
H. Dobson and Charles Habeck.
and
Cotton M. Lindsay. Institute for Contemporary
Studies, San Francisco, CA.
1980, 301 pp. A vailabiKty: Institute for Contemporary co, CA 94111.
Studies, San Francis-
analyzed, particularly those of Canada and Great Britain. Dis-
Health Care Programs
cussion encompasses the political dilemma of centralized medicine, the gulf between government and private services, geographical maldistribution of health care services, and the replacement of quality with quantity. Other chapters deal with the organization of medical care markets, including the dispute over economic efficiency and medical need; the administration's case for hospital cost containment, including opposition to the Hospital Cost Containment Act and the implications ofmandatory revenue controls; and the history and analysis of public sector medicine, particularly the effect of medicare and medicaid. Proposals under consideration are reviewed, including the Carter plan and proposals of Senators Kennedy, Long, Dole, Danforth, and Schweiker. Next, the long-run effects of NHI on medical care prices and output are considered, as well as the politics of NHI. Finally, the book assesses the ideal health care delivery system and the fallacies of distinguishing between NHI and nationalization. Tables, an index, and approximately 75 references are provided,
Descriptor(s):
National health insurance (NHI), Cost contain-
ment efforts, Supply/availability of services, Policy initiatives, Comparisons of health care programs, Comparisons regarding foreign health policies, Publicly sponsored/mandated health plans.
percent) by their employers. Of the 159,956 employees with comprehensive major medical expense plans, 36 percent had a single deductible of $100, 98 percent had maximum benefits of $100,000 or more, and 95 percent had benefits for treatment of nervous and mental disorders. In 1975, 91 percent of employees had some type of arrangement available to them by which they could continue their coverage upon termination of employment. In 1980, 87 percent had continuation or conversion coverage. Coverage for employees was provided through a continuation of the group plan at retirement for 30 percent in 1975 and 19 percent in 1980. Conversion to individual plan without physical examination upon retirement was available to 90 percent of the surveyed employees in 1975 and 87 percent in 1980. Si_ tables are included in the booklet. (Author abstract modified)
Based on surveys by the Health Insurance
Institute
policies is-
sued in 1980, l_ve year trend 1975-1980. Descriptor(s): Health care costs, Health insurance industry, Private health care plans, Plan design/program provisions (under health plans), Source of premium payment, Health c.are/services, Participation in health care programs.
645. New Health Professionals. Physician's Assistants.
Nurse Practitioners
and
644. New Group Health Insurance. Ann A. Bliss and Eva D. Cohen. Health Insurance Inst., Washington, De 20006 1980, 16 pp. Availability: Health Insurance Inst., Washington,
1977, 451 pp. Availabih'ty: Aspen Systems Corp., Rockville, MD 20850. DC 20006.
A survey conducted annually by the Health Insurance Institute focuses on new group health insurance policies written by insurance companies. This survey is of 3,622 new cases written between January 1 and March 31, 1980, by the 31 companies that accounted for nearly 60 percent of company group health insurance premiums written in the United States during 1979. The sample is considered broad enough to provide an accurate picture of new group policies for the entire year. Total new policies were held by 781,099 insured persons. Of this number, 333,212 were employees and the remainder were their dependents. The group cases are divided into four sizes by number of insured employees: those less than 25 persons, 25 to 99 persons, 100 to 499 persons, and 500 or more individuals. In addition, the booklet contains a section comparing trends in new group plans over the period 1975 through 1980. Of the 333,212 employees in the 1980 survey, 298,515 were covered by group cases written for the first time. Overall, 71 percent of all employees either had health insurance coverage paid entirely (58 percent) or in part (13
Issues associated with the emergence of nurse practitioners and physician's assistants as the "new health professionals" are discussed in a series of papers. The first section of papers provides an overview of new health practitioners. One presentation profiles the physician's assistant (PA) and includes discussions of the historic evolution of the PA, the location and content of PA training programs, the selection of student candidates, tuition, demographic characteristics of graduates and students, a pracrice profile, and issues affecting the future evolution of the PA concept. The section on major determinants of practice includes chapters on the legal scope of nurse practitioners (NP) under nurse practice and medical practice acts and PA and NP laws for expanded medical delegation. These discussions consider the legal status of NP's under nurse practice acts, definitions of professional nursing practice, and the prohibition of independent medical practice by NP's. The analysis of new State legislation governing expanded delegation is deemed to be unduly restrictive and incomplete. Another chapter in this section discusses third party payment for the services of the assistant to the pri-
I-2'_1
mary care physician. Current third party payment policies for PA services are examined, and issues of reimbursement for PA services are considered. The economic effectiveness of family nurse practitioner practice in primary care in California is considered in another presentation. Problems, issues, and national implications are discussed, based on results from a pilot study of nine private practices and a survey of 93 primary care practices, Problems of PA's and Medex from their own perspectives are considered in another presentation in this section. The clinical impact of the new health professionals is assessed in a third
a new approach to hospital reimbursement which considers case mix, referred to as the diagnosis related group (DRG) system. Hospitals are paid an established amount before services are rendered for patients with specific problems, regardless of how long they axe hospitalized. The DRG system derives payment from costs of treating specific eases or patients, with no consideration given to length of hospital stay. The State's rate setting authority extends over all charges for inpatient and outpatient services, not just those reimbursed by Blue Cross or medicaid, and broadens the definition of reimbursable costs to include
section of papers, and a fourth section deals with evaluative research on new health professionals. One paper evaluates the impact of the Utah Medex program using a quasi-experimental approach, and the Social Security Administration Physician Extender Reimbursement Study is discussed in another paper. Issues and conclusions are presented in the final section. Extensive supplementary material is appended, and notes are provided at the end of each presentation,
expenses not previously covered. Depreciation is adjusted for inflation and no longer based entirely upon historical or actual costs. Hospitals having an unsatisfactory working capital position receive payments. A capital facility allowance replaces depreciation and interest expenses for building and fixed equipment, although interest on short term debt is not reimbursed without appeal. Computation of case-mix payment rates is complex, and sections are provided explaining the calculation of direct patient care and all the other costs.
Descriptor(s):
Supply/availability
of services, Impact of third-
party coverage, Health care/services, Methods of payment determination, Present legislation/regulations, Policy initiatives, Evaluations/outcome of health care programs, Allied health professionals.
Descriptor(s):Reimbursement, Methods of payment determination, Present legislation/regulations, Cost containment efforts, Hospital services.
647. New York State Long Term Health Care Program. 646. New Jersey Hospital Reimbursement Under S-446. Elements and Effects, 1980.
New Jersey Hospital Association, Princeton, NJ 08540 1980, 47 pp. Availability: New Jersey Hospital Association, Center for Health Affairs, Princeton, NJ 08540.
New York State Dept. of' Health Office of Health Systems Management, Albany, NY 12237 New York State Dept. of Social Services, Albany, NY 12237 Feb 1980, 163 pp. AvMlability: New York State Dept. of Health, Office of Health Sysytems Management, Albany, NY 12237.
Numerous States have already implemented rate review programs to control hospital costs, and a handful of States require hospitals to charge approved payment rates, usually to medicaid or Blue Cross. A typical mandatory program requires hositals to submit uniform cost information about their financial conditions and operating characteristics on a per diem approach in which
The New York State legislation establishing the Long Term Home Health Care Program (LTHHCP), or the "Nursing Home without Walls," provides disabled individuals in need of longterm care with an alternative to placement in an institution. The major objectives Of LTHHCP are to reduce fragmentation in the provision of home care services and to demonstrate the effective-
inpatient costs are separated from outpatient costs. Hospitals are reimbursed for whichever is lower, the actual cost or the mandated ceiling. With this type of reimbursement practice, differences in types of patients treated among hospitals is not adequately taken into account, and hospitals have no incentive to provide quality care efficiently. Since the mid-70's, the New Jersey State Department of Health has administered a mandatory hospital prospective per diem rate setting program. But in 1978, the State legislature enacted Senate Bill 446 which mandated major revisions in the establishment of hospital payment rates, including
ness of coordinating such services through a single health care provider. Several major features distinguish LTHHCP from trao ditional home care programs in New York State. For example, a limit is placed on LTHHCP patient expenditures, holding the cost of services to no more than 75 percent of the average medicaid cost of comparable care. Also admission is limited to patients efigible for placement in institutions, and patients and their families must be notified of the service. Thirdly, 24-hour per day availability of care is emphasized. Finally, certain services not reimbursable under medicaid are reimbursable under the
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Health Care Programs
LTHHCP program, and LTHHCP provides environmental, social, and psychological services usually unavailable through the traditional health agency. Recommendations for improvement of the program include reaUocating slots when underused by providers; changing the 75 percent limit from a monthly to a yearly average, allowing certain patients whose initial costs may exceed the limit for a short time to enter the program; and the development of quafity assurance mechanisms. The possibility of developing housing linkages with the LTHHCP's should also be examined, although these should not become quasi-institutions, Traditional home care services are easier for patients to gain access to because costs or quantity of services are not restricted. The LTHHCPandmay be a superior model compre-to hensiveness patient assessment, but because it may ofbeitsunable compete with traditional care as a result. Further experience and evaluation of the LTHHCP is needed before expansion throughout the State should be under-taken. The historical development of LTHHCP is reviewed, the nine approved programs are examined, and recommendations for legislative amendments are made. Graphs, tables, footnotes, and a glossary are included, and data collection instruments, expenditure data, and other infor-
ance. The increased insurance coverage would certainly improve access to care by some persons, most notably those just above the medicaid eligibility line. But as a mechanism to control costs, NHI is a poor choice. Increased insurance coverage reduces costs at the time services are received, but total expenditures must rise, to be met either privately by insurance premium increases or publicly through tax increases. Finally, NHI is a poor vehicle to control medical quality and cannot be expected to serve that end. Footnotes are provided. (Author abstract modifled) This article adapted from the author's address at the Sixth AnhUM Csthoh'c Health Assembly, in Washington, DC, June 1977. Descriptor(s): Health care cost trends/projections, Cost containment efforts, Inpatient facilities, Outpatient facilities, National health insurance (NHI).
mation are appended.
649. Norms Hypothesis and the Demand for Medical Care.
Desczqptor(s): Home health services, Present legislation/regulations, Long term care facilities, Plan design/program provisions (under health plans), Publicly sponsored/mandated health plans.
Joseph P. Newhonse and M. Susan Marquis. Rand Corp., Santa Moniea, CA 90406 Department of Health, Education, and Welfare, Washington, DC. 1978, 24 pp. Availability: Jnl. of Haman Resources v13 p159-182 Sttpplement 1978.
648. NHI Won't Control Costs, Quality, or Access. This paper discusses a potential statistical bias that results from Charles E. Phelps. 1977, 7 pp. Availability: Hospital Progress v58 nl0 p79-85 Oct 77.
Three mechanisms are discussed in which extension of health insurance coverage and benefits leads to increased medical care expenditure. They include increased quantities demanded, increased quality chosen by consumers, and increasing price per unit. In the extreme of full coverage for all participants in the health market, no logical mechanism exists for setting prices. If society maintains an interest in containing medical expenditures, health insurance policies must be structured in ways to provide incentives to patients and doctors to counteract these side effects of health insurance. Deductibles and coinsurance in the ambulatory sector and variable-coverage insurance in the hospital sector are devices that seem to hold some promise. The provision of national health insurance (NHI) would reduce a substantial risk now facing many persons, especially persons with poor ties to the labor force who do not have good _ to private group insur-
using individual (micro) data rather than aggregated data to estimate the insurance elasticity of demand for medical care services. Specifically, this study examines the norms hypothesis. The norms hypothesis states that the level of a community's insurance coverage determines physician norms, and these norms determine treatment decisions. The data used to compare utilization among the same households before and after a change in insurance were collected by Scitovsky and Snyder and analyzed by them and by Phelps and Newhouse. The data allow comparison of usage for a group of Stanford University eraployees in 1966 and 1968; in 1966 the coinsurance rate had been zero, whereas in 1968 a 25-percent coinsurance rate was iraposed. In addition to evaluation of this data, a review of the relevant literature was completed. Results indicated that the one study in the literature that directly supports the norms hypothesis is misspecified. When it is correctly specified, it provides no support for the hypothesis. Two versions of the hypothesis are distinguished. The stronger maintains that physicians do not take account of within-area variation in insurance coverage. This version is firmly rejected by the data. A weaker version states
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that the physician does take account of within-area variation, but that between-area differences in average coverage have an independent effect on demand. Little or no support is found for this version. Seven tables, 22 footnote references, and appended tables are included. (Author abstract modified)
group had a direct impacl on hospital admissions, h expiain_ why Group Health was the plan with the lowest age-adjusted, medical-surgical rates for both admissions and days and why it experienced the greatest decrease in hospital days. Tabular data and seven references are appended.
Descriptor(s): Demand/utilization pact of third-party coverage.
Also See "Comparison of t_heHospital Cost Experience Competing HMOs. ""
of health care programs, Im-
of Three
Descriptor(s): Competition/interaction among third-party payors, Service benefit plans, Prepaid plans, Plan design/program 650. Note on the Comparison of the Hospital Cost Experience of Three Competing HMO's.
Andrew A. Sorensen, Richard P. Wersinger, mann and J. William Gavett. 1979, 5 pp. Availabili(y:
(under health plans).
Klaus J. Rogh651. Nurse Practitioners.
A Review of the Literature
1965-
1979. Inquiry
v16 n2 p167-171 Summer
1979.
This commentary is an update of a 1976 comparison of the hospital cost experience of three competitive health maintenance organizations (HMO's) in Rochester, N.Y. Current data on the relationship between the type of prepayment plan and the inpatient hospital utilization of its members is reported. The HMO's are Health Watch (a foundation-type of plan); the Genesee Valley Group Health Association (Group Health), a centralized multispecialty group practice modeled after Kaiser Permanente and sponsored by Blue Cross and Blue Shield; and the Rochester Health Network (RHN), a decentralized group practice with seven delivery sites. This review found that variations in the structure of the HMO's, as well as organizational differences in the financial risk of the plan physicians, appear to have profoundly affected the differences in hospital utilization rates, While Blue Cross and Blue Shield Plan inpatient days increased by only 3 percent, Group Health enrollees achieved a 27 percent decrease from 1972 to 1975. In contrast, Health Watch enrollees increased their rate by 29 percent, ending with a 1975 rate nearly 50 percent above the regular Blue Cross and Blue Shield Plan. RHN also experienced a significant increase by 1975. Between 1972 and 1975, the medical-surgical-rates varied only slightly for the Blue (:ross and Blue Shield program enrollees. In contrast, Group Health and RHN enrolles had lower utilization rates, while Health Watch enrollees had much higher rates for both admissions and days. The decline in the age-adjusted, medicalsurgical rates for both admission and days, from 1972 to 1974 and the substantial increase in 1975 to a level considerably higher than 1972 indicate that Health Watch had little if any impact on inpatient hospital utilization. Of the three prepaid plans, Group Health was the one directly exposed to the consequences of high hospital utilization upon physician income. This financial risk structure and the economic pressure on the physician
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provisions
Barbara H. Dunn and Marilyn A. Chard. American Nurses' Association, Kansas City, MO 64108 National Association of Pediatric Nurse Associates and Practitioners, Pitman, NJ C_8071 ANA/NP-62/2M-3/81R 1980, 24 pp. A vailability: American 64108.
Nurses' Association,
Kansas City, MO
This review of the literature on nurse practitioners was the result of an effort, initiated in 1978, which sought to compile in abstract form all available sources both published and unpublished, related to nurse practitioners. This final document contains 100 citations, each of which includes the author, title, journal and journal volume, date of publication, and page numbers. The abstracts are not included The literature review is divided into four sections, each of which summarizes relevant results of research, with references to specific studies as indicated. All reference citations appear at the end of the appropriate section. The four sections cover the subject areas of demography, attitudes and acceptance, impact on care delivery and practice setting, and psychosocial aspects. Studies cited in the demographic section reported the degree to which graduates of nurse practitioner programs applied skills learned in the programs, the variety of practice settings available to nurse practitioners, a profile of the nurse practitioner, the role of the nurse practitioner, and work satisfaction. Studies in the section on attitudes and acceptance generally cited acceptance by clients of the nurse practitioner as a primary care provider. Next, impact studies generally documented a favorable impact on the quality and type of care delivered and on the practice setting when nurse practitioners were used as providers, but more research is needed to evaluate these services. Studies in the final section, covering psychosocial as-
Health Care Program_
pects, suggested that nurse practitioners, once their formal education is completed, have a need for support groups in order to maintain their identities. Autonomy and assertiveness seemed to
653. Norsiag Home Ut/lizztion Policy.
be important to achieving success in the role, but further re-
Wifilam Scanlon.
search is needed to measure independence-antonomy countability. (Author abstract modified)
Administration on Aging, Washington, DC. National Center for Health Services Research, HyattsviUe, MD.
and ac-
Descriptor(s): Nurses, Allied health professionals, Supply/availability of services, Participants in health care programs, Outcome/evaluation of health administration,
Patteras. Implications
for
1980, 23 pp. A va//ab/h'O,: Jnl. of Health Politics, Policy and Law v4 n4 p619-641 Winter 1980. Nursing homes represent the fastest growing component of health care expenditures, over half of which come from public
652. Nursing Home Cost Studies and Reimbursement Issues.
Christine E. Bishop. Health Care Financing Administration, Washington, DC. 1980, 18 pp. Avxilabih'ty: Health Care Financing Review vl n4 p47-64 Spring 1980. This review of nursing home cost function research first defines the concept in economic theory as a relationship between a measure of average cost per unit output and rate of production which allows average cost to vary systematically by provider type, input price level, and output type. Nursing home function studies using regression analysis to identify variables that are significant in explaining cost variation across providers are then compared and listed. Most researchers used costs per patient day as the dependent variable in their cost equations; some used average total expense per patient day; one study used 'price charged to private patients. Independent variabM considered in the studies cited include scale of production; provider type;, end product characteristics, such as certified level of care, services, patient characteristics, patient turnover, and source of payment. Of these, occupancy rate, ownership and provider type, location, and level of care have been confirmed as associated nursing home costs in a systematic fashion. Important questions remain to be answered with respect to the effect that patient mix, services, and quality have on costs. For this reason, econometric cost functions cannot yet provide reimbursement rate setters with predictions about the cost of the efficient provision of nursing home care appropriate to patient needs. However, the foundation provided by research literature concerning differences across States on the impacts of cost-related factors may be applied to individual State analyses of cost determinants. Tabular data, footnotes, and about 30 references are provided, Descriptor(s): Health care cost trends/projections, Cost/benefit analyses, Long term care facilities, Intermediate care facilities, Methods of payment determination,
funds. This paper reviews research on nursing home utilization with regard to several policy issues concerning the subsidization of long-term care by medicaid. The paper defines and contrasts three concepts: need, demand, and utilization. It then indicates how medicaid policies regarding reimbursement of homes and eligibility for support can result in a chronic shortage of beds and describes the estimated effects on utilization of eight variables: medicaid generosity, age stxucture, family resources, racial composition, residence, financial capability of the elderly, price of nursing home care, and alternative sources of care. The paper concludes that there is a need for subsidization of a more cornprehensive set of long-term care services, a review of reimbursement policies, and improved methods of allocating existing nursing home beds among persons desiring care. Tables and 19 referenoes are included. (Author abstract modified) Descriptor(s): Long term care facilities, Medicaid, utilization of health care programs.
654. Oceulmdomd I_m'les and _ by Industry, 1978.
Demand/
in the Ulited
States
Bureau of Labor Statistics, Washington, DC 20210 Aug 1980, 94 pp. Availabib'ty: Available from the Superintendent of Documents, Government Printing Office, Washington, I_ 20402, order number 029-001-02432-1. The data presented in this publication were collected in accordance with the provisions of the Occupational Safety and Health Act of 1970. It reports the occurrence of injuries and illnesses resulting from working conditions as reported by employers in private sector establishments for the years 1972-1978. For the 1978 survey, 280,000 sample units were selected nationwide, and 91 percent, or 256,000 responded. The 1978 estimates were based on reports from about 95,000 manufacturing industries and 161,-
1-295
000 nonmanufacturing industries. Results are reported for total injuries and illnesses (incidence rates, number of injuries and illnesses), injuries (incidence rates, incidence rates by establishment size, number of injuries), worktime lost (injuries involving days away from work and days of restricted work activity, lost workdays due to injuries, comparison with time lost from work stoppages), injury incidence rate trends since 1972, fatalities (incidence rates, number of fatalities, objects or events associated with fatalities), and illness (incidence rates, number of illnesses), Numerous text tables, charts, and reference tables are provided, Appendices provide information on the scope of the survey and technical notes.
care provided. A formal compliance program was established to monitor qualified HMO's. Special attention was given to financial viability, loan repayment, quality assurance, and health care use. With this compliance program, the Office of HMO's has improved its capability to detect potential problems and to assist HMO's to develop effective corrective action. The compliance program also includes a component designed to revoke the qualification of an HMO no longer meeting the requirements of the HMO law. Tabular data are provided. Four appendices conrain an organization chart, functional statements, regulatory changes, and development activities for 1975 to 1979 for the Office of HMO's. (Author abstract modified)
Bulletin
Descdptor(s): Cost containment efforts, Prepaid plans, Demand/utilization of health care programs, Participation in
2078.
Descriptor(s):
Trends in health status,
655. Office of Health Maintenance Organizations. al Report to the Congress.
health care programs, Pre_nt
5th Annu-
legislation/regulations.
656. Office of Personnel Management Should Promote Medical Necessity Programs for Federal Employees' Health InSUFRllCe.
Department of Health and Human Services Office of Health Maintenance Organizations, Rockville, MD 20857 DHHS/PUB/PHS-81/50138 1979, 107 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-002-00145-3.
Comptroller General of the United States, Washington, 20548 Jul 1980, 63 pp. Availability: General Accounting 20760.
Office, Gaithersburg,
DC
MD
The benefits of medical necessity programs and their advantages Federal activities on behalf of health maintenance organizations (HMO's) are reported for Fiscal Year 1979 in this annual report to the Congress. During 1979, HMO enrollment grew by 12 percent over 1978, bringing the total membership to 8.25 million. The number of prepaid plans reached 215 from a previous total of 203 in 1978, with at least one HMO operating in 35 States, the District of Columbia, and Guam. During the year, the Office of Health Maintenance Organizations continued efforts begun in the reorganization of 1978, to strengthen the HMO program and streamline program activities. Promotional activities were undertaken to increase consumer awareness, improve employer and union understanding of the HMO concept, and stimulate greater physician involvement in HMO's. Special efforts were directed toward increasing the Federal employee enrollment in HMO's. A long-range strategy for doubling the number of plans and tripling nationwide enrollment was established, and applications for grants and qualification were processed more expeditiously due to increased review capability and broader knowledge of the critical factors leading to successful operations. A quality assurance program was developed to upgrade the capability of HMO's to monitor the quality of health
I-2%
for the Federal Employees Health Benefits program are discussed; recommendations are offered for Office of Personnel Management (OPM) action in this area. Medical necessity programs have been developed to help contain health care costs and promote good health care. They can reduce the incidence of and payment for health care procedures not found to be medically necessary or consistent with generally acceptable medical practice. Federal Employees Health Benefits program plans have not been required to have medical necessity programs. As a result, the plans' use of medical necessity programs has varied greatly. Improved care and cost reduction benefits of medical necessity programs can be realized more fully if OPM keeps abreast of program developments and ensures that they are adopted promptly. Medical necessity programs are relatively new; benefits realized so far have been limited. However, these programs enjoy widespread physician acceptance, and benefits appear likely to increase as the programs are expanded and more widely used. To ensure that medical necessity programs receive appropriate attention and consideration, the Director of OPM should (1) systematically monitor developments in these programs in the private and public sectors, (2) evaluate these programs to
Health Care Programs
determine how Federal Employees Health Benefits program plans might use them to foster better health care and lower health insurance costs, and (3) require the Federal Employees Health Benefits program plans to use aspects of these programs that are proven beneficial. OPM's comments on this draft report generally emphasized the difficulties associated with using medi.cal necessity programs. While OPM supported the general medical necessity concept, it did not make a commitment to consider fully the recommendations Comptroller
General's
offered. (Author
Report
asstract modified)
to the Congress, HRD-80-79.
Descriptor(s): Cost containment efforts, Government employee plans, Outcome/evaluation of health administration.
Comptroller
General's Report
to the Congress, HRD-80-89.
Descriptor(s): Government employee plans, Participation in health care programs, Outcome/evaluation of health administration.
658. On Broadening the Definition of and Removing Regulatory Barriers to a Competitive Health Care System. Walter McClure. McKnight Foundation, Minneapolis, MN. 1978, 25 pp. Availabib'ty: Jnl. of Health Politics, Policy and Law v3 n3 p303-327 Fall 1978. This position paper discusses a broadened definition of a health
657. Office of Personnel Mauagement's Medical Plans Network Experiment.
Comprehensive
Comptroller General of the United States, Washington, DC 20548 May 1980, 34 pp. Availability: Comptroller General of the United States, Washington, DC 20548. Results are reported from a Comptroller General's review of the Office of Personnel Management's (OPM's) administration of the Blue Cross and Blue Shield Comprehensive Medical Plans Network experiment in the Federal Employees Health Benefits (FEHB) program. The program was intended to provide new options for health benefits coverage to Federal employees and to relieve OPM of administrative costs associated with contracting with a number of comprehensive plans. Based upon its findings, the review recommends that Congress decide whether continuation of a comprehensive medical plans network is appropriate. If it is determined that continuation is appropriate, legislation should be enacted that would detail financial, admission, and administrative requirements to be applied to this unique health care delivery system. The review also recommends that pending congressional action, the Director of OPM should (1) improve monitoring to ensure that FEHB program requirements are applied to all comprehensive plans in networks, (2) develop an alternative to the present uniform rate system that is more closely tied to prevailing local costs in individual plans' service areas, (3) terminate from the Network plans that do not individually qualify for admission to the FEHB program, and (4) arrange for the orderly transfer of enrollees in terminated plans to other FEHB program plans. A table is provided of the characteristics of comprehensive plans in OPM's network experiment during 1979. (Author abstract modified)
care plan and the removal of legislative and regulatory obstacles to the formation of competing plans in private and public health benefit programs. It presents legislative language defining health care plans in broad terms to encourage effective competition. In addition, it presents language explicitly defining possible arangements and practices of health care plans permitted under this definition which are presently prohibited either in Federal or in many State laws. This language could serve in committee reports to establish legislative intent. It could also function in either Federal or State legislation to supercede contrary laws or make Federal funds conditional on State repeal of contrary laws. Finally, a proposal is presented to make cost regulation complement and encourage competitive forces rather than inhibit them as is now the ease. This would be done by exempting competitive health care plans from cost regulation since these plans operate under effective competitive conditions. Subjecting them to public cost controls is unnecessary, superfluous, and inhibitory. Cost regulation would continue to apply to traditional providers where the absence of effective competition makes it necessary. Twelve notes are given. (Author abstract modified) Descriptor(s): Prepaid plans, Present legislation/regulations, Policy initiatives, Competition/interaction among third-party payors.
659. On Having Your Cake and Eating It Too. Econometric Problems in Estimating the Demand for Health Services. Joseph P. Newhonse, Charles E. Phelps and M. Susan Marqnis. Rand Corp., Santa Monica, CA 90406 RAND/R-1149-1-NC National Center for Health Services Research and Develop-
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ment, Hyattsville, MD. Oct 1979, 40 pp. Availability: Rand Corp., Santa Monica, CA 90406. This report reviews the econometric literature on the price (insurance) elasticity of demand for medical care services. Because the econometric literature contains inconsistent estimates of the demand elasticities, the report considers the sources of these inconsistencies and quantifies their magnitude. First, the systematic dependence between the price variable and the error term, arising when the insurance policy contains a deductible, is analyzed. Second, three sources of systematic error are identified in the own-price variable. Problems caused by aggregation are then examined in terms of aggregation across services, the effects of instability, and the appropriateness of data aggregated across individuals. Finally, the cross-price variable and use of nominal price variables are discussed. It is concluded that the problems encountered in the studies reviewed here are due to the restrictive nature of available data and cannot be remedied short of gathering more appropriate data. A method of estimation is recommended for determining demand elasticities in the range of coinsurance from zero to 25 percent. The method uses various data sources and different techniques from the ones reviewed here. Tables and figures are included. Appendices contain material on specific problems in three studies and related technical data. A 34-item bibliography is provided.
Descriptor(s): Demand/utilization ductible/coinsurance, Limitations party coverage.
of health care programs, Deon coverage, Impact of third-
sponsored prepaid group practice. Opposition by the private, solo practice sector of the community to this new mode of medical practice was considerable. Since 1969, with the introduction of universal health insurance in Ontario, the cost and benefit differences between solo and group practice medical care have been eliminated. Although actual clinical records were not available for analysis, the survey found essentially the same patterns of health care organization and use after universal health insurance as before. The essential differences between solo and group practice appear to have persisted, even if they are somewhat diminished. The insurance mechanism in Ontario seems to have adapted itself to the existing prepaid (capitation) and fee-forservice systems. By instituting the universal health insurance system, complete coverage of the population has been assured, but the organization of services and the patterns of consumer use characteristic of these systems of medical practice have not undergone major change. The lesson may be that it is not possible to alter fundamental aspects of a health care delivery system through change in the financial mechanism and 18 references are provided.
alone. Tabular data
An earh'er version of this paper was presented at the Annual Meeting of the American Sociological Association in Montreal, Quebec, in August, 1974
Descriptor(s): Funding/financing of health care programs, Outcome/evaluation of quality assurance, Comparisons regarding foreign health policies, Evaluations/outcome of health care programs.
661. On the Cost of National Health Insurance in Quebec. 660. On Paying the Fiddler to Change the Tune. Further Evidence From Ontario Regarding the Impact of Universal Health Insurance on the Organization and Patterns of Medi. cal Practice.
Gordon H. DeFriese. 1975, 32 pp. A vailabihty: Milbank Memorial Fund Quarterly/Health Society v53 n2 p117-148 Spring 1975.
and
Selected evidence from a 1973 household interview survey in Sault Ste. Marie, Ontario (Canada) in 1973 is compared to previously published data from a similar study conducted under the sponsorship of the World Health Organization in 1967-68 to determine what changes may have occurred in the pattern of medical services use and consumer satisfaction in this community since the enactment of Ontario's universal health insurance plan. Sault Ste. Marie is the site of the first Canadian consumer-
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Lee Soderstrom. 1978, 7 pp. Availabib'ty.. Inquiry v15 n3 p284-290 Sep 78. This article is in rebuttal to an earlier article which is to exaggerate the cost consequences of public financing of believed physician services in Quebec, Canada. The large cost increase attributed to medicare reflect special circumstances which did not exist in other Canadi,'m provinces at the time and which do not presently exist in the United States. Data show that the increase in total expenditures in 1971 reflect primarily the record increase in average expenditure per physician, although there was also a record rate of increase in the number of physicians that year. The increase in the number of physicians can in part be attributed to the attractiveness of relatively higher incomes resulting from medicare. However, other contributing factors include the elimination or the citizenship requirment for licen-
Health Care Programs
sure of foreign-trained physicians, medical school expansion the late 1960's and early in 1970's, and even data problems. That fact that large increase in physician numbers cannot be attributed solely to medicare implies, in turn, that part of the reported increase in total expenditures cannot be attributed to it. The Quebec experience should not be used to judge what would happen to costs in the United states under universal public financing of physician services. Specifically, the difference in coverage (about 49 percent of Quebec's population compared to 80 percent in the United States) suggests that the resulting cost increased in the United States would be much lower than those in Quebec. Finally, in other provinces, where insurance coverage was more extensive and the physicians did not forcefully agitate against medicare, the initial cost increases were not as great. Tabular data and 17 references are appended. Descriptor(s): Supply/availability of services, Health care cost trends/projections, Participants in health care programs, Physicians, Comparisons regarding foreign health policies.
662. On the Rationing of Health Services and Resource Availability.
Bernard S. Friedman. 1978, 19 pp. Availability: Jnl. of Human Resources v13 Supplement p5775 1978. The rationing of health services is discussed and illustrated by a model of a physician's behavior, which shows why physicians able to induce demands would not raise prices to equilibrating levels. A theoretical model of rationing should be consistent with existing evidence on delays, disequilibrium, and access to care. The model discussed in this paper has a foundation in the mutual advantages of a long-term association between an individual client and physician, and is in effect, an implicit contract for rationing with predictable results. The usefulness of a trusting relationship between doctor and patient has been discussed, but little testing of the implications of an implicit contract for rationing has been conducted. Specific advantages of an implicit contract must be proposed, and some evidence that doctors act to preserve a long-term association must be offered. Evidence of nonprice rationing, either temporary or persisting, should have specific characteristics predicted by the model. An important criterion of the model is that it be capable of producing the sort of cross-sectional "availability effects" found in econometric research. In considering the optimal availability of physicians, the study found the rationing model to be promising. With respect to aggregate constraints on physician services, it remains unclear
whether price regulation is inferior to entry restriction. According to introductory price theory, the two are basically equivalent, and this model suggests that neither pure alternative is sufficient. Footnotes, tables, and 22 references are provided. (Author abstract modified) Descriptor(s):
Supply/availability
of services, Physicians.
663. Opening Up the Health System. Public and Private Sectur Friction. National Journal, Washington, DC 20036 1980, 85 pp. Availability: Government Research Corp., Washington, 20036.
DC
This publication is an edited transcript of conference: proceedings held on June 7-8, 1979, in Washington, D.C., concerning public and private sector friction in the health system. Speakers at the opening general session discussed competition versus regulation from the viewpoints of the Federal Trade Commission and State and Federal governments. Two new chairmen of subcommittees that deal with health care in the U.S. House of Representatives discussed current issues of health delivery, cow._rage, and costs. Encouraging cost-consciousness among providers, consumers, and payers through new incentives was the topic of a midday address. Working groups concentrated on the future of hospital cost containment, the costs and benefits of the teehnology explosion, the relationship of planning and competition, and the merits and drawbacks of Congressional proposals for catastrophic health insurance legislation. During the final session, speakers discussed the likelihood of national health :insurance, the Government's role in health care financing, and the successful development of a competitive health care market in the Twin Cities area (Minnesota), as well as the lessons to be learned from this experience by the rest of the Nation. Illustrations are provided" Proceedings of the Fourth Annual Leadership Conference Health Poh'cy, Washington, DC, June 7-8, 1979.
on
Descriptor(s): Cost containment efforts, Economic/commercial influences, Funding/financing of health care programs, Policy initiatives, Policy/changes re health care.
664. Ordering Social Objectives. National Health Service and National Health Insurance as Policy Options in Organizing the Medical Care System.
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George A. Silver. 1978, 8 pp. Availability: Yale Jnl. of Biology and Medicine v51 n2 p177184 Mar/Apr 78. This article examines both national health service (NHS) and national health insurance (NHI) and discusses policy implieations for their implementation. For many years, a sharp distinction was made between NHS and NHI on the basis of payment and program focus. First, NHS was def'med as a program essentially based on congressional appropriations (general revenue), while NHI would be based on premiums largely derived from the insured. Second, NHS guaranteed service, while NHI guaranteed only payment for services rendered. This distinction was later extended to include differences in response to resource needs, changing task descriptions and personnel assignments, more equitable redistribution of manpower, centralized administration, and consumer participation. In general, if the goal was equity, NHS seemed more responsive than NHI. However, in recent years the approach to NHI has been moditied in response to criticism as well as to increasing recognition of changed needs. Proposals for NHI, like the Kennedy-Corman bill, have become more like proposals for an NHS. In short, the difference today is largely one of immediate as opposed to eventual transformation of the medical care system into a social instrument aiming to achieve equity. The major disagreement is whether the present medical care system lends itself to modifications to achieve that end. Policy options appear to either continue in the present system with some constraints; recognize that the ultimate social objective of true equity, dignity, and equality will not be met; or to overturn the system altogether, guaranteeing equity but risking the very real accomplishments of technical excellence. The debate should not be and is not, between NHS and NHI, it is between equity and inequity. Ten references are appended. (Author abstract modified) Modi_ed version of this paper was presented at the American Public Health Association's Annual Meeting, November 1, 1977, Washington, DC
A vailability: InterStudy,
Excelsior, MN 55331.
This report describes results of a survey designed to provide a systematic overview of planning, development, and operational experiences which would support the technical assistance efforts and add to the body of knowledge about group practice health maintenance organizations (HMO's). Group practice HMO's include HMO's in which physicians are organized as a physician partnership, staff, or a network of group practices. Individual group practice associations were not included in the survey. Survey questionnaires were mailed to all known group practice HMO's. The questions focused on description of the plan, preoperational and startup issues, utilization patterns, method of physician reimbursement, controls on utilization, relationships with hospitals and other physicians, and an evaluation of problems and overall success. The final study sample consisted of 83 HMO's categorized either &snewly established groups or preexisting fee-for-service groups. Generally, the newly established groups appear to have been more successful in achieving low levels of hospital utilization than have the fee-for-service groups. The HMO's finance their startup activities in several ways. Internal funds and/or loans were most often used by the plans created by preexisting, fee-for-service medical groups, while private grants were used exclusively by plans for which medical groups were set up. As might be expected, when preexisting groups are enlisted to join a HMO, less time is required for them to become operational. The HMO's sponsored by preexisting medical groups and those in which preexisting groups were enlisted broke even the fastest, usually in 2 years or less. In addition, doctors in preexisting group practice HMO's are more frequently at fmaneial risk for hospital utilization and referrals to specialists than are physicians in newly established groups, many of which are group models. Tables, footnotes, and appendices giving lists of survey respondents and the survey instruments are included.
Descriptor(s): Prepaid plans, Funding/financing of health care programs, Comparisons of health care programs, Reimbursement.
Descriptor(s): Supply/availability of services, Policy initiatives, National health insurance (NHI), Comparisons of health care programs. 666. Overview of Health Insurance
665. Overview of Group Practice March 1979.
HMOs.
Linda Krane Ellwein and Lenore Kligman. InterStudy, Excelsior, MN 55331 Sep 1979, 43 pp.
!-300
Survey Results,
Study Publications.
Joseph P. Newhouse and Rae W. Archibald. Rand Corp., Santa Monica, CA 90406 Department of Health, Education, and Welfare, Washington, DC. Nov 1978, 61 pp. Availabih'ty: Rand Corp., Santa Monica, CA 90406.
Health Care Programs
This overview of health insurance study publications contains abstracts of papers that were based on a grant to analyze the demand for medical care using existing data and to assess the desirability and feasibility of a social experiment in medical care financing. The first section contains the nonexperimental research that has been completed to date; papers related directly to the experiment are abstracted in the second section. The report concludes that full coverage of hospital services is likely to cause little change in demand but that full coverage of ambulatory services will increase demand markedly. It has also been found that above a certain point, further increases in a deductible impose risk without a real change in demand; that demand is quite responsive through an intermediate range of deductibles; and that family rather than individual deductibles are preferable if administrative considerations are ignored. In addition, the size of existing insurance markups suggests that most individuals would not buy supplementary insurance to cover a moderate-size deductible ($50 to $200 per person per year). The report also found that higher income classes benefit more from the medical deduction despite the higher absolute amount of the deductible; that an almost fully insured market will not behave like a competitive market but rather will show a faster ra:e of price increase; that the most important element in patient satisfaction with medical care is the conduct of the physician; and that individuals in areas with more resources did not exhibit better measures of health, although individual characteristics (such as age, income, and education) did explain variation across the population. (Author abstract modified)
Descriptor(s): Private health care plans, Plan design/program provisions (under health plans), Deduetible/coinsurance, Funding/fmancing of health care programs, Policy initiatives, Demand/utilization of health care programs, Hospital services, Trends in health status.
power to control physician malpractice, peer review; economic incentives; and public and private controls in hospitals are discussed. The legal profession and its role in exploiting the crisis are evaluated and such remedies as no-fault and the supposed venality of contingency fees are analyzed. Both proposed and enacted "reforms" are felt to be either ineffective or destructive. Finally, the book analyzes the least-understood and least-publicized part of the malpractice crisis, the insurance system. A review of the insurance industry and its relation to malpractice highlights the efforts of the American Medical Association and the National Association of Insurance Commissioners to hide actual costs and profits of medical malpractice insurance. The timing and abruptness of the malpractice crisis of the 1970's resulted more from the economic insecurity of the indtLstry as a whole than from factors strictly related to malpractice. The emergence of the group plan as the dominant form of malpractice insurance coverage for both individual practitioners and institutions has several significant ramifications. First, it gives the group which sponsors the plan an advantage in recruiting members and exercising influence. Second, the monopoly position enjoyed by a particular insurance company puts physicians at its mercy as illustrated by the practices of the Argonaut Insurance Company. Rate-making and the failure of State regulation, the holding company phenomenon, and the possibility of Federal intervention are also discussed. Regulatory controls are discussed in terms of the State response to the crisis, the joint underwriter association (JUA), and the shifting of risk. Captives, physician or hospital-owned mutual companies which often "capture" the insurance market; self-insurance; and no insurance alternatives are examined. Excerpts from Gonzales v. Nork, notes on the text, and a subject index are appended. (Author abstract modified)
Descriptor(s): Non-employment related plans, Physicians, Policy initiatives, Economic/commercial influences, Economics of third-party payors.
667. Pain and Profit. The Politics of Malpractice.
Sylvia A. Law and Steven Polan. 1978, 305 pp. Availability: Harper and Row Publishers Inc., New York, NY 10022.
This examination of the politics of malpractice focuses on the medical, legal, and insurance systems' roles. The section on the medical system discusses the maldistribution of malpractice; the nature, extent, and impact of chronic substandard practice; the effectiveness of State disciplinary procedures; and methods of professional self-regulation. Hospitals' positions, including their legal responsibility for the quality of medical care and their
668. Participation
of Private Practice Dentists in Medicaid.
John E. Kushman. California Univ., Davis, CA. 1978, 9 pp. Availability: Inquiry v15 n3 p225-233 Sep 78.
This paper presents evidence from individual practices on the participation of private dentists in Medi-Cal, the California version of medicaid. Dental services are available to all Medi-Cal eligibles primarily through fee-for-service private practices, while a minority receives services through prepaid health plans.
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A model of profit maximization is developed and used in this paper to interpret data on participation by practitioner age, location, specialty, and size of practice. Although the method is opposed by the American Dental Association's Task Force on National Health Insurance (NHI), fee schedules are contemplated in some NHI proposals. The evidence presented in this study shows how the participation of dentists varies under a statewide fee schedule that consistently lags behind fees outside the program. Twenty percent of the private practice dentists in the State would refuse treatment to at least some new welfare patients, and 12 percent would exclude them while taking new private patients. It cannot be analytically determined whether or not participation is sufficient, but the empirical evidence shows that lagging reimbursement rates can be a substantial barrier to the program goals. The analysis suggests that in California, a State with a relatively large number of dentists, the major variations in participation were among dentists in an area rather than between metropolitan and nonmetropolitan counties. The pattern of results for individual practitioners shows that participation is predictably sensitive to variations in demand and costs, Policies which reduced private demand, such as water fluoridation or overall increases in the number of dentists could be expected to increase participation. Similarly, policies which reduce costs, such as the introduction of expanded duty dental assistants and the growth of non-solo practices, would increase participation. The use of a fixed statewide fee schedule which lagged far behind private fees tended to concentrate medicaid services in providers who were young, in non-solo practices, or in specialities in relatively abundant supply. These results should also serve as a general warning against simple but inflexible fee schedules tbr other types of Medi -- cal providers. The investigation also found direct and indirect evidence that non-solo practice yields important economies of scale for general dentists but not for specialists. The results suggest that private demand, productivity, and implicit wage rates are significantly less for younger dentists. Over 20 reference notes and tabular data are appended. (Author abstract modified) Presented to the Southern Economic Association, New Orleans, LA, November 3, 1977. Giannini Foundation, Researck Patx;r No. 474. Descriptor(s): Demand/utilization Supply/availability of services, Physicians
of health care program',;, Dental services, Medicaid,
669. Patient Outcomes in Three Alternative Settings. Janet B. Mitchell. Abt Associates, Inc., Cambridge,
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MA 02138
Long-Ternt Care
Veterans Administration, Washington, DC. Dept. of Medicine and Surgery. Apr 1977, 27 pp. Availability: Abt Associales, Inc., Health Care Systems Area, Cambridge, MA 02138. Three types of Veterans Administration hospital treatment programs for chronically ill patients who require extended medical care are compared: home care, community nursing home care, and hospital-based nursing home care. The home care (HC) program delivers medical care and ancillary services to the patient's own home following discharge from the acute care hospital. In the community nursing home (CNH) program, each participating hospital is given a certain number of "contract" nursing home beds by the Central Office, based upon local hospital demand. The hospital-based nursing home (HNH) program provides skilled nursing and rehabilitative services similar to those delivered in community nursing homes. This program opcrates on distinct wards with less intensive staffing patterns than those provided for acute care patients. The principal hypothesis of the study is that patients in community-based programs show better outcomes than do patients in more institutional settings, all other factors being equal. Disability measures--the extent to which patients maintain or regain previous levels of physical functioning -- were used as the study's outcome measures. The study controlled for sampte selection bias through multivariate analysis and the choice of nonequivalent control group design. Four subsamples of patients were drawn, one from each of the four selected hospitals representing different treatment program combinations. The total sample was 318 patients, each of whom were included in the followup. The study shows that most patients requiring extended medical care will be more successful in the HC program than will similar patients in the CNH or HNH programs. Community nu_:sing homes appeared to be the treatment program of choice only for patients with poor prognoses. This finding suggests that future Federal policy should encourage the development of home care programs. Tabular data, footnotes, and 22 references are provided. Discussion Paper No. HCSA-12. Descriptor(s): Hospital services, Home health services, Long term care facilities, Comparisons of health care programs, Policy initiatives, Publicly sponsored/mandated health plans.
670. Payer, Provider, Consumer. Industry Confronts Health Care Costs. Diana Chapman Walsh and Richard H. Egdahl. Boston Univ. Health Policy Inst., Boston, MA 02215 1977, 117 pp.
Health Care Programs
Availability:
Springer-Verlag,
New York, NY 10010.
This paper investigates the relationship between physicians' behavior and two critical health policy goals: (1) controlling the
This monograph is the first of a series launching an in-depth exploration of the current and potential future role of industry -- both management and labor in all private sector enterprises -as a financer of health care benefits, as a provider of health care services, and as an extremely influential "consumer" of health care. The assumption behind the series is that private industry has the capability, as an alternative to increased government intervention, to effect major changes in the health care delivery system. Industry's payer role is viewed in terms of employee health benefit expansion, the causes and effects of rising costs, and approaches to cost containment. The cost containment strategies discussed here are grouped into three categories: the costs of administering a benefit package, the use of services financed by that package, or the charges for the services used. The objectives and rationale behind each approach are briefly described and major unresolved issues identified. For example, changing the benefit package, through consumer cost sharing or cost reducing methods (i.e., health maintenance organizations), is a nearly universal strategy among large-scale payers for medical insurance. In addition, industry as provider is examined through health programs sponsored by employers or unions, their history, occupational safety concerns, and the possibilities for alternative delivery systems with industry involvement, Moreover, health planning, consumer health information, and community health are discussed as areas of concern to industry
rate of increase in the cost of physicians' services, and (2) ensuring an adequate supply of care to beneficiaries of publicly financed health programs. Four studies are summarized: an examination of variations in charges and reimbursement rates between programs and geographic areas within California; an analysis of changes in indexes of actual charges, reimbursement rates, service complexity, service volume, and revenues in both medicare and medicaid between 1972 and 1975; the development of an econometric model of physicians' price and output decisions; and a study of physicians' decisions to participate m medicaid. The project's primary data source was all claims paid by the medicare and medicaid programs during the last qrlarter of each of 4 fiscal years (1972 to 1975) to a sample of 5,003 physicians in California. The project concluded that a system which establishes a price floor like medicare or medicaid leads to an increase in average actual charges. It was recommended that the customarily prevailing reasonable (CPR) method used to determine payments to individual physicians by medicare and by many medicaid and private insurance programs be elirninated. Further, a policy should be adopted to limit increases in medicare prevailing fees to a value determined by national rates of growth in physicians' costs and incomes. Medicare's economic index is one such policy. Footnotes and 10 references art: included.
as the health care consumer. A list of conference participants quoted is appended. Notes and an annotated 28-item bibliography are provided.
Descriptor(s): Demand/utilization of health care programs, Cost containment efforts, Medicare, Medicaid, Policy iniitiatives, Comparisons of health care programs, Supply/availability of services, Medical/surgical services.
Based on a conference sponsored by the Boston Univ. Health Policy Institute, aided by grant from the Robert Wood Johnson Foundation, held in Boston, MA, June 1977. Springer Series on Industry and Health Care, No. 1. 672. Paying for Primary Care. Time for a Change. Descriptor(s):
Cost containment
efforts, Economic/commercial
influences, Voluntary initiatives, Prepaid plans, Source ofpremium payment.
671. Paying for Physician Services Under Medicare Medicaid.
and
John Holahan, Jack Hadley, William Scanlon, Robert Lee and James Bluck. Urban Inst., Washington, DC 20037 Social Security Administration, Washington, DC. 1979, 29 pp. Availability: Milbank Memorial Fund Quarterly/Health and Society v57 n2 p183-211 Jun 79.
Philip R. Lee and Lauren B. LeRoy. 1979, 3 pp. Availability: American Jnl. of Medicine v68 n3 p319-321 80.
Mar
Issues related to the proposed reform of third party reimbursement policies that affect primary care are examined. Numerous disadvantages of the current payment structure may be identifled. For example, insurance benefits for ambulatory services are less comprehensive than those for hospital services. Also, hospital outpatient departments and emergency rooms see a disproportionately large number of patients from low-income groups who have little or no insurance coverage for ambulatory services. Moreover, the higher per unit cost resulting from education programs in ambulatory settings places the outpatient clinic at
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a competitive disadvantage compared with physicians in private practice who are not involved in residency training. Current medicare, medicaid, and private health insurance policies for physician and hospital reimbursement constitute a significant barrier to controlling the inflation in health care costs and to achieving national goals with respect to access to primary care. in addition, these policies place severe restrictions on the expansion of primary care residency training programs. Finally, the failure to modify present policies of reimbursement will result in increasing efforts to regulate physicians and hospitals in terms of the costs of care and the need for services. Thus, reimbursement reforms, if they are to have an impact on the number and distribution of primary care physicians, will have to address the differentials in reimbursement among specialists, the geographic disparities in payment for equivalent services due to the policy of paying physicians on the bases of prevailing charges within narrow geographcc areas, and the bias of present hospital reimbursement policies toward inpatient services. Extending health insurance coverage to all ambulatory care services, a negotiated fee schedule, or linking hospital reimbursement with policies regulating the number and distribution of residency positions are possible reform options. Five references are included,
that produces medical care at the lowest possible cost. Basic approaches to reform may be divided into the four categories of budget review, setting a maximum rate of increase, payment based on relative performance, and placing a cap on hospital expenditures. Although experiments have been conducted with all of these approaches, any empirical evidence available relates only to short-term effects of different mechanisms. With regard to the prospective reimbur:_ement approach, several variations have been tested in Connecrficut, Maryland, Rhode Island, New Jersey, and Indiana. The second approach involves choosing a rate that is to be the maximum allowable rate of increase in reimbursement for any hospital. Statistical analysis shows that the New York State experience with this approach, while appearing to reduce costs, cannot be deemed a success. Under the third approach, the individual hospital is paid on the basis of how its performance compares with that of other hospitals. The Blue Cross plan of Western Pennsylvania has extensively experimented with reimbursement along these lines. Placing a maximum allowable rate of increase in total expenditures for all hospitals in an area constitutes the final approach. None of the four proposals is without significant drawbacks. Twenty-seven references and three tables are included.
Descriptor(s): Reimbursement, Funding/t'mancing of health care programs, Impact of third-party coverage, Limitations on coverage, Outpatient facilities.
Descriptor(s): Health care costs, Third-party payors, Private health care plans, Publicly sponsored/mandated health plans, Hospital services, Inpatient facilities, Reimbursement, Funding/ fmancing of health care programs, Policy/changes re health care.
673. Payment for Hospital Services. Objectives tives.
and Alterna674. Pediatric Care. Charges, Payments and the Medical Set-
Paul J. Feldstein
and John Goddeeris.
ting.
National Council of Community Hospitals, Washington, DC. Robert Wood Johnson Foundation, Princeton, NJ. 1977, 17 pp. A vatTability: Health Care Management Review v2 n4 p7-23 Fall 1977.
Daniel C. Walden and Louis F. Rossiter. Nov 1979, 27 pp. Availability: National Center for Health Services Research, Hyattsville, MD 20782.
Alternatives to present reimbursement methods are discussed in relation to reducing hospital costs. In general, hospital costs have been rising at rates that are higher than the Consumer Price Index, and it is suggested that cost-based reimbursement is at least partially responsible. The bulk of hospital payments are made by third parties who generally pay hospitals on the basis of reasonable costs or customary charges. Interest groups that influence hospitals with regard to reimbursement proposals include the Federal and State Governments, Blue Cross, commercial insurers, industry, unions, uninsured consumers, and physicians. Ideally, hospitals should be reimbursed in a manner that provides them with incentives to operate within a system
Charges and payment for pediatric care are analyzed by the characteristics of children, including color, education of parents, residence, and region of the country. Discussion also focuses on whether children with particular characteristics are more or less likely to receive care in any medical setting, or in doctor's offices, hospital outpatient departments, or emergency rooms. The data used are from the first quarter of 1977 of the National Medical Care Expenditure Survey, particularly information from household respondents during the first three interviews. During the first quarter of 1977, over 60 percent of the visits made by children were to doctor's offices; 5 percent were to hospital outpatient clinics; and 5 l_rcent were to hospital emergency
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Health
Care Programs
rooms. The average total charge for the visits in the doctor's office was $19.47, compared to $41.16 in hospital emergency rooms. The percent of visits where the family paid the entire charge varied by setting; the family was the only payer for 58 percent of the visits in the doctor's office, 16 percent in the hospital outpatient clinic, and 28 percent in the hospital emergency room. The percent of visits where medicaid paid the entire charge was highest in hospital outpatient clinics (24 percent), Over 40 percent of the children had at least one visit in the first quarter. There were some differences among children of different characteristics in the average charge, percent paid by source, and likelihood of visit. The largest differences were between children of the two color groups and among children from families of
discharge diagnosis, instead of the traditional disaggregated feefor-service approach. Primary research objectives were to test the effects of PCR on inpatient hospital use and to determine any associated changes in medical care costs. Comparisons with cross-sectional and longitudinal control groups indicate some modest favorable changes in average length-of-stay, with concomitant potential cost savings. However, the effectiveness of this method of reimbursement varies significantly from one hospital to another. In general, the PCR method can be expected to result in higher levels of Blue Shield payout to physicians. Tables and 39 references are included. Detailed data are appended. (NTIS abstract modified)
different educational levels. Of white children 43 percent had at least one health care visit compared to 30 percent of the black
Research Report
children. The likelihood of at least one visit in the first quarter rises with household educational level. The child's age was not related to the percent paid by source among the medical settings examined, but it was related to the likelihood of a visit; children in the youngest age group were most likely to have had at least one visit. Footnotes and tabular data are provided.
Descriptor(s): Cost/benefit analyses, Demand/utilization of health care programs, Service benefit plans, Inpatient facilities,
Prepared for presentation at 107th APHA Annual Meeting, Health Administration Section, New York City, November 8, 1979.
Descriptor(s): Demographic features of population, Demand/ utilization of health care programs, Participation in health care programs, Inpatient facilities, Outpatient facilities, Medical/surgical services.
675. Per-Case Reimbursement for Medical Care. Final Report. Gene A. Markel. Pennsylvania Blue Shield, Camp Hills, PA 17011 National Center for Health Services Research, Hyattsville, MD. Mar 1977, 64 pp. Availability: National Technical Information Service, Springfield, VA 22161, PB-267 496. The Per-Case Reimbursement (PCR)project was an experimental program conducted by Pennsylvania Blue Shield (PBS) to test an alternative method of reimbursing physicians for in-hospital medical care services. Under the per-case reimbursement concept, the primary physician in charge of an inpatient medical case received a prospectively determined single payment for each case, with the amount of payment depending on the reported
Physicians,
77-5.
Reimbursement,
Medical/surgical
services.
676. Perceived Health Insmnmce Coverage. Gall R. Wilensky and Daniel C. Walden. 1978, 5 pp. A vaJlability: National Center for Health Statistics, ville, MD 20782.
Hyatts-
This study identifies the characteristics which predict whether individuals accurately perceive the types of medical care for which they are covered and the depth of that coverage. Knowledge of the perceived level of coverage for a non_hospital physician visit is also estimated jointly with the probability that the individual has an ambulatory visit during the approximate period January to June 1977. Study data are derived from the National Medical Care Expenditure Survey, a panel design survey of 13,500 households. Emphasis throughout the study is on perceived coverage and level of coverage rather than on actual coverage or on relative plan knowledge. Data analysis shows that people who are older, white, more educated, and who pay a greater dollar value for their premiums tend to think they know whether or not they are covered for various items of care. Perceived health status and marital status also tend to be important. None of the models used to predict perceived coverage work well. It is possible that a linear model which was the basis for the models presented, may be unsuitable, that there may be missing variables and missing interaction terms, and that measurement of perceived health coverage is so abstract that it is subject to random responses. It is not clear how perceptions of health insurance should be measured, but further analysis of the data will continue. Five references and three tables of model results are provided.
1-305
Reprinted t)-om the 1978 S_ial Statistt'cs Section Pn_'ecdtngs the American StatAtical Assc_:iation.
of
Descriptor(s): Participants in health care programs, Plan design/program provisions (under health plans), Methods of payment determination.
Descript,_t(s): Dcmand/utiiization of h_-,ilih cal _ pr..,_ v,,m:,. Prcpaid plans, Compalisons of hca!th c,_' _J,_-,cam.,. ;,l.; _ic.'_d. Source of premium payment.
678. Personal Responsibility. fective Health.
Key to Effective and ( ,_,t-Ef-
Donald M. Watkin. 677. Perceptions merit.
Emil Berkanovic, san Schwartz.
of Medical Care. The Impact of Prepay-
Leo G. Reeder, Alfred C. Marcus and Su-
1974, 139 pp. Availabihty: D.C. Heath and Co., Lexington,
MA 02173.
This study attempts to assess the impact of a health maintenance organization (HMO) on the experience of medical care from both the patients' and the physicians' points of view. The HMO studied is the Physicians' Association of Clackamas County (PACC), Oreg. In 1969, PACC contracted with the State to administer medical care under medicaid on a prepaid basis for all welfare recipients residing in Clackamas County. The impact of this administrative mechanism with respect to medical care and attitudes is assessed. In evaluating the problems of access and acceptability to medical services among medicaid recipients in PACC, comparisons were made with medicaid recipients in Washington County. Information was collected through interviews and questionnaires for physicians and recipients; completed interviews totaled 296 and 297 for recipients, in their respective counties, and 25 for physicians in each county. Data indicated little difference between the prepaid and fee-for-service systems regarding problems respondents encountered in seeking access to medical services. Washington County recipients were slightly legs satisfied with their health care; although over 80 percent of the respondents from both counties indicated that they were satisfied. In general, the data were consistent with the conclusion that prepayment had little effect on medicaid recipients' experiences with medical care. Further, the data also suggested that physicians working in a prepaid setting did not experience the delivery of medical care to welfare patients much differentl), than physicians practicing under fee-for-service. It is therefore concluded that prepayment will have little impact on the organization of medical care. In addition, the findings also suggest that there are noneconomic barriers to the use of services which are not being addressed in either national health insurance or HMO legislation. Approximately 50 tables are included, and questionnaires and a bibliography are appended to the study.
t-3oo
1978, 7 pp. Availability=" Family and Community 78.
tiealth
vl nl pl-7 Apr
Convincing leaders and, through them, convincing society that personal responsibility for health is cost-effective and attainable, and preparing primary health professionals to guide citizens in persomd health care respo_l:dbilities are discussed. American society is searching for solut:,ons which will satisf_ public demand for quality health care while containing cost. Among proposed solutions, one in particular is rational and of proven effectiveness: individuals' acceptance of lifelong personal responsibility for their health. In implementing a plan for cultivating population groups' assumption of personal responsibility t\_r good health, charismatic, knowledgeable leaders must be solicited to motivate population groups to change destructive and lax health habits. The task of recruiting such leaders lies with those few health professionals who have collected information indicatiug that high levels of compliance with personal responsibility for health can be attained in population groups and that with this attainment, the effectiveness and cost-effectiveness of health can be assured. Writing letters to strategic professionals and public officials, participation in public hearings before legislators and executives representing governments at all levels, and presentationsbefore professional societiesandorganized pressure groups are some of the ways leadership in personal health responsibility can be nurtured. The role of the front-line health professional is critical in providing authoritative guidance in personal health care. Continuing education for such professionals is neces_ry to keep them current on personal health care issues and help them avoid misinformation. Three references are provided. Descriptor(s): vices.
Preventive _ervices, Providers
of health care ser-
679. Personnel Leadership in Action. Doing Something About Health Care Cost Containment. 1979, 6 pp. Availability: 79.
Personnel Jnl. v58 nl 1 p751-754,757,811
Nov
Health Care Prog_a_:,.
This report which is based on interviews with program leaders, examines two innovative programs in Milwaukee, Wis. and a comprehensive evaluation project in Cleveland, Ohio. An ad hoc committee of Milwaukee personnel directors was formed 2 years ago to coordinate planning for group action on health care costs, In addition, the Milwaukee Industrial Clinic opened a new facility within easy reach of hundreds of companies with minimal health facilities, with the objective of controlling costs and ralsing the standards of health service. In Cleveland, the Coalition on Health Care Cost Effectiveness grew out of a Case Western Reserve University workshop which included a group of personnel professionals concerned with health care costs. All three projects attack the same problems but, with different strategies, One emphasizes employee well-being as a corporate responsibility, and shows employer concern by sponsoring weight loss groups, nutrition sessions, and an athletic club program. Resolving the issue of pregnancy disability as defined by businesses is emphasized in another program. The vice president of a Milwaukee company involved in efforts to reduce health care costs suggests that employers must (1) openly support quality health care but not at any cost, (2) be willing to speak out constructively to all segments of the health care system, (3) educate employees not to abuse health care programs, and (4) show true appreciation for superb private health care capability. The Cleveland coalition is focusing on reducing the inappropriate use of facilities and services, developing and implementing educational programs, improving hospital management, and reducing excess beds.
those components in the physical, socioeconomic, and family environments that form the milieu for the development of disease and that are largely outside individual control. Two potentially effective approaches to disease prevention that are st rongly linked to behavioral factors are discussed: (1) changing conditions in the sociocultural environment that encourage unhealthful behavior, and (2) changes in individual behavior. These approaches are analyzed in the areas of nutrition, physical activity, psychosocial stress, tobacco use, alcohol and drug abuse, accidents, and violence. The paper describes the various disease categories that bring people into contact with the health care system and explores the complexities of developing comprehensive prevention programs. The paper also discusses health education and two specific prevention services packages: the Lifetime Health-Monitoring Plan, an age-specific, goal-oriented package of preventive services for each of 10 age groups; and the Health Hazard Appraisal approach which uses precursors of premature death both as a prognostic tool and as identifiers of appropriate interventions. A special section focuses on including preventive services under national health insurance (NHI), reviews the lack of coverage for preventive services under the present health insuranee system, discusses the prevention services an NHI proposal might include, and details the preventive care aspects of prototype NHI legislation. None of the six major NHI proposals had a well-developed prevention component, including public health programs, and no attempt had been made to set specific prevention goals and priorities. References, charts, and tabular data are included.
Descriptor(s): Cost containment efforts, Source of premium payment, Voluntary initiatives, Preventive services,
Descriptor(s): National health insurance (NHI), Trends in health status, Preventive services, Policy initiatives, Exclusions from coverage.
680. Perspectives on Health Promotion tion in the United States.
and Disease Preven681. Perspectives on Medicines in Society.
Elena O. Nightingale, Mary Cureton, Vicki Kalmar and Michelle B. Trudeau. Institute of Medicine Div. of Health Promotion and Disease Prevention, Washington, DC 20418 IOM-78/001
Albert I. Wertheimer and Patricia J. Bush. 1977, 584 pp. Availability: Drug Intelligence Publications, IL 62341.
May 1978, 244 pp. Availability: National Academy of Sciences, Institute of Medicine, Div. of Health Promotion and Disease Prevention, Washington, DC 20418.
This book considers the social, behavioral,
This paper, an overview of health promotion and disease prevention in the United States, is intended to aid the Institute of Medicine in program development and to furnish an information base for others interested in the field. It begins by discussing
Inc., Hamilton,
and professional
as-
peels of drug use. It provides a general perspective into the past and present use of medicines in our society; treats the medical use of medicines and related contemporary issues; and discusses drug abuse and the strategies employed to counteract it and its effects. Medicine use is examined from the point of view of the various allied health professions, the consumer, and some of our institutions. In addition, the distribution and availability of medicine is explored through a discussion of the pharmaceutical
1-307
industry, the role of government, the effect of payments schemes, and a review of drug and medicine services around the world. In the final section, a look is taken at the future biological and social problems of drug use. The importance of cost control is emphasized in a chapter that assesses prospective and retrospective drug utilization review and concludes that such review can decrease the expenditures for prescription drugs by at least 20 percent. A chapter on dnig payment mechanisms describes the extent of population coverage, methods of reimbursing either the consumer or the vendor, cost control methods such as benefits
ly on their expectations about the flexibility of reimbursement in terms of its adjustment to changes in area prices over time. The fact that physicians in nonmetropolitan areas are more likely to take medicaid patients than those in metropolitan areas suggests that the medicaid program provides private sources of medical service in rural areas where alternative public facilities are not likely to be available. Tabular data and footnotes are provided. Appendices present additional data and discussions of data sources and validity of the data.
for prescribed drugs only, drug utilization review and control, controls on drug taking, and methods of cost control in national health insurance proposals. References are provided for each chapter, as well as charts, tabular material, and a genera_ subject index.
Descriptor(s):
Descriptor(s): Pharmaceutical services, Cost containment efforts, Demand/utilization of health care programs, Melhods of payment determination.
682. Physician
availability
Medicaid,
Physicians,
Reimbursement,
Supply/
of services.
683. Physician and Cost Control. Edward J. Cards, Duncan Neuhauser and William B. Stason. 1980, 180 pp. A vailabilitv: Oelgeschlager, Gunn and Hain, Publishers, Inc., Cambridge, MA 0213 L
Acceptance of Medicaid Patients. Physicians cart reduce or prevent the rising costs of medical care
Larry M. Manheim, Philip J. Held and Judith Wooldridge. Mathematica Policy Research, Inc., Princeton, NJ 08540 Bureau of Health Manpower_ Hyattsville, MD. Aug 1978, 38 pp. A vailability: Mathematica NJ 085.,*0.
Policy Research,
Inc., Princeton,
This research report examines the extent to which physicians accept mtxiicaid patients and relates the acceptance of medicaid patients to the reimbursement received from medicaid. It also briefly outlines the major features of the medicaid reimbursement procedures, the expetted effects of Medicaid reimbursement on physician acceptance of medicaid patients, the data used in the analysis, and the results. The data used to estimate the effects of medicaid reimbursement levels on physician acceptance of medicaid patients came from the 1975 Physician Capacity Utili_ation Survey. Available from this data set are observations on general practitioner averages for 258 areas, Long-run acceptance of medicaid patients is measured by the percent of the physician's patient load that consists of these patients. The report concludes that the generosity of medicaid reimbursement relative to area fees appears to be an impo "rtant determinant in physician acceptance. The report found a lm:ge difference between the estimated effect of medicaid reimbursement on medicaid patient load when ordinary least squares and two-stage least squares procedures were used. This suggests that physicians' targeted medicaid patient loads may depend primari-
1-308
because they control a large share of medical care resources through test ordering, prescriptions, direct care, and admissions to hospitals. These papers review various proposals for reducing physician costs. Contributors stress three areas for attention including the physician's role in the generation of costs, developing models of behavioral change which incorporate cost awareness, and co'sI savings in the patient-physician interaction. Physicians should strive for appropriate care, not cost containment. Appropriate care involves knowing how effective specific diagnostic and therapeutic interventions really are and knowing where and by whom that ,:are is most effectively delivered. With appropriate care, quality and cost are not necessarily related. The public needs to be convinced that quality medical services are not necessarily the most expensive, and that the best medicine is sometimes doing nothing. The public also needs to know that malpractice suits wild not necessarily make better medical care and, in fact, may actually stimulate inappropriate use of medical resources in the farm of defensive medicine. Third party payers need to realize that they encourage inappropriate care with economic incentives for more diagnostic tests and more expensive settings for care. Physicians themselves need to develop appropriate use of consultations. Doctors have been eminently successful in teaching risk-effective decisionmaking and they should begin to teach cos_-effective decisionmaking. The biggest step for physicians, however, is realizing that all the billions spent for medical care are their billions, not somebody else's. The future freedom of the profession depends upon this issue. If doctors do not assume iesponsibility for the economic conse-
Health Care Programs
q_Jences of their decisions, the regulatory agencies will, and with tttat will go the profession's freedom to render what they believe to be appropriate care for their patients. An index, 11 figures, 21 ta01es, and references are provided. (Author abstract modified)
Health Care Financing Administration, Washington, DC. 1979, 12 pp. A vailability: Jnl. of Ambulatory Care Management v2 n2 pl12 May 79.
Based on a conference sponsored in part by Harvard School of Public He_dth, Center for the Analysis of Health Practices, held Decem_,er9-10, 1978.
The Physician Extender Reimbursement Experiment is a nationwide research effort conducted by the Social Security Administration, now the Health Care Financing Administration (HCFA), since 1977. The goals of the experiment are to determine the circumstances under which medicare reimbursement should be made for the services of physician assistants (PA's) and nurse practitioners (NP's), also referred to as physician extenders (PE's); and the most equitable and noninflationary reimbursement methods and amounts of such reimbursement. Major components of the study include (1) a baseline suLrveyto obtain data from all participating practices, (2) a reimbursement
Dcsc,Tptor(s):
684 Physician
Cost/benefit
analyses, Physicians.
Control of Blue Shield Plans. Staff Report.
David [. Kass and Paul A. Pautler. F_:dera_ frade Commission Bureau of Economics, Washing_on, DC 20580 ?.;ov 1979, 139 pp. :__aiIabili_y: Federal Trade Commission, Bureau of Economits, Washington, DC 20580.
experiment in which participating practices employing PE's are assigned to various methods and amounts of experimental medicare reimbursement for PE services, and (3) evaluation activities to arrive at a description of the quality of care provided in participating practices, practice costs, and onsite validation of selected portions of the baseline survey. The study found that
_d,_ repu_t contains the results of two different empirical tests conducted to determine whether physician control of Blue Shield plans might result in important differences between such plans and ti,_.'se which operate without physician influence. In the fast t_:st_fee limits were regressed against demand and supply factors along with various measures of physician control. The test found e_idence that control was associated with significantly higher physician fees. Reimbursement rates were 16 percent higher where a local medical society or other organized group of physiclans selected board members; further, reimbursement rates were, on average, 10 percent higher if physicians, regardless of their method of selection, composed 50 percent or more of a Blue Shield board. The second test found little evidence that physician control was associated with lower costs or that physician control was associated with change in claims payment speed or in error tare of claims processing. Footnotes and 45 tables are given. Five appendices contain physician fee and administrative cost results, a list of variables used in the cost and efficiency sections, a list of physician control variables from 1973 to 1977, and data sources for the Blue Shield study. About 70 references are given. (A uthor abstract modified)
practices with PE's scored higher in quality of care ratings than comparison practices without PE's. In addition, PE task skills were rated at a high level, while physician supervision of PE's in the ambulatory care practice was at a relatively low level. No significant variation appeared in the use or performance ,0f PA's and NP's. Other study results showed that average charges per visit to the patient or third party payers were lower in practices with PE's than in non-PE practices; the legal boundaries of PE practices, which vary from State to State, are continually being revised; practices with PE's provided more patient visits per $1,000 of practice costs than non-PE practices; and among those practices with PE's, solo practices saw more patients than nonsolo practices. Thus, the use of PE's in ambulatory care settings appears to be beneficial in terms of costs, providers, and patients. It is recommended that model legislation or regulatory parameters for PE's should be designed at the national level to provide guidance to States in order to minimize the diversity of current statutes and administrative regulations. Tables and one reference are supplied.
D_'scnptor(s): Cost/benefit Physicians, Reimbursement.
determination.
analyses,
Service
benefit
plans,
Descriptor(s): Cost/benefit analyses, Allied health professionals, Outpatient facilities, Policy initiatives, Methods of payment
686. Physician Glut Will Force Hospitals to Look Outward. 6ti5. Physician Extender Reimbursement
Experiment. Paul M. Ellwood and Linda Krane Ellwein.
Joseph Romm, Alan Berkowitz, Marjorie A. Cahn, Paul B. Comely and Barbara Kerlin.
1980, 5 pp. Avnilabi_'ty:
Hospitals v55 n2 p81-85 16 Jan 81.
1-309
Physician response to manpower oversupply, policy initiatives and their _mpact on community hospitals are explored in this article. There is widespread agreement that by 1990 approximately 600,000 physicians will be practicing in the United States, a projected increase of 41 percent over 1980 levels. The impact of the projected surplus on practicing physicians will be drama:tic. Under inevitable pressures, physicians are likely to act in the following ways to secure a patient base and maintain an adequate income: provide more time and services for each patient, provide more convenient access, leave or avoid areas of oversupply, affiliate with health care institutions, restrict the professional practice of others, and join or form competitive health care plans. In addition to these anticipated actions by physicians, two major policy actions are likely to emerge in response to the physician surplus: more legislation aimed at cost containment (either regulatory or procompetitive) and a reduction of public monetary support for medical education. Moreover, commum_y hospitals will probably find themselves at cross-purposes with other segments of the health care industry as the physician surplus
tions for physician licensure and finds that the variance of licensing standards across Statc._ is consistent with a consumer-demand rationale for intervention. The evidence does not imply that licer, su re :s an efficient institution or even that the levels of the standard:, are consistent with a public-interest model In particular, the study has neglected alternative goven_mental respouses a:s well as many of the costs of licensure Three alternafives _._a hcew,_.we are discussed: removal of all State intervention; State certi_l_.ation that info.qns the public about the physician's competenc}' b_tt does not [irnit entry to those above any given quality level; and retennon of a licensing system_ with removal of many _.as_s currently reserved for licensed physicians. Five tables a_d 6,_ footnotes are given. (Author abstract modified)
causes increased competition among hospitals_ Academic medical centers will seek to survive in the tight medical market by expanding and diversifying services, bringing them into direct competition with community hospitals. Finally, third party payers, already sensitive to the cost-generating effects of the surplus of hospital beds and high-priced technology, will be simulated to become even more aggressive in their cost containment ef[orts by the assumed inflationa_ impact of too many doctors. Two photographs and five references are provided.
688° Physician Migration in Response to Income Opportunities I !_der _Jniversal Health Insurance in Quebec.
Descriptor(s): tient tacilities
Based on an evaluation of the first 5 years of Universal Health Insurance (UHI) in Queb_, Canada, this study uses data that were obtained from the Quebec Health Insurance Board and determi:_es _,heextent of lzhysician migration resulting from income opportunities under UHI in Quebec. The geographic location and _he gross payments received from the board for all physicians in the province for each of the 5 years (1971 to 1975) form the basis of the migration data. Basic economic and demographic data for each medical care market area were obtained
Supply/availability
687. Physician Lieensure. American Medicine°
of services, Physician,s, Inpa-
Competition
and Monopoly
in
Keith B. Leffier. Rochester Univ, Roch_;ter, NY. Center for Research m Government Policy and Business. California Univ., Los Angeles, CA. Foundation for Research in Economics and Education. 1978, 22 pp. Avadabi]_ty: Jnl. of Law and Fx:onomics v21 nl p165-186 Apr 78.
This paper examines the regulation of the supply of physicians' services and finds that regulatory agencies do not exclusively serve a single economic interest. Section I of the paper presents evidence that physicians have received only small rents during equilibrium periods. Section II examines public interest explana-
1-310
Desc_p_or(,).
Supply/avatlability
of services, Physk:ians
Philip J. Held, Barbara H. Kehrer and Larry M. Manheim. Mathemat,_ca Policy Research, Inc., Pnnceton, NJ 08540 Jun 1979, 29 pp. A vailabdiO ,_ Mathematica Policy Research, Inc., Princeton, NJ 08540
from other sources. Additional information on the medical practices in each market area _¢asobtained in a telephone survey of the province's general practitioners. Results indicate that the period initially following the inception of UHI saw a substantial growth in the quantity of raedica! services demanded, pa_i_:tdarly in Paral areas. According to the economic theory of migration, a shift would have occurred in the geographic distribution of income potential for physici;ms, with the greatest gains likely to occur in the rural areas. I_: the first year of UHI, nonmetropolitan physicians grossed payments higher than their urban colleagues; by the end of tl-:e fifth year of UHI, the differential between rura! and urban areas had been reduced to zero for general practw,.:.ners and up to 4 percent for specialists. The observed migration of general practitioners in the 5-year period is consisten_ wi_h the reduced differentials in payments, l'hus,
Health Care Programs
payments of subsidies to physicians may be a useful policy instrument for effecting a redistribution of physicians. Footnotes, tabular data, and nine references are provided,
Descn'ptor(s): Physicians, Comparisons regarding foreign health policies, Supply/availability of services,
689. Physician Participation dence on Blue Shield.
in Health Insurance Plans. Evi-
Frank A. Sloan and Bruce Steinwald. Florida Univ., Gainesville, FL 32601 National Center for Health Services Research, MD. 1978, 27 pp. Availability: Jnl. of Human Resources Spring 1978.
that participation proportions of NHI will vary with personal and professional characteristics of the physician; participation rates will vary positively with reimbursement level; and partici. pation rates will be negatively affected if case-by-case participation is permitted, as is presently the case under medicare. Footnotes and 45 references are provided. (Author abstract modified)
Earlier version of this paper presented at the Western Economic Association meeting, San Diego CA, June 1975.
Descriptor(s): Service benefit plans, National health insurance (NHI), Impact of third-party coverage, Publicly sponsored/ mandated health plans, Supply/availability of services, Reimbursement, Physicians. Hyattsville,
v13 n2 p237-263 690. Physician Participation
in State Medicaid Programs.
Various health insurance programs, including Blue Shield, have developed arrangements whereby the physician agrees to accept the insurer's reimbursement as payment in full. Physician incentires to accept the insurer's reimbursement as payment in full are reviewed in this study. The empirical work uses data on individual physicians from a 1973 survey. The results indicate that physician willingness to accept insurer reimbursement as payment in
Frank A. Sloan, Janet B. Mitchell and Jerry Cromwell. Abt Associates, Inc., Cambridge, MA 02138 Social Security Administration, Washington, DC. 1978, 35 pp. Availabih'ty:Jnl. of Human Resources v13 p211-245 Supplement 1978.
full is sensitive to the amount the insurer pays for specific procedures and to other insurance program characteristics. Physicians who have prestigious credentials or who are located in high patient income areas are less likely to accept insurer payments as payment in full. The empirical t'mdings are used to generate policy implications for medicare and medicaid programs, for
Medicaid requires that physicians who accept medicaid reimbursement for treating a patient to accept its payment as payment in full. Policy instruments under medicaid's control are both levels of reimbursement and various administrative burdens imposed on physicians by the program. A model depicting the physician's participation decision is developed, and predictions from the comparative smiles analysis are discussed. Data came from a 1975-76 survey of fee-for-service physicians. The results indicate that high fee schedules and low administrative burdens are ways to stimulate physician involvement with medicaid patients. Results of the medicaid policy instruments and other explanatory variables on the whole lend support to the proposed model of physician behavior which hypothesized that the officebased physician's decision to accept medicaid patients reflects a mix of demand, supply, and medicaid policy factors. The results of this study imply a tradeoff between two social objectives: high-quality medicine and the availability of health services to disadvantaged groups. Tables, footnotes, and 17 references are provided. A mathematical appendix is included. (Author abstract modified)
tradeoffs between medical care quality and access, and for national health insurance (NHI). The study's results concerning manpower policy and access rather clearly suggest a tradeoff between two social objectives: Cadillac-quality medicine and the availability of health services to disadvantaged groups. For example, suggestions have been made to limit the inflow of foreign medical school graduates (FMG's) to the U.S. because they are thought to have received relatively poor training. However, the study's results suggest that lower income persons have greater access to FMG's working in office-based practice. Presumably, if the FMG's were less numerous, a larger proportion of the lower income population would use hospital outpatient clinics and emergency rooms or curtail their utilization. Findings also show that the vast majority of physicians do participate in Blue Shield when given the option, even though reimbursement levels tend to be well below prevailing fee schedules, and therefore would participate in NHI if NHI contained physician-reimbursement provisions similar to medicare's. The article predicts
Descriptor(s): Medicaid, Physicians, Policy initiatives, Methods of payment determination.
1-311
691. Physician
Reimbursement
and Hospital
Use in HMOs.
Gerald B. Meier and John K. Titlotson. InterStudy, Excelsior, MN 55331 Health Care Financing Administration, Washington, Sep i97g, 178 pp Availab£tity: InterSt_ldy
Management Center. 1978, 5 pp. Availability: New England Jnl. of Medicine v299 n2 p76-80 i3 Jul 78.
DC.
Excelsior, MN 55331.
Results are reported from an investigation of physician reimbursement methods within health maintenance organizations (HMO's) to determine what, if any, effects the reimbursement arrangement may have on the physician's use of the hospital, Data were obtained from site visits and interviews in nine HMO's together representing a variety of physician reimbursement methods. Physician reimbursement methods in the participating HMO's are analyzed, and the "degree of risk," the reimburseme_t me_hod imposed on the physician and organization, is mterpreied. Particular attention is given to identification of the incentives that the reimbursement method provided as a means to: limit inpatient hospital use. Factors which influence hospital use are determined, along with an analysis of the factors most int!uentiai m controlling hospital use and cost. Findings show that competition or the threat of competition motivates physicians to accept risk and imposes rigorous mechanisms to modii), hospital use. Furthermore the level of tinanciai_ risk investigated in the study did not directly cause physicians to lower hospital ,npatient use. Financial risk it appears, can motivate physmians to adopt more stringent control mechanisms which directly modi_ practice behavior; and peer interaction and a cost-effective orientation are the most effective modifiers of physician practice behavior. Finally, medical leadership appears to be critical to the development of peer interaction and costeffective orientation among physicians. Implications of the firMings for government policy are discussed. Appended a,re a description of the HMO selection process of the study:, a brief description of the organization and relevant characteristics of each HMO in the stndy, the site visit protocol used as a guide in collecting data for the study, and a bibliography of :56 references. Tabular and graphic data are provided.
Most diagnostic and therapeutic services are ordered by physiclans, but physicians practicing under the fee-for-service system have few incentives to contain the costs of medical care. Without such incentives, effective cost control mechanisms, such as Professional Standards Review Organizations, have produced disappointing results. However, several legal approaches might be used to increase physicians' responsibility for the cost of unnecessary services:expansionofthetortlaw, implied contract, redesign of insurance mechanisms, equitable estoppel, and informed consent. Increasing physician responsibility will require uniform but flexible detinitions of medical necessity, reliable means for predetermining the need for services, and effective penalties or incentives. A peer review system that would involve the sharing of financial risk among the physician, the hospital, the insurer, and the patient is an attractive solution which preserves the fee-for-service structure and yet gives all parties the incentive to use health care resources prudently. However, several elements are necessary for this system to work: easy access to necessary information, full and effective due process available to the physician, and sufficient lattitude for the doctor to exercise professional judgment. Past patterns can be changed by incentives rather than negative sanctions. The potential savings are impossible to estimate, but the chance for physicians to accept partial risk for the cost of unnecessary services is an opportunity to obviate the need for external regulation. Twenty-nine references are provided. (Author abstract modified)
Desc_ptor(s): Medical/surgical services, Physicians, Therapeutic services, Diagnostic services, Health care costs, Policy/ changes re health care.
693. Physician-Induced Descdptorr_): Competition/interaction among third-party payors, Prepaid plans, Hospital services, Reimbursement, Physicians, Policy initiatives, Outcome/evaluation of quahty asstJrance.
692. Physicim_ Responsibility Medical Services.
for the Cost of Unnecessary
Jonn M. Eisenberg and Arnold J. Rosoff. Robert Wood Johnson Foundation, Princeton, NJ. Pennsylvania Univ., Philadelphia, PA. National Health Can_
I-312
Demand for Medical Care.
Jerry Green. 1978, 14 pp. Availability: Jnl. of Human Resources 34 1978.
v13 Supplement
p21-
The assertion that the availability of medical resources influences the demand for their utilization is examined theoretically in this study by concentrating on equilibrium and disequilibrium models of demand for medical care. According to the equilibrium model, there is no in'tbalance between the supply of physiclans and the demand for their services with the result that
Health Care Programs
observed prices represent an equilibrium. While the market remaining in balance, however, the mechanisms affecting the balance and the behavioral assumptions under which they operate are of two types: competitive and monopolistic. Analysis shows that the neoclassical, competitive version, in which physicians adjust their quantity according to demand, rests on demandcurve and physician-choice assumptions which are ambiguous and dubious enough to render it nontestable. The monopolistic version, on the other hand, in which physicians act as rational price-setters able to manipulate the utility of their services, can support econometric tests of physician-induced demand, but not in an unequivocal manner because not all of the assumptions of all of its alternative versions can be tested with the data available, According to the disequilibrium model, market imbalances exist, and the short or supply side has the advantage in terms of price and quality of service. Although alternative specifications of the model are presented, evidence for and tests of it are inconclusive, The inability to test these models conclusively derives from the lack of available empirical evidence, especially at the micro level, Several econometric proofs, 10 footnotes, and 17 references are provided,
Descriptor(s): Physicians.
694. Physicians 1980s.
Demand/utilization
of health
reviewed carefully before it is concluded that maldistribution exists. A variety of approaches to dealing with distribution problems can allow for creativity and build upon existing resources. A second major issue affecting both medical education and health care is the disproportionately small number of minority students in medical schools. Minority enrollment application rates are low and may be caused by precollege factors. A clear delineation of purpose and a unified strategy is needed to increase minority medical school enrollments. A third problem is the emergence of new health practitioners. The issues of patient acceptance, physician acceptance, quality of care, and productivity have for the most part, been resolved, although many legal issues and reimbursement policies remain in question. The expected increase in the number of practicing physicians need not prevent the utilization of these new practitioners, but doe,s make it necessary to reconsider their future role. They now lack flexibility mainly because legally they must practice under a physician's supervision in most cases. The appropriate use of the new health practitioners may make it possible to achieve distribution goals that are unrealized under the current patterns of medical care organization. Two hundred and twenty-three annotated footnotes are provided.
care programs, Descriptor(s): Supply/availability of services, Policy initiatives, Providers of health care services, Policy/changes re heakh care.
and New Health Practitioners.
Issues for the
Richard M. Scheffier, Nell Weisfeld, Gloria Ruby and Sunny G. Yoder. Health Resources Administration, Hyattsville, MD. 1979, 35 pp. Availability: Inquiry vl6 n3 p195-229 Fall 1979.
During the next decade, physicians will face the major challenge of improving health while moderating costs. One continuing problem, even with the expected oversupply of physicians, will be distribution. Defining desired distribution has involved identifying geographic areas or specific populations that need additional health manpower, comparing U.S. delivery systems to those in other countries, and defining the health service needs of a given population. At present, no single approach is totally satisfactory. In addition, to clearly define distribution goals, pollcies must take into account factors such as physicians' choice of speciality and practice location. Presently, the most promising policy tools appear to be medical school admissions policies, medical education itself, and possibly the structure of health care financing. Furthermore, health services can be delivered by vailous combinations of manpower and facilities, and these must be
695. Physicians' Charges Under Medicare. Assignment Rates and Beneficiary Liability.
Thomas P. Ferry, Marian Gornick, Marilyn Newton and Carl Hackerman. 1980, 25 pp. Availability: Health Care Financing Review vl n3 p49..73 Winter 1980.
A detailed description of physicians' assignment rates for Medicare's Part B program services for 1975 is provided, and total beneficiary outlays are analyzed to determine the burden on beneficiaries; this total is compared with program reimbursemerits. Under Medicare's Part B program, the physician decides whether to accept assignment of claims. When assignment is accepted, the physician agrees to accept as full payment medicare's allowed charge. Physicians' acceptance of assignment is of considerable importance in relieving the beneficiaries of the cost burden of medical care services. Data from physicians' claims for services in 1975 show that 45.8 percent of the services and 47.2 percent of the charges were assigned for the elderly. Wide variations were found in the rate of acceptance of assignment by physican specialty and by age, race, and residence of beneficiar-
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ies. Total beneficiary liability from the deductible, coinsurance, and unassigned claims amounted to 37.7 percent of total physicians' charges due. When the premium which the beneficiary pays for Part B is included, beneficiary liability rises to 69.2 percent of total physicians' charges due. Of the total Part B outlays, beneficiary contributions play a smaller role now than when medicare began and are likely to continue to decline; however, of the total physicians' charges that are liable for paymerit, the beneficiary portion may not simultaneously decline because the rate of reduction (difference between what the physician's charge and what medicare allows) has been increasing and the assignment rate has generally been declining. Tabular and graphic data are provided along with footnotes. A technical appendix presents data on the reliability of estimates. One reference is furnished.
Descriptor(s): Supply/availability of services, Physicians, Nurses, Allied health profi._ssionals, Policy initiatives.
Descriptor(s): Medicare, Physicians, Deductible/coinsurance, Reimbursement, Medical/surgical services, Methods of payment determination, Impact of third-party coverage,
This paper investigates how familiar physicians are with the cost of the diagnostic tests they order. Most analyses of medical care costs focus on the macro level, with such matters as capital expenditures, duplication of services, and more efficient use of personnel. Micro level items, however, can make significant differences in individual patient's bills, and while the rapid increase in types and volume of tests performed in hospital laboratories has been noted, they have been largely ignored. Previous studies at the University of Rochester Medical Center (N.Y.), the Gen-
696. Physicians
for the Future.
Josiah Macy, Jr. Foundation Commission on Physicians for the Future, New York, NY 10020 1976, 98 pp. A vat'lability: Josiah Macy, Jr. Foundation, New York, NY 10020.
This report of the Macy Commission on the availability of physicians for the future identifies nine areas of concern: (1) the changing supply and distribution of physicians, (2) primary care and family medicine, (3) graduate medical education as a determinant of medical care, (4) continuing education for the practicing physician, (5) foreign medical graduates, (6) women in medicine, (7) minorities in medicine, (8) nurse practitioners and physicians' assistants, and (9) financing medical education and biomedical research. The commission concludes that a national commission on medical education, manpower, and services is needed with a proposed membership of 20 persons balanced among public leadership, educational and consumer groups, and the medical profession. Support would be solicited from private foundations, and an overall public report of the commission's activities would be presented at least once a year. Four appendices contain major studies on the need for physicians in the United States from 1960 to 1970, a history of legislation supporting medical education, a summary of recent State reports on the supply of and need for physicians, and dissenting comments. A total of 27 appendix tables are given, and a bibliography of about 100 citations is included. (Author abstract modified)
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697. Physicians' Knowledge of Cost. The Case of Diagnostic Tests.
James K. Skipper, Gary Smith, Jack L. Mulligan and Mohan L. Garg. National Fund for Medical Education, New York, NY. 1976, 5 pp. Availability: Inquiry v13 n2 p194-198 Jun 76.
eral Medical Clinic of the George Washington University Medical Center (Washington, D.C.), of a 500-bed community general hospital, and of senior st_adents from the Medical College of Ohio tend to support the hypothesis that physicians are not well informed about the cost of laboratory tests, especially where third party payers are involved. The study reported here was conducted at the Medical College of Ohio for the calendar year 1972, and attempted to determine the familiarity of physicians and student physicians with the cost of laboratory tests. A list of 31 frequently used tests was developed, and a 2-page questionnaire was constructed, pretested, and sent to 90 individuals in 6 groups. The analysis was based on 61 completed questionnaires. The tendency was for the: total sample to underestimate cost, although first, second and third year medical students reflected increasingly good knowledge of laboratory prices. However, it appears that the more familiar the students become with the need and uses for the diagnostics tests, the more they tend to underestimate the tests' costs. Given the data that physicians and student physicians have a limited knowledge of the laboratory tests' costs and tend to underestimate rather than overestimate their costs, plus the available evidence that all tests ordered may not be absolutely necessary to maintain quality patient care, it is recommended that physicians be better informed of the cost of diagnostic tests. Tables and 15 references are provided.
This is a revt_ion of a paper presented at the Western Social Science Association Convention in Denver, CO, May, 1975.
Health Care Programs
Descriptor(s): Diagnostic services, Physicians, Outcome/evaluation of quality assurance, Health care costs.
698. Planning for Posthospital
Care. A Followup Study.
Ruth Ellen Lindenberg and Claudia Coulton. 1979, 6 pp. Availability: Health and Social Work v4 nl p45-50 Feb 80.
699. Planning of Health Care Delivery.
Thomas C. Dolan and Gayle C. Lane. Center for Research in Ambulatory Health Care, Denver, CO 80222 Kellogg (W.K.) Foundation, Battle Creek, MI. 1979, 4 pp. A vailability: Medical Group Oct 79. The purpose
A study that describes the post-hospital needs of patients and the extent to which these needs are met subsequent to discharge is discussed. Social work departments in nine community hospitals in the Cleveland, Ohio area participated in the study. Social workers gathered data from all medical and surgical inpatients who received social work assistance with discharge planning and who returned to the community, but not to an institution, during a 5-week period in 1978. The sample consisted of 290 patients, and the mean patient age was 61.4 years. Data were obtained about the specific needs of patients, resources available to meet these needs, and subsequent judgments made by patients and workers after discharge concerning the effectiveness of the resources provided. Nineteen types of needs were delineated, including followup medical supervision, nursing care, physical therapy, and legal services. Researchers identified the following resources that could be used to meet these needs: patients, family members, significant others, hospital personnel, community health and welfare agencies, and self-help groups. Medicare covered the hospital costs for 55 percent of the sample. The most frequent diagnostic patient categories were cardiovascular disease, cancer, orthopedic problems, and cerebrovascular disease, A total of 67 percent of the patients lived with one or more family members, and 29 percent lived alone. Severely and moderately impaired patients were more likely to have many types of needs than those who were less impaired. For a surprisingly large percentage of needs, family or friends provided planned services. This finding raises questions about what effect this responsibility has on the performance of other family functions, Another surprising finding was the limited use of community agencies for other than skilled nursing care. In general, findings imply that a substantial number of patients being discharged from hospitals do not have their needs met. Even when services are received, an unacceptable number prove inadequate. Social workers must exercise greater responsibility for following discharged patients to assure that post-hospital plans are carried out. Three tables and five reference notes are provided,
Descriptor(s): Demand/utilization of health care programs, Health care/services, Inpatient facilities, Allied health professionals, Outcome/evaluation of health administration.
of the National
Management
Health
v26 n5 p29-31, 61
Planning
and Resources
Development Act of 1974 (Public Law 93-641) is to facilitate equal access to quality health care services at a reasonable cost for all U.S. citizens. Nationally, the law mandates the development of a national health planning policy. Of particular significanoe to group practice managers are the references to the development of primary care resources and programs, and the promotion of medical group practices. A National Council on Health Planning and Development is established by Public Law 93-641 to develop a national health planning policy, implement laws, and monitor new medical technology. At the State level, the law mandates the formation of a statewide Health Coordinating Council (SHCC) and a State Health Planning and Development Agency (SHPDA) to administer the State certificate of need law. At the local level, Public Law 93-641 mandates the establishment of health systems agencies (HSA's) for each of the 205 health service areas. The HSA may take the form of a nonprofit corporation, a regional planning body, or a unit of local government, but the vast majority are nonprofit corporations. The SHCC is responsible for the review and approval of the State health plan, the State medical facilites plan, and the budgets of its HSA's. The SHPDA conducts the health planning activities of the State, developing the State health plan and addressing specific statewide health planning issues. Responsibility for the administration of many Federal and State regulatory programs falls upon the SHPDA. The HSA is the local unit responsible for the development and implementation of the health plans. The past 3 years have been spent organizing the health planning structure, and little has been done in the way of developing a more appropriate health care delivery system. Public Law 93-641 calls for participation by providers, including group practice managers, giving group practice managers the opportunity to participate directly in policy formation by joining these groups. The future role and goals of group practice are linked to the plans produced by HSAs. Group practice managers need to develop their goals prior to the HSA planning process and then work with the HSA's to integrate long-range goals with HSA plans. Ten references are provided.
Article is second in a series of three, covering the topics of Politics, Planning and Regulation of health care delivery.
1-315
Descriptor(s): Supply/availability tion/regulations.
of services,
Present
legisla-
HEW/PUB/SSA-79/11808 1978, 792 pp. A vailability: Superintender_t of Documents, Government Printing Office, Washington, DC 20402, order number 0 l7-070-00342-7.
700. Policies for the Containment of Health Care Costs and Expenditures. Stuart O. Schweitzer. National Inst. of Health, Bethesda, MD 20205 •DHEW/PUB/NIH-78/184 1978, 490 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-053-00070-1. This volume presents papers related to policies concerned with health care cost containment both in the United States and in countries throughout the world. An introductory section provides a framework for the study of containment measures. Such topics as process or outcome measures for cost containment of health care and strategies for health care cost containment are discussed. A consideration of pricing and cost sharing encorepasses specific papers on roles of cost sharing in health care cost containment in Belgium, the Australian health care system and recent changes in its financing and organization, and cost and cost sharing in the health services of Switzerland. Next, alternative approaches to the reimbursement of providers are examined in seven papers coveting the United Kingdom, the Federal Republic of Germany, the United States, and the Netherlands. Utilization review programs in several countries are discussed, as well as the role of health planning in such nations as Denmark, the United States, the United Kingdom, Sweden, and Israel. The final section presents papers on alternative policies for containing health care costs. Each section concludes with a discussion. Tables, graphs, references, and footnotes are included in individual papers. An index and an annotated bibliography of approximately 420 references are supplied, Proceedings of a Conference sponsored by the John E Fognrty International Center for Advanced Study in the Health Sciences, Bethesda, MD, April 26-28, 1976. Descriptor(s): Cost containment efforts, Comparisons regarding foreign health policies, Comparisons of health care programs, Reimbursement, Funding/financing of health care programs,
701. Policy Analysis with Social Security Research Fries. Social Security Administration Office of Research tics, Washington, DC 20203
I-316
and Statis-
This document contains papers given at a workshop on the full range of Social Security Administration (SSA) data .bases now being used to research public policy questions. Sessions examined the following data bases: the Continuous Work History Sample (CWHS), the Longitudinal Retirement History Study (LRHS), and the 1973 Exact Match Study. (The study was a joint undertaking of the Census Bureau and the Social Security Administration, and its starting point was the March 1973 Current Population Study (CPS). It entailed matching CPS sample subjects with social security benefits and earnings records and a set of tax items furnished by the Internal Revenue Service (IRS). The study is here titled the CPS-IRS-SSA Exact Match Study.) Surveys of supplemental security income (SSI) beneficiaries and surveys of disabled beneficiaries were also examined for relevant data. Statisticians, economists, analysts, and policymakers representing the SSA, other Federal Government agencies, and nongovernmental agencies, as well as several representatives from the Canadian research community, participated. The first session examined Social Security research files and their potential for public policy study. ¬her session on Social Security health and disability research examined, among other things, aggregate medicare enrollment by age, sex, and race as a resource in analyzing demographic change in local areas, SSA public-use data tiles for di_;ability research, and data on serious work injuries. The sessions on the CPS-IRS-SSA exact match study dealt with its past, present, and future; age and family income; and projected rates of return to future social security retirees under alternative benefit structures. CWHS research was examined through an intercohort analysis of lifetime earnings, the SSI data and statistical system, and the use of the CWHS for labor market information. Health conditions and earnings capacity, determination of a health variable, and a survey of low-income aged and disabled were among the topics covered in the session on social security disability research files. Additional papers were on social security, health, and retirement plans; the treatment of short-service workers under the old-age, survivors, and disability insurance (OASDI) retirement provisions; and reduced form versus strucl:ural equations of the growth in earnings of Manpower Development Training Act (MDTA) employees. The CWHS' description and contents, as well as its limitations and prospects for improvement are also discussed. Among additional exact match research literature were papers on economic models of social security wealth, the impact of alternative inflation adjustments, and the use of system dynamics to model the social security system. In addition to the papers,
Health Care Programs
two appendices contain an outline of the workshop program and a list of the SSA publie-nse files currently available to outside researchers. Tabular data, references, and notes for individual papers are provided,
decreased use of other services. Overall, national health policies should be guided by analysis of service constraints, nolLby the special interests of insurers and professional groups. Thirty-nine notes and references are appended.
Proceedings Virginia.
Descriptor(s): Policy initiatives, Mental health services, Demand/utilization of health care programs, Cost containment efforts, Methods of paym(mt determination.
of a workshop held March 1978 at Wilh'amsburg,
Descriptor(s): Demographic features of population, Health information/data systems, Health insurance industry, Publicly sponsored/mandated health plans, Economic/commercial influences, Participants in health care programs.
703. Policy Options and the Impact of National surance Revisited.
Health In-
Joseph P. Newhouse, Charles E. Phelps and William B. Schwartz. 702. Policy Issues in Financing Mental Health Services. Patricia L. Ewalt. 1979, 8 pp. Availability: Jnl. of the National Association ers v24 n4 p283-290 Jul 79.
of Social Work-
Department DC.
of Health, Education,
and Welfare, Washington,
1977, 7 pp. Awd/ability: International Jnl. of Health Services v7 n3 p503509 1977. An author response is given to a critique of a paper on policy
This article describes policy options for fmancing mental health care services under a national insurance program, as well as suggesting alternatives for service delivery. Despite claims that the cost of prepaid and insured outpatient psychiatric services may be exorbitant, research studies have shown that people do not use such services for lengthier periods just because they are prepaid. Application rates are affected by limitations placed on benefits, the site of service, and the extent of a program's outreach activities. Thus, costs can be controlled by the manipulation of constraints on service provision. No clear Federal policy has been formulated concerning whether insurance or other coverage should be extended to provide for mental health services as opposed to psychiatric care. Proponents of broader mental health care suggest that title XX of the Social Security Act could be a basis for a universal social service system for all income levels and that national health insurance eventually could be restricted to psychiatric care. Policy issues in this scheme concern which services would be included in each program, particulaxly those for persons with chronic mental illness. A plan's commitment to either mental health or psychiatric care must be determined before decisions about service delivery can be made. Eligibility, reimbursement, and extent of coverage depend on the program's orientation. For example, a system of psychiatric services would reimburse only physicians' services whereas a mental health approach would advocate reimbursement for a variety of practitioners and treatments. Other policy considerations inelude outreach programs and constraints on long-term users of services. Research projects have not found any conclusive relationships between the use of outpatient psychiatric services and
options and the impact of :national health insurance (NHI). The author refutes the premise of the critique -- the paper on :national health insurance conehides that any NHI which does not provide for high user copayment, particularly for ambulatory services, would swamp and ultimately wreck the health care delivery system, particularly for ambulatory services. In fact, the paper stated that if a plan with no user payments (or even 25 percent payment) were enacted, the short-term adjustrnent for ambulatory services would generate an increased dem_md that would far exceed the current capacity of the delivery system. As a result, the rise in use would inevitably be limited by some or all of the following mechanisms: an increase in dollar prices, delays in receiving appointments, an increase in waiting time at office or clinic, a change in the character of the services provided, and a change in the mix of medical problems seen by physicians. These effects would be short-term because the medical care systern could relieve the stress by adjusting to the increased demand through such mechanisms as increased physician productivity, expanded use of physician assistants, and peer review. Over time, the delivery system (if fi'ee to respond) would adjust to the increased demands with an eventual level of expend!iture on medical care of some 11 percent of gross national product (if technology does not change). Evidence from Canada is consistent with this analysis. Graphic data and 10 references are provided. Descriptor(s): Supply/awdlability of services, EconomLic/cominertial influences, National health insurance (NHI), Comparisons regarding foreign health policies.
1-317
:
704. Policy, Politics, and Child Health. Four Decades of Federal Initiative and State Response.
Christa Altenstetter and James W. Bjorkman. National Center for Health Services Research and Development, Hyattsville, MD. 1978, 35 pp. A vailabilitv: Jnl. of Health Politics, Policy and Law v3 n2 p196-197,200-207,210-234 Summer 1978.
This paper analyzes the continuity and change in the relationship between Federal and State governments in the formation and implementation of child health programs. After reviewing developments in Federal child health policy since the SheppardTowner Act of 1923, methods of implementation and changes in State laws and administrative organization in Vermont and Connecticut are compared with a focus on the major programs authorized by Title V of the Social Security Act. Four broad interactive areas of comparison -- governmental relations, program delivery systems, expenditure patterns, and private interests -- serve as vantage points for exploring, understanding, and explaining the process of policy implementation. Specific conclusions are drawn regarding each area and the overall conclusion is that Federal efforts under Title V have not lessened the general neglect of child health in State legislation; nor have they greatly expanded the volume of direct services for child care. They have been sufficiently ambiguous and diffuse to leave the providers dominant, treating diseases and existing conditions rather than focusing energy on preventive measures. Federal resources have been absorbed by expanding administrative overhead, and State bureaucracies have been inflated rather than motivated. Re-
In the 1900's, the Federal Government added a wide range of new health programs -- medicare, medicaid, health manpower training, occupational safety, and others -- t_ its lop,g-established support for biomedical research and hospital construction. Total Federal hcalth outlays rose from $5 billion in 1965 to almost $37 billion in 1975. This paper describes the legislative history of Federal health programs and reports the recent trends in expenditures by functional category, which include research, manpower training, medicare, medicaid, construction, direct Federal provision of services, prev,ention and control, and health planning. The expenditures of major programs are related to the populations they serve, and data are presented to document the enormous inflow of resources to medical care since 1968. This inflow has been induced by the structural changes in the medical care market first set in motion by private health insurance, and accelerated by the new Federal programs. Designing some way to control this inflow of resources and rising costs of medical care is a major problem in health policy. The present system fails to recognize that resources are costly and that these costs must be weighed in making decisions about the allocation of resources. A system must be devised that will again consider the costliness of resources while maintaining the best achievements of the current system. Tables and 31 references are given. (Author abstract modified)
Descriptor(s): Health care cost trends/projections, Economics of third-party payors, Parttcipants in health care programs, Present iegislation/regulation;_.
search for the study was conducted during 1972 to 1976. Fourteen tables and 35 footnotes are provided. (Author abstract modified)
706. Politics and Econontics of Hospital
Descriptor(s): Supply/availability of services, Publicly sponsored/mandated health plans, Inpatient facilities, Comparisons of health care programs, Demographic features of population, Present legislation/regulations.
1978, 25 pp. Availability: Jnl. of Health Politics, Policy and Law v3 nl p87-111 Spring 1978.
705. Political Economy of Federal Health Programs in the United States. An Historical Review.
Louise B. Russell and Carol S. Burke. 1978, 23 pp. Availability: International Jnl. of Health Services v8 nl p5577 1978.
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Cost Containment.
Arnold H. Raphaelson and Charles P. Hall. Social Security Administration, Washington, DC. Office of Research and Statistics,.
Experiments and other private sector efforts to contain hospital costs have clearly failed to achieve adequate control over increases. Although some States have adopted hospital rate or cost controls in spite of objections by the hospitals, these efforts have had no national effect for hick of adequate startup time. Furthermore, the voluntary or limited controls that exists in only a few States lack the scope to bring about national trends, and the goal of State regulatory effort:i to control hospital costs has little effect on a national, inflationary economy. An examination of costs by cost per patient day reveals that the principal causes contributing to hospital cost inflation are the inability of hospi-
Health Care Programs
tals to reduce their capacity in response to decreasing needs, the inability to measure increased quality in care on the patient day basis, and increases in wages and other commodities over which individual hospitals have little control. Proposals to increase competition and allow the marketplace to control costs assume that insured persons paying premiums or the taxpayers have the political and economic power to allocate resources in such a way as to reflect social values. Proposals to make hospital care a pure public good without individual cost, similar to public education, underestimate the economic powers of special interests which are likely to have more direct force than can be expressed through the national political process. It should be noted, however, that private sector hospitals have adequately met the demands expressed by society for decades. The appeal of regulation is that it provides an opportunity for the present structure of hospital care to meet the demands of new social goals. Voluntary efforts to contain costs and the recent State efforts to limit hospital costs provide relevant guidance for the regulatory process. Depending upon experience with regulation and national insurance, further changes may be required to meet new social goals. Thirty-four annotated footnotes are provided,
needs though confronted by the same problems. As a result, it is often difficult to serve all these interests with a particular policy. For example, whether one disease gets treated more effectively than another may be a function of both available funds and political support. Although 10 million Americans are injured in accidents each year, less than $3 is spent on every emergency victim, while roughly $300 goes for research on every victim of cancer, and about $200 for each heart attack. As illustrated by statistics such as these, the book concludes that politics very often places .the interests of the health care community above those of the consumer. Along with the analysis of how political mechanisms influence the development of health care: policy, suggestions are made on how to blunt that influence when it retards the progress of health care quality, Tabular and graphic data, an index, and chapter notes are provided. The bibliography includes almost 300 entries. (Author abstract modified)
Descriptor(s): Supply/availability of services, Medical technology impacts, National economic conditions, Impact of third-party coverage, Health care/setwices, Providers of health care ,;ervices, Policy/changes re health care, Health care costs.
Early draft of this article was presented at the Annum Conference of the Atlantic Economic Society in October 1976, Washington, DC 708. Politics of Health Care Delivery. Descriptor(s): Cost containment health care, Inpatient facilities.
707. Politics
efforts,
Policy/changes
re
of Health Care.
Thomas C. Dolan and Gayle C. Lane. Center for Research in Ambulatory Health Care, Denver, CO 80222 Kellogg (W.K.) Foundation, Battle Creek, MI. 1979, 4 pp. Availability: Medical Group Management v26 n4 p56-59 Jul/ Aug 79.
J. H. U. Brown. 1978, 153 pp. Availability: Ballinger Publishing Company, Cambridge, MA 02138. This book is an attempt to examine the human factors that enter into decisions on health care at all levels. Those forces of society are defined as "political" which attempt to maintain the status quo or to force change on a system. Such political inputs are common to all forms of government, unions, professional societies, consumers, and experts; and each element has to sway the development of the health care system to its own ends, even though these ends may be altruistic. Controversies arising from these diverse interests are analyzed here; all sides of such health questions are examined, including manpower, health insurance, government control of the health system, technology, hospital usage, costs and charges, quality of care, consumerism and preventive medicine. Divergent political interests preceive different
The role of each level of government in the direct delivery of, planning for, financing of, and regulation of health care services is discussed, and the role of the health care administrator in influencing political policy is considered. All three levels of government are responsible in some measure for public health funetions related to the promotion of health and prevention of disease. State governments are the primary providers of sanitation measures and a pure water supply. Communicable disease control and drug and food inspection are cooperative efforts of all government levels. Health education is also another function of all government levels. In 1974, Congress passed the most sweeping health planning legislation to date. The National Health Planning and Resources Development act created State health planning and development agencies and local health systerns agencies. The expectation is that this law will facilitate the development of a national health planning policy which can be implemented at the State and local levels. In the area of financ-
1-319
ing, all levels of government finance the direct delivery of certain health services. The Federal and, to some extent, State governments provide grants to nongovernmental organizations to support biomedical research and specific programs, such as the development of health maintenance organizations. The Federal Government funds medicare, which provides partial payment for medical services for the aged, disabled, and those with endstage renal disease. In the area of regulation, Section 1122 of Public Law 92-603 established a mechanism to review and control capital expenditures and service changes by health care facilities and created a quality control program for physicians' services -- professional standards review organizations. State regulatory functions include the licensing of health manpower and health facilities, hospital rate regulation, regulation of health insurance organizations, and the establishment of safety codes for health facilities. The regulatory powers of local government are derived from the State. Effective group practice participation in the health legislative process requires constant attention to all
findings show that health n,_ds of the poor never failed to move the majority of citizens to f_LvorGovernment action on the problena; medicaid was the eventual result. Help for the elderly in the health field seemed to arou_ more than 6 out of 10 of the public favorably as medicare approached the final stages of legislative decisionmaking in the 1960's. Medical care for all citizens was an issue before Congress in 1974 and 1975. From the patchwork of poll questions, it can be concluded that although the need is considered less urgent for all citizens than for the poor and the elderly, approval has been g_eater than disapproval for the entire 40 years of inquiry. Finance of health insurance is a more controversial issue. Public support for Government involvement in the program has ranged irregularly from 40 to 60 percent, with little or no difference in choices for the elderly or the general public. In 1972, a survey _:eported that citizens were 49 to 32 percent in favor of a Government health insurance plan rather than private insurance. (Author abstract modified)
government health-care activities. This includes the identifieation and analysis of proposed health care legislation and the development of group practice positions on such legislation, Thirteen references are provided.
Descriptor(s): Publicly sponsored/mandated health plans, Funding/financing of health care programs, National health insurance (NHI), Policy/changes re health care.
Article is/_rst in series of three, covering the topics of Politi_ Planning, and Regulation of Health Care Delivery. Descriptor(s): Publicly sponsored/mandated health plans, Funding/financing of health care programs, Present legislation/ regulations.
709, Polls. Health
Insurance.
710. Potential for a Competitive ton, Massachusetts.
Health Care System in Bos-
David Aquilina and Walter McClure. InterStudy, Excelsior, MN 55331 Henry J. Kaiser Family Foundation, Palo Alto, CA. John A. Hartford Foundation, New York, NY. Bush Foundation, St. Paul, MN. Jan 1980, 78 pp. Availability: InterStudy, Excelsior, MN 55331.
Hazel Erskine. 1975, 16 pp. Availability: Public Opinion Quarterly p128-143 Spring 1975.
This report analyzes the Ix_tential for the development ofa competitive health care system in Boston, Mass. It is intended to assist leaders in business, local government, medicine, and the
Results are reported from U.S. opinion polls on health insurance coverage from 1938 through 1974. About 75 percent of the respondents favored Government action on medical care for the needy when it was on the pollsters' agenda from 1936 to 1944. Approval of medical care for the elderly ranged from 56 to 82 percent on various questions asked from 1961 to 1966, when it was a priority issue in Congress. Favorable opinions on these widely varying questions clustered around a midpoint approval for medicare of about 64 percent. Questions on health plans for the entire citizenry span the period from 1936 to 1974. Approval has ranged from 40 to 80 percent, depending on the emphasis of the query. On 14 such measures of every nuance over the years, the midpoint has been around 58 percent approval. Overall, poll
health industry whose de¢isions will determine the future of Boston's health care system. The underlying cause of spiraling health care costs - the al:_ence of market forces in the system - is discussed. The competitive alternative is described, including the characteristics of a functioning competitive medical care system and the community conditions which contribute to its development. The prerequisite to such competition is the formation of organized groupings of providers, or health care plans, each with separate preminms. The key finding of this report is that while competition in Boston's health care system is currently weak, the prospects for market competition are good. However, strong market forces cannot be established unless Boston's leaders decide to support the concept. Specifically, for Boston's
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Health Care Programs
health care plans to become effectively competitive, major employers must become informed regarding the potential advantages of market competition and help inform community leaders; they must structure their employee health benefit programs to allow health care plans to compete fairly with conventional providers for consumers and exert personal leadership to assist new health care plans to become fully competitive. Major employers, particularly those located in suburban Boston, currently offer health benefits which provide substantial coverage. Thus, potentially there is a good market for competitive plans. At present, there are only two potentially competitive health care plans in Boston, but there is an oversupply of medical resources. Nine footnotes, 18 tables, and an appendix are included. (Author abstract modified)
Descriptor(s): Supply/availability efforts, Competition/interaction Policy initiatives,
of services, Cost containment among third-party payors,
711. Potential Market Competition tem of Baltimore, Maryland.
tion, particularly in business and in State government. Prospects for the development of more effective competition are not good unless (1) either existing or new health care plans become more aggressive in expanding their membership and delivery sites; (2) business and labor leaders promote competition by offering employee options for health care plans; (3) Blue Cross enhances the prospects for competition by adopting more flexible policies for the network plans; (4)the State government promotes competition by adopting appropriate policies, notably by enabling the Health Services Cost Review Commission to allow competitive plans and hospitals to negotiate rate agreements more freely; and (5) organized medicine more actively supports private competition among more economically and professionally pluralistic forms of medical practice as a preferred alternative to greater public regulation. Tabular data and footnotes are provided.
Descriptor(s): Competition/interaction among third-party payors, Prepaid plans, Outcome/evaluation of health administration, Private health care plans.
in the Medical Care Sys-
David Aquilina. InterStudy, Excelsior, MN 55331 John A. Hartford Foundation, New York, NY. Henry J. Kaiser Family Foundation, Palo Alto, CA. Bush Foundation, St. Paul, MN. Oct 1980, 54 pp. Avai/ab//ity: InterStndy, Excelsior, MN 55331.
The potential for the development of a competitive medical-care system in Baltimore, Md., is analyzed. The prerequisite for competition in the health care system is the formation of organized groupings of providers (health care plans), each with its own premium. Competitive market forces are introduced into the health care system when these plans compete for consumers among themselves and with fee-for-service physicians and insurante plans; competition is on the basis of service, benefit coverage, and price. Findings show that such competition does not now exist in Baltimore. In 1979, five health-care plans were operational in metropolitan Baltimore. Together they enrolled less than 2 percent of the area population. With such a small market share, existing plans have not yet caused fee-for-service physicians to lose a significant number of patients. Three sets of factors currently impede the creation of effective market forces in Baltimore's medical care system: (1) structural defects in the current market; (2) the generally non competitive character of the operational and developing health care plans; and (3) the absence of clear support for multiple health plans and eompeti-
712. Poverty and Health. Economic Causes and Consequences of Health Problems.
Harold S. Luft. 1978, 263 pp. Availab_'ty: Ballinger Publishing Company, 02138.
Cambridge, MA
This book investigates the economic causes and consequences of health problems by examining empirically the magnitude of the issues and the causal relationships involved. It outlines a causal model of the relations between various economic factors and different types of health problems and then develops an approach to empirically estimating this model through a discussion of types of data including the 1966 Survey of Disabled Adults and the 1967 Survey of Economic Opportunity. Data drawn from the National Health Examination Survey and the National Health Interview Survey are provided in a broad overview of available national data relating to socioeconomic factors as causes of health problems. Factors related to the incidence of disability are examined, and factors that influence the various outcomes of disability such as job changes or hours worked per week are emphasized. The magnitudes of the effects of disability are explored, and some policy proposals are suggested, based on the assumed existence of three major social programs: some form of universal basic income support for the poor, a basic commitment to maintaining a full employment economy, and some form of national health (medical care)insurance. Within this context, an integration of medical care, disability, accident and hazard,
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rehabilitation, and life insurance is proposed to internalize the currently existing externalities and to improve the incentives for people to stay healthy and to recover from their health problems, Two sets of incentives are involved, financial and informational, and both revolve around the development of a health status index that includes not only current status but the person's prognosis and life expectancy. Specific suggestions are given for the use of risk factors such as not penalizing individuals for things not under their control and reducing the incentives to select good risks by basing experience rating on a predicted risk level. This predicted risk uses as its norm not the population average but, instead, the risk level for the people in question, abstracting only from those variables that the firm should be able to influence. The concept may be extended to provide additional incentives to changing private behavior as in risk-reduction programs of various organizations such as religious or employeeemployer groups. Suggested social incentives include national advertising for healthy behavior, taxes levied on industrial pol-
to adopt healthier lifestyles or to follow prescribed medical regimens. Although the importance of behavioral changes by the public are frequently mentioned, the means to motivate such changes are not well understood. The success of behavioral approaches in the management of obesity and other areas suggests that incentives may be applicable to such health-related behaviors as smoking and lowering cholesterol intake. After demonstrating the theoretical value of incentives, the dissertation discusses an operational incentives program to improve adherence to medical regimens to control high blood pressure, which the author and colleagues are testing with a randomized clinical trial. Similar incentive systems could be offered by employers or unions to help enrollees control blood pressure, stop smoking, or lose weight. Thirteen figures, 22 tables, extensive references, and footnotes are included in the dissertation. An appendix contains a study of patients, reward preferences. (Author abstract modifled)
luters, and the use of funds to design incentives to change both behavior and risk. Figures, tables, and a bibliography of about 170 citations are included,
Submitted
in partial fulfilhnent
gree of Doctor of Philosophy Descriptor(s):
Cost/benefit
of the requirements to Harvard
for the de-
Univ., 1976.
analyses, Preventive services.
Descriptor(s): Trends in health status, Health information/data systems, Preventive services, Demographic features of population, Present legislation/regulations, Policy initiatives. 714. Preliminary Analysis of the Costs of Maintaining sion and Health Benefits in Selected Plans. 713. Prediction and Incentives in Health Care Policy.
Donald S. Shepard. May 1976, 342 pp. Avuilability: University MI 48106.
Microfilms
International,
Ann Arbor,
This dissertation develops two proposals, the prediction strategy and the incentives strategy, that are designed to improve the productivity of expenditures to promote health. The prediction strategy refmes the analytical framework that informs policymakers about the projected impacts of alternative programs. A type of cost-effectiveness ratio is proposed, where costs are incremental present value costs and benefits are increases in discounted, quality-adjusted years of life. The method for estimating benefits represents an extension in methodology. This method, termed "standardized assessments," incorporates the variability in risk of death from specified causes among individuals of the same age and sex. The present cost per additional adjusted year of life was calculated for certain preventive programs. For exampie, the cost of mobile coronary care units with complete utilization was calculated at $2,000. The incentives strategy proposes that incentives be offered to help inform and motivate the public
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Pen-
ICF, Inc., Washington, DC 20006 Department of Labor, Wa_hington, DC. Office of Policy Planning and Research Jan 1979, 40 pp. Availability: ICF, Inc., Washington, DC 20006. This paper presents estimates of the expected maintenance of benefits (MOB) costs for the health and pension plans of six collective bargaining units scheduled for wage negotiations during 1979. This analysis wa_ undertaken by the Office of Pension and Welfare Benefit Programs, U.S. Department of Labor, in order to identify the potential impact on selected bargaining units of the revised wage guidelines issued by the Council on Wage and Price Stability (COWPS). MOB costs reflect the increase in contributions required to fund fringe benefits under current benefit formulas. In a revision of the original wage guidelines, COWPS permitted employers to exclude part of MOB costs in determining their compliance with the 7 percent limit on increases in total compensation. The bargaining units reviewed in this analysis included the Teamsters; the Oil, Chemical, and Atomic Workers; the United Rubber Workers; and the International Ladies Garment Workers Union. The cost analysis employs information that is available to the public through annual
Health Care Programs
reporting requirements under ERISA and other laws. The analysis concluded that pension MOB costs vary widely among the bargaining units studied and that final pay and fLXed benefit plans are affected by the wage guidelines in substantially different ways. In addition, despite potentially significant pension and health MOB costs, potential increases in wages dominate the application of the wage guidelines. However, the analysis found that the wage guidelines may produce some potential inequities among individual bargaining units. Nevertheless, increases in total compensation appear to be limited to less than 8 percent under the guidelines. Footnotes and seven tables are given; background data on benefit plans for six bargaining units are appended in addition to calculations of wage and compensation increases under the wage guidelines. (Author abstract modified)
Descriptor(s): Private health care plans, Health care/services, Cost/benefit analyses, Health care costs, Outcome/evaluation of
straints of the risk-sharing contract include an open enrollment period made available annually to medicare beneficiaries in the area. This requirement intensifies the potential financial vulnerability of the HMO because a group with significantly higher use rates is admitted without screening. A second constraint is the lock-in provision, mandating that medicare beneficiaries use only the facilities of the HMO in which they are enrolled. Medicare enrollees' protests aaainst this requirement need to be reconciled with the philosophical commitment of an HMO member to the organization's principles. Even though Group Health was able to realize a savings share that has improved its services and reduced costs to its medicare enrollees, this case is but a sample of one. Analysis of the proposed amendments suggests limited net business incentive to an HMO for enrolling medicare beneficiaries. Incentives for the beneficiary remain balanced against the loss of flexibility in choice of physicians and service locations. Only for the Government is the incentive of savings definite if medicare beneficiaries enroll in HMO's under condi-
health administration,
tions of the proposed amendments.
Present legislation/regulations,
Footnotes are provided.
"Skills Development for the HMO Managers p146-155 1980, edited by Eugenia Warhol. 715. Preliminary Maintenance
of the 1980%"
Results From a Risk-Sharing Health
Organization.
Karen Wintringham. 1980, 10 pp. Availability: Group Health Association of America, Inc., Washington, DC 20036.
This paper relates the actual experience of an HMO (health maintenance organization) that has been receiving reimbursement on a risk-sharing basis since 1976 and discusses some of the implications of legislative proposals that would require all HMO's to accept risk-based medicare reimbursement. The Group Health Cooperative of Puget Sound antedates the medicare program by 20 years; at the time it entered the risk-sharing agreement with medicare in 1976, it was the first and only riskbasis HMO in the country. At the close of 1977, Group Health realized apppoximately a $1.3 million savings share. The cooperative's total adjusted medical costs were 30 percent less than the Government's estimate of community costs or the average area cost estimated per medicare enrollee per month. The Federal Government's savings share exceeded $1.7 million. The most important financial impact of the risk-basis program at Group Health has been the retroactive adjustment of payments; a final settlement has still not been reached for 1976 through 1979. Furthermore, the average area per capita cost has been reduced retroactively; this in turn reduces the savings share. Such delays and adjustments hamper the ability of an HMO to apply the savings generated to enrollees and the HMO budgetary process, which is based upon prospective prepayment. Structural con-
Descriptor(s): Prepaid plans, Medicare, Participants in health care programs, Funding/financing of health care programs, Present legislation/regulations, Policy initiatives, Outcome/evaluation of health administration.
716. Preliminary Study of Diaenrollees Plan of Pemmylvmtht.
From Health Service
Shari D. Sobel and Doran J. Twer. 1980, 8 pp. Availabib'ty:
Group Health Assooiation
Washington,
of America,
Inc.,
De 20036.
This article reports the results of a study conducted to ascertain why the membership of the Health Service Plan of Pennsylvania (HSP), a federally qualified health maintenance organization operating out of 4 centers in Philadelphia, dropped by 3,300 members in three-quarters of 1979. The survey was conducted by telephone interviews with 254 members who had left the plan during yearly renewal months, prestmaably for reasons of dissatisfaction with some aspect of their medical care, their nonmedical service, their access to treatment, or their coverage and its costs. Of those queried, 62 subscribers had left the plan because of relocation or job change. The analysis of responses pertains to the remaining sample of 192 whose reasons for disenrollment were dissatisfaction with HSP care, service, or cost.
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Special consideration is given to one variable -- the HSP center -- in this analysis because care, operations, and access may differ from center to center. The results indicate that the primary cause of disenrollment for 43.8 percent of the respondents was dissatisfaction with some aspect of medical care. Of this group, 19.3 percent were unhappy with their limited choice of physicians, Other complaints concerned inadequacy of general care or setvice, such as poor provider communications, misdiagnosis, or treatment by paraprofessionals. Access in terms of distance was noted as a problem in the less urbanized centers. Cost-benefit considerations were cited as the reason for leaving by 27.6 percent of the respondents. Respondents from two of the centers cited waiting time. Another predominant secondary was never using the plan. Cost was found to play a minor role as a secondary contributing factor in disenrollment, even though large percentages of disenrollees in all centers cited cost as the main reason for leaving HSP. Two-thirds of the disenrolles subsequently joined Blue Cross or a private carder.
From 'SlaTls Development for the HMO Mnnagers 1980's," p 85-92, 1980, edited by Eugenia Warhol. Descriptor(s): grams.
Prepaid plans, Participants
95th Congress second session, Report
No. 95-749.
Descriptor(s): Medicaid, Prepaid plans, Source of premium paymeat, Policy initiatives, Evaluations/outcome of health care programs.
of the 718. Pressures and Problems for Organized Ambulatory Services in the Next Decade,
in health care pro.-
717. Prepaid Health Plans and Health Maintenance zations.
Stephen F. Loebs. 1977, 9 pp. Availability: Jnl. of Ambulatory Care Management v 1 n 1 pl-9 Jan 78. Organi-
Committee on Governmental Affairs CLI.S. Senate) Permanent Subcommittee on Investigations, Washington, DC 20515 Feb 1978, 62 pp. Abuses in California's prepaid health plans (PHP's) are documented, and suggestions are offered for Federal action to reduce or eliminate such abuses in PHP's receiving Federal health care money. In 1972, California's medicaid program began contracting with PHP's. The PHP program was plagued by large-scale profiteering medical commercialism. PHP officers and directors created or contracted with for-profit entities they owned or controlled in order to provide PHP services. Enrollment techniques were often deceptive and fraudulent, and many enrollees were involuntarily disenrolled when their health care became expensive. The quality of care provided in some plans was below reasonable standards as judged by the State's medical auditors, Congress responded to the situation with the Health Maintenanee Organization (HMO) Act Amendments late in 1976, which require that all PHP's receiving medicaid funds be federally qualified. The record of the California program should alert other State health program administrators, Federal program
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managers, and the Congress to the kinds of fraud and abuse possible in PHP systems. It is a clear warning that effective regulatory and management safeguards are essential in these and other State and Federal health care programs. Existing laws and regulations are inadequate to cope with marketing abuses and problems related to corporate structure and contractor management. Legislative and regulatory recommendations are proposed in an effort to deal with similar PHP problems in other states. A U.S. Comptroller General report on California PHP's is uppended.
This paper identifies specific types of ambulatory services (arrangements people make to obtain medical services without admission to a hospital); lists forces with potential impact on ambulatory care services; and outlines problems in developing these services. Organized ambulatory services are defined as including first-contact medical services as well as continuing contacts in settings which do not require overnight stays. The distinguishing characteristic is the integrative and centralized arrangement for the services in which a multidisciplinary health care team, consisting of various professional personnel and aides, work together for diagnosis and treatment. Specifically, 11 types of organized ambulatory services have been identified in the United States: fee-for-service medical groups, prepaid group practice plans, hospital-based ambulatory care centers, mental health centers, community health centers, school/university health centers, health department clinics, home care programs, family planning clinics, industrial clinic.s, and ambulatory surgical centers. A consensus seems to exist that the various types of ambulatory services will increase rapidly. Analysis suggests these forces for change: (1) increasing consumer demand for organized and centrally ltx:ated ambulatory services, (2) continuing increases in costs for inpatient hospital care, (3) pressures on insurance carriers to change and expand their benefits, (4) a competitive environment for the health care industry, (5) profes-
Health Care Programs
sional standard review organizations (PSRO's), (6) health maintenance organizations (HMO's), and (7) hospital-based ambulatory services. However, several obstacles could deflect and retard access to these services. There may be a vacuum in leadership, because health care professionals have not been particularly
to disparage it could delay the adoption of changes needed to improve its effectiveness. Notes, figures, and 70 references are included. (Author abstract modified)
prominent in advocating the changes needed to develop ambulatory services. In addition, hospital administrators are constrained by institutional goals and environment, and third party agencies have been unable or reluctant to promote ambulatory care services. Moreover, the financing of ambulatory services is a severe problem. Eight references are provided.
Descriptor(s): Trends in health status, Voluntary initiatives, Preventive services.
720. Preventive Health Care in the HMO. Cost Benefit Is. Adapted from a presentation made at the 19th Annual Symposium on Hospital Affairs, University of Chicago, April 1977.
sues.
Daniel S. Rowe and Gerald E. Bisbee. Descriptor(s): Demand/utilization of health care programs, Cost containment efforts, Impact of third-party coverage, Prepaid plans, Competition/interaction among third-party payors, Health care/services, Outpatient facilities,
719. Prevention.
Rhetoric and Reality.
Neil A. Holtzman. 1979, 15 pp. Availability: International 39 1979.
Jnl. of Health Services v9 nl p25-
Stating that no single strategy is capable of preventing untimely deaths and disabilities, this article assesses preventive care strategies. In the United States, in particular, the contribution of medical care is limited by inadequate provision of services (particularly to the poor), inappropriate training of physicians, and unnecessary costs. Lack of knowledge about disease universally limits medicine's effectiveness. Among nonmedical strategies, campaigns for lifestyle change are most likely to succeed in those with the lightest burden of illness. Efforts to increase individual responsibility might well reduce health expenditures, but at the same time, the disparity in health between rich and poor will increase. Restrictions on the use of harmful substances and on the manufacture of toxic or hazardous products, along with humanization of the work process itself, would reduce deaths from cancer, heart disease, and violence; however, resistance to these changes is, and will remain, great. The socioeconomic and environmental changes that are necessary to afford each citizen an equal opportunity for optimal health will be adopted slowly, if atall. Considering thelimitedacceptabilityofthesenonmedical strategies, the prospects for prevention are less than what has been promised. Despite its imperfections, medical care can contribute to the prevention of early death and disability. Attempts
1978, 5 pp. A vailabib'ty: Jnl. of the American College Health Association v26 n2980301 p298-301,316 Jun 78.
The cost-benefit of providing annual physical examinations for a sample of graduate students in the Yale Health Plan is analyzed; the role of alternative forms of health education is discussed, as well as recommendations for the continued fk_:4d and medical efficacy of the annual physical examination. The Yale Health Plan is a health maintenance organization serving members of the Yale community. The data were obtained from the Internal Medicine Department, which is responsible for about 24 percent of the total ambulatory care visits, 14 percent of the hospital discharges, and 28 percent of the short-term are discharges. Data were collected during 60 working days from July 15, 1976, to October 6, 1976. The sample population consisted of 5,142 patient encounters, of which 1,252 were by graduate students and 3,890 were by faculty, staff, and their dependents. Costs were determined by measuring direct expenses, which are a function of physician time, laboratory, and radiology procedures, along with other direct expenses. The study found that (1) the mean cost of preventive routine physical examinations for graduate students was significantly greater than the mean cost of other examinations conducted in the Internal Medicine Department; and (2) the cost of performing a routine preventive physical examination regularly does not appear to be justified for medical reasons when conducted on a young healthy university student population. These findings indicate that each institution must make individual resource allocation decisions regarding the benefit of conducting routine preventive physical examinations; nonmedicai benefits may inelude marketing and health education. For reasons of cost effectiveness, mid-level health care workers, such as nurse practitioners, could conduct routine preventive medical examinations on a healthy population. Tabular data and references are provided.
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Presented before the combined sessions on administrat_bn and health education, fifty.sixth annual meeting,, American College Health Association, New Orleans, LA, March 29, 1978.
DescHptor(s):Characteristics of U.S. health care system, Health care costs, Preventive services, Policy/changes re health care.
Descriptor(s):
722. Price Setting in the Market for Physicians' Review of the Literature.
Cost containment
tive services, Cost/benefit
efforts, Prepaid plans, Preven-
analyses, Health care/services.
Services.
A
David A. Juba.
721. Preventive Medicine USA. Health Promotion and Consumer Health Education. National Inst. of Health, Bethesda, MD 20205 American Coll. of Preventive Medicine, Washington, 20005 1977, 255 pp. Availability: Prodist,
DC
New York, NY 10010.
Pennsylvania Blue Shield, Harrisburg, PA 17120 Health Care Financing Administration, Washington, Sep 1979, 99 pp. Availability: Health Care Financing Administration, Publications Baltimore. MD 21235. This study reviews recent health services research
DC. ORDS
of supply,
demand, and price in the physicians' services market. Data i11ustrate the growth in prices, expenditures, and utilization of physicians' services. Increases ill the levels of such expenditures paid by third parties are documented. Basic competitive and monopolistic models of the physi(:ians' services market are developed
A three-part report on health promotion and consumer health education is presented. The work emphasizes the relationship between health status and lifestyle and the timeliness of the current challenge to consumer health education. Current programs, practices, and problems of health education are then summarized and analyzed. The book concludes with recommendations for health professionals, policymakers, and citizens who work to resolve consumer health issues. Specific topics considered include lifestyle and health status, the inadequacy of therapeutic medicine, cost and financing, effectiveness, and a need for national leadership. First, the report notes that factors of individual behavior and lifestyle play a major role in health, illness, disability, and premature death. Also, individual behavior and lifestyle are influenced by multiple factors, some of which are internal to the individual and some of which are related to the
and critiqued. The physician's ability to function as the patient's "agent" is discussed, as are the principal behavioral objectives often attributed to physicians. The demand for physicians' services and the supply of such services are examined separately; empirical evidence shows how each is related to market price. The elasticity of demand with respect to time (acting as a price) is also discussed along with the physicians' purported ability to generate demand for their services. Evidence of "backward bending" supply curves is presented. Price equations are developed which relate prices to various market conditions. Empirical evidence suggests that revenues per visit are positively related to the extent of insurance coverage. Evidence linking prices and the local supply of physicians as well as the quality of their services is still inconclusive. The relationship between practice organization form and prices is not clear, although some evi-
environment or society. Health education must address both and is therefore related to general policies affecting health. The justification for health education and health promotion depends partly on assumed economies but even more on the conviction that good health demands individual knowledge, responsibility, and participation. Although the effectiveness of most current health education programs and practices is unknown, society can only learn by doing; and waiting until all the data are available would be unwise. Substantial resources should be committed to the advancement of health education and health promotion by public and private sectors. The Federal Government should promote these efforts and take into account the probable effects on health of all major national policies. A rigorous approach to research, a regional approach to programs and practices, and mechanisms for adequate financing should be emphasized. Chapter references and appended information are included. (Author abstract modified)
dence suggests that revenue-sharing physicians' groups charge somewhat lower prices. Tabular data, mathematical examples, and over 70 references are provided.
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HeMth Care Financing
Grants and Contracts
Report
Ser_es.
Descriptor(s): Supply/availability of services, Physicians, Medical/surgical services, Demand/utilization of health care programs, Impact of third-palrty coverage.
723. Pricing, Demanders, and the Supply of Health Care. Alan Maynard. Social Sciences Research Council, 1979, 13 pp.
New York, NY.
Health
Care Programs
Availability: International 133 1979. The role of the demander
Jnl. of Health Services v9 n 1 p 121-
in health care markets is identified and
analyzed. In addition, the use and effects of the price mechanism in the health care market are examined, along with the market (liberal) and the collectivist (needology) mechanisms for regulating the supply and demand of health care. The neoclassical paradigm maintains that, other things being equal, the demand for. a commodity is related to its price. Here the paradigm is developed to show that insurance with coinsurance variables might produce an efficient allocation of resources. This converttional wisdom is then challenged by arguing that demand might be determined not by the patient-demander but by the physiciandemander in an agency role. The effects of pricing on patientdemanders are examined with reference to available empirical evidence. It is argued that if the use of the pricing policy instrumerit is aimed at curbing expenditure inflation and increasing the efficiency of resource allocation, it might be ineffective because of the physician-demander agency role. If resource allocation is to be improved, alternative remuneration and budgeting systems should be tested in an effort to encourage decisionmakers to act more efficiently. If liberal and needologist positions were examined regarding the supply and demand of health care, the liberal would be likely to believe that consumer sovereignity should be preserved and intervention limited to market-supplementing measures which mitigate the effects of the agency relationship and take account of consumption of externalities. The needologists, on the other hand, would prefer to take account of the externalities by supplanting the market and the monopoly of the physician agency role with an efficient public choice mechanism. These two views are expected to underlie much of the health care debate in future years. References (52 items) are provided. (Author abstract modified)
Findings are presented from a survey of the primary care services available to and used by the population of Durham CourLty, N.C. from 1975 to 1976. The ambulatory care services of private practices and institutions in the county were sampled four times during 1975 to 1976 to determine the relative contributions to primary care made by specified types of practices and sources of care. All the institutions and 96 percent of practicing physicians participated. Use of primary care services was analyzed by race, sex, age, and health insurance status. One striking finding was the predominant role in the delivery of primary care played by the private specialists practicing in the community in contrast to the relatively minor role of the university teaching hospital. Another important finding was the low proportion of blacks and medicaid patients served by these community physicians. Removal of legal and financial barriers was found to have made little impact as yet on the patterns of health care delivery established before the mandatory integration of health services. Further, private physicians in the community and at the university were found to be seeing virtually all patients with private irLsurance, leaving the ambulatory services of the community clinics with a disproportionate share of noninsured patients. The teaching hospital, by providing only a small proportion of the total primary care rendered to the county residents, projects a model of specialist practice with implications for the future organization of the health care delivery system. Charts, 17 references and tabulax data are provided. (Author abstract modified)
Descriptor(s): Demand/utilization of health care programs, Supply/availability of services, Participation in health care programs, Health care/services, Facilities providing health care, Providers of health care services.
725. Primary Health Care in an Academic Medical Center. Descriptor(s): Supply/availability of services, Economic/commercial influences, Health care costs, Policy/changes re health care.
724. Primary Care in Durham County. Who Gives Care to Whom.
Stephen B. Thacker, Eva J. Salber, Lawrence H. Muhlbaier. Duke Univ. Medical Center Dept. Medicine, Durham, NC 27706 Robert Wood Johnson Foundation, 1978, 10 pp. AvMlability: Medical Care v127 nl
Carolee
Stephen B. Thacker, Eva J. Salber, Carolee Osborne Lawrence H. Muhlbaier.
and
Duke Univ. Medical Center Dept. of Community and Family Medicine, Durham, NC 27706 Robert Wood Johnson Foundation, Princeton, NJ. 1978, 5 pp. Arailnbib'ty: American Jnl. of Public Health v68 n9 I)853-857 Sep 78.
Osborne and
of Community Princeton,
NJ.
and Family
p69-78 Jan 79.
This paper is the second report of a study on primary care in Durham County, N.C. The first report described the whole primary care system of Durham County, included 47 of the 50 private community practices, and demonstrated the effects of race, sex, age, and insurance status on utilization behavior in specific institutional facilities and types of practice. This present
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paper focuses on the private and public clinics of Duke University Medical Center. Although Duke renders some primary care through its Emergency Room and Family Practice Center, the data results reported here are based upon that collected from only the Private Diagnostic Clinic (PDC) and the Public Outpatient Clinics (OPC). Data were analyzed to document differentials in sociodemographic characteristics of patients attending the two systems of care during four sample periods in 1975 to 1976. It was found that the OPC clearly treats a very different segment of the population than the PDC. A large proportion of OPC services are provided to children, and virtually all medicaid patients attended the OPC. Furthermore, practically all medicaid patients attending the OPC were black. On the other hand, most primary care visits to the PDC were from adults, less than 10 percent were persons with medicare, none had medicaid, and over half carried additional private insurance. The implication of the two-class system of care is, first, that the quality of care given in the OPC and the PDC are not the same. The OPC is less comfortable and convenient, the care is fragmented, episodic, uncoordinated and, it seems reasonable to assume, inferior to that given in the PDC. The second implication is that medical education is not optimal in an institution with a two-class system of care. However, alternative service and teaching models are possible in university settings, as illustrated by the Beth Israel Hospital in Boston, Mass., and the Duke Family Medicine Cen-
addressed by the usual methods of regulation such as payment control, quality review, planning and certificate of need requirements, or building codes and standards. Despite innovative proposals to introduce elements of competition into the medical marketplace such as health maintenance organizations, it is virtually certain that legislative bodies will continue to see health care as a noncompetitive 'industry requiring extensive and detailed regulation. Up to now, antitrust laws have not been forcefully applied to the health care industry, but hospitals need to be aware that antitrust actions are frequently invoked by private parties believing they have suffered from restraint of trade. Hospitals are likely to become increasingly involved in this type of litigation even in the absence of active government antitrust enforcement. Antitrust and regulatory interventions are not necessarily mutually exclusive, and antitrust laws may provide hospitals with an additional legal avenue for defending their rights to compete. Federal antitrust interventions could ensure the opportunity for alternative forms of health care delivery to develop without fear of hindrance from existing provider organizations. In addition, some forms of exemption from regulation might encourage greater participation in nontraditional delivery methods in response to the consumer's persistent problems of increasing costs, difficul_ access, and unverifiable quality. Thirty-five footnotes are provided.
ter which abolished them with one-class Two tables showing ing distribution of references.
Earlier draft of this article, presented June 24, 1977.
the traditional general clinics and replaced primary care hospital-based group practices. population distributions and 2 figures showprimary care visits are included, as are 29
at Ohio State University,
Descriptor(s): Demand/utilization of health care programs, Supply/availability of services, Present legislation/regulations.
Descriptor(s): Outpatient facilities, Participants programs, Providers of health care services.
in health care
727. Private Cost Containment.
726. Primer on Antitrust and Hospital
Regulation.
David F. Drake and David M. Kozak. 1978, 17 pp. Availability: Jnl. of Health Politics, Policy and Law v3 n3 p328-344 Fall 1978.
This paper compares the effects of regulation and antitrust litigation on general market dysfunction and describes the medical marketplace and the effects both regulation and antitrust efforts have had in this area. The demand for health care services is different from the demands for other services in the marketplace, but most regulatory mechanisms in health care were developed on the assumption that the usual marketplace constraints failed to control costs. The problems of health care service are not
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Clark C. Havighurst and Glenn M. Hackbarth. National Center for Health Services Research, Hyattsville, MD. 1979, 8 pp. Availability: New England Jnl. of Medicine v300 n23 p12981305 7 Jun 79.
Physicians should recogni_,e that a more competitive health-care market would provide the best defense against government regulation. Aside from establishment of group-practice health maintenance organizations, the cost-containment steps that might be taken in such a market are not well understood. In particular, little attention has been paid to how private health insurers might redefine their coverage to limit the cost-increasing effects of third-party payment. Insurer-provider agreements negotiated in a competitive environment are especially promis-
Health Care Programs
ing. Competing insurance plans would be variously organized and operated according to provider and consumer preferences, Traditional doctor-patient relations as well as fee-for-service payment could be preserved. Plans that rely on provider selection to control costs embody implicit benefit limitations in that the chosen providers' benefit-cost decisions have the practical effect of limiting coverage. However, an insurance plan with numerous explicit limitations and exclusions cannot function without excluding providers who are unwilling to prescribe administrative procedures. Physician accountability, plus the influence that consumers exercise over the plans themselves, is the essence of competition in medical care. The antitrust laws, while curbing concerted effort to prevent change, should assure that physicians are not exploited by dominant buyers. Lucrative opportunities already exist for enterprising and efficient providers, A total of 15 references are included. (Author abstract modified)
Descriptor(s): Economics of third-party payors, Commercial health insurance plans, Competition/interaction among thirdparty .... payors, mmatlves,
Physicians,
Cost containment
728. Private Health Insurance Abuse and Mental Illness.
efforts, Voluntary
Benefits for Alcoholism, Drug
should attract more third-party coverage it" private insurance offered better coverage. Discrimination, treatment costs, 'patient needs, and provider activity have all played a role in States which have enacted laws mandating these benefits. The major problem with existing insurance coverage of substance abuse and mental illness is a traditional preference for inpatient medical treatment. The literature on the illnesses suggest that hospital care may be neither the most efficacious or cost effective. However, there are justifiable concerns about such things as the high cost of outpatient psychiatric care, the "success" rate of drug treatment programs, and the potential for increased utilization. Policymakers and others considering expanding or mandating insurance benefits for these diseases find limited cost and utilization data on insurance benefits for existing mental health coverage. Even less information exists on the cost of insurance coverage for drug abuse. Yet a California pilot program demonstrated that benefits would have cost only $2.05 per year per policy, this cost being based on very low utilization rates. The Wisconsin State Insurante Office data also supports the findings that only small premium increases are necessary to cover mandated benefits. Model benefit packages, developed through various Federal grants and contracts, attempt to balance the need for treatment with cost containment concerns by limiting treatment duration anti dollar payments for care. If field tests of these packages are conducted, more reliable information about the cost of insurance benefits for alcoholism, drug abuse, and mental illness should become available.
Mary Lou Cooper. George Washington Univ. Intergovernmental Health Policy Project, Washington, DC 20006 Jul 1979, 34 pp. Availability: George Washington Univ., Intergovernmental Health Policy Project, Washington,.
Descriptor(s): Mental health services, Publicly sponsored/mandated health plans, Mandated benefits, Policy initiatives, Nonparticipants in health care programs, Private health care plans, Limitations on coverage.
This study of mandated insurance benefits for the treatment of alcoholism, drug abuse, and mental illness examines the health
729. Private Health Insurance
programs and statutes of State governments. Because private insurers have extended only limited coverage for substance abuse
Marjorie S. Carroll. Health Care Financing 20203
and mental illness, some States have mandated expansion of such benefits. However, insurers and employers offer a multitude of philosophical and practical reasons for opposing comprehensive health insurance benefits for all or one of these diseases. For instance, some insurers object to nonmedical treatment of alcoholi,_m and drug abuse because they believe these are social problems. Many disapprove of substance abuse centers staffed by social workers or ex-addicts and prefer Joint Commmmission on Accreditation of Hospitals (JCAH)accreditation to State regulation of treatment centers. Although private health insurance coverage of alcoholism, drug abuse, and mental illness will not necessarily reduce the need for public financing of treatment programs, there is evidence that at least some of the programs
Plans in 1976: An Evaluation.
Administration,
1978, 14 pp. Availability: Social Security Bulletin
Washington,
DC
v41 n9 p3-16 Sep 78.
This article presents trends and statistics for private health insurance plans in 1976. The net number of different persons who had private health insurance increased, although total enrollments dropped as duplicate coverage declined. The steady rise in the cost of health care, higher use and the demand for eapanded services was reflected in a record $39.4 billion collected in premiums by private health insurers, with $35 billion returned to subscribers as benefits. Claims and operating expenses under
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insurance company group business ran 3 percent above premium income, resulting in a net underwriting loss of $6 i 1 million, About 77 percent of the civilian population had some form of private hospital insurance, and about the same percentage had some form of surgical insurance. Dental coverage rose sharply, and coverage for nonhospital-associated care showed some gains. An estimated 12-13 percent of the population under age 65 had no economic protection against the costs of illness or health-related care, either under private insurance or a public program. Although virtually all of the aged were covered by Medicare, some 13-15 million bought private insurance designed to cover the gaps in the Federal program. Other areas of analysis include the quality of health insurance (group coverage, individual policies), the insurance industry (growth in total enrollments, net coverage, major medical coverage, independent group practice prepayment plans, financial experience, operating statistics, premium income and benefit trends, benefit expenditures by type of care and insurer, operating expense), and effects on the consumer (consumers' net cost, proportion of consumer expenditures met by insurance). Gross enrollment figures are total enrollments reported by the various insurers, by type of cart.', Blue Cross and Blue Shield data were supplied by the associations. The data for insurance companies were compiled by the Health Insurance Association of America. A technical note prorides detailed information on data sources. Twelve tables are provided, plus two additional tables in the technical note. Foolnotes are also included. (Author abstract modified)
Desct4ptor(s): Participants in health care programs, Third-party payors, Commercial health insurance plans, Service benefit plans, Prepaid plans, Non-participants in health care programs.
percent of the elderly have at least one private health insurance policy to cover the gaps in medicare coverage. The annual premium volume of this "medigap" business has been estimated at $1 billion. The lack of consumer information in the medicare supplement market is so great that it is almost impossible to comparison shop or to make rational purchase decisions. In an effort to get complete protection, many people over 65 buy 2 or more policies. However, most supplimental policies fall far short of the consumers' expectations, since they will not pay for preexisting conditions, nursing home care, excess provider charges, and prescription drugs. In response to complaints, several States have tried very different regulatory solutions, such as establishing minimum standards for s_cpplemental policies, categorizing the policies, or labeling the policies according to the benefit level. Federal Government initiatives to address the regulation of health insurance for the elderly could take several approaches, but the one most likely to eliminate the purchase of unnecessary duplicate coverage would be to focus on all health insurance policies sold to the elderly. In order to promote competition, any initiative with respect to supplemental insurance should provide complete information in a usable form, ensure access to that information, standardize t;overage, and eliminate duplication. Governmental action concerning health insurance for the elderly could take three principal forms: minimum standards, a system of standardization combined with disclosures, or provision of information to consumers. Recommendations include conducting an impact evaluation to determine the effectiveness of existing State regulations of insurance sold to supplement medicare. Footnotes and 15 appendizes of related material are provided. (Author abstract modified) Policy Planning Descriptor(s):
730. Private Health Insurance to Supplement Medicare. Volume
I.
Issues Paper.
Impact of third-party
coverage, Non-employment
related plans, Medicare, Exclusions from coverage, Participants in health care programs, Present legislation/regulations, Policy initiatives.
Anne DeNovo and Gall Shearer. Federal Trade Commission Office of Policy Planning, Washington, DC 20580 Jul 1978, 235 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 018-000-00234-5.
731. Private Industry Health Insurance ministration and Insurer ill 1974.
Plans.
Type of Ad-
Daniel N. Price. 1976, 21 pp.
Health care costs are a major expense and source of concern for the eldcrly. Medicare covers only 38 percent of their health care costs. These people must pay for medicare's deductibles and coinsurance and for many kinds of care which medicare will not cover, including drugs, dental care, eyeglasses, hearing aids, rou-. tine examinations, and most nursing home care. More than 50
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Availability:
Social Security Bulletin v40 n3 p13-33 Mar 77.
This report examines the major forms of administration of private health insurance plans. Plans are classified according to whether they are employer-only or joint worker-employer operated and according to whether they are negotiated or not. The
Health
Care Programs
report also examines whether the plans cover workers of a single employer or involve multiemployer arrangements. These classifications of administration and the method of insuring benefits are examined in terms of proportion of workers with specified plan characteristics and health benefits. The data represented in this report derive from a 1974 Bureau of Labor Statistics survey involving 51,600 plans that provide at least a basic hospital benefit or a comprehensive major medical benefit and have at least 26 participants. Most employer-administered plans, whether or not negotiated, were established to provide benefits to workers of a single company, but 9 out of 10 of the workers in jointly administered programs were in multiemployer plans, More than 6 out of 10 health benefit plans and workers were covered through commercial insurance, 3 out of 10 through Blue Cross, and the remainder through self-insurers and independent plans. Workers in employer-administered, negotiated plans were more likely to be employed in manufacturing industry where large numbers of workers are paid by the hour. In general, workers in employer-administered negotiated plans were more likely to have basic hospital benefits, service benefits or higher cash allowances, more days-in-hospital coverage, and basic surgical benefits and higher cash benefits than those in other plans, Tabular data are provided; footnotes and graphs are also given, (Author abstract modified)
Descriptor(s): Participants in health care programs, Commercial health plans, Service Health benefit plans, Private health care plans, insurance Claims administration, care/services.
732. Private Physicians and Public Programs.
national survey. After adjusting for a 30 percent ineligible rate, a net sample of 1,545 was obtained from which 1,014 national interviews were completed. The final response rate after conversions was 66 percent. A five-part questionnaire was used in the interviews. The analytical and attitudinal questions focused on the organization and characteristics of the physician's practice and the extent of participation in third-party reimbursement programs. Other questions collected information on costs and income. The results were consistent with the general model of price discrimination in which physicians are assumed to order patients by their ability to pay. Physicans cited low medicaid fee schedules as a major reason for nonparticipation. However, it is concluded that raising the fee schedules of public programs would not effectively spread the current medicaid population across a broader number of physicians unless private payers also held their fees constant. Further, the red tape involved in obtaining reimbursement directly from the Government definitely lowers physician participation in public programs. The marginal dollar, perhaps, would be better spent on improving payment mechanisms than on raising fees. Furthermore, doctors are dependent upon hospitals for medical labor such as technicians and nurses, so that effective Federal regulation of hospital costs, including wages and salaries, could have a positive, unintended side effect on access by the poor to physicians in their offices. Since political attitudes about public welfare programs do not dominate physician decisionmaking, a general reluctance of physicians to participate, based on ideology, can be overcome through raising fee schedules, reducing payment delays, simplifying data requireraents for reimbursement, controlling hospital costs, and continuing the influx of foreign-trained physicians. Inefficiency in all settings is tolerated by consumer and provider alike because of the difficulty in defining and measuring practice output, subsidized utilization by third-party payers, and a general disinterest in cost control on the part of high-income physicians. Footnotes, 6 figures, 27 tables, and an index are provided.
Frank A. Sloan, Jerry Cromwell and Janet B. Mitchell. Abt Associates, Inc., Cambridge, MA 02138 Health Care Financing Administration, Washington, 1978, 173 pp. Availability: D.C. Heath and Co., Lexington,
Abt Associates
Series in SociM Policy Analysis.
DC.
MA 02173.
This study focuses on the technical, organizational, and personal reasons why the costs of private physicians' practices vary so much; the true dimensions of the red tape involved in Government reimbursement of physicians' services; and factors affecting physician participation in public programs. Private practice physicians constitute the key element in the delivery of medical care in the United States, yet little attention has been given to the role of financial incentives in physicians' decisions to treat certain patients, delegate responsibility, bill patients, and administer their practices efficiently. A nationwide survey of 2,000 private practice fee-for-service physicians was conducted. A total sample of 2,148 physicians was originally drawn from the
Descriptor(s): Cost containment efforts, Impact of third-party coverage, Medicaid, Physicians, Medicare.
733. Private Sector Perspective on the Problem Care Costs.
of Health
Washington Business Group on Health, Washington, DC 20003 Department of Health, Education, and Welfare, Washington, DC. Apr 1977, 50 pp. Availability: Washington Business Group on Health, Washington, DC 20003.
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This report presents the second phase of an ongoing effort to have major employers and the Carter Administration work cooperatively in pursuit of an improved health care system for the United States. The main theme presented is that the rapidly growing quantity and quality of private and private-public ef-. forts to contain health care costs without reduced quality of care is evidence that methods other than price controls can effectively achieve an improved health care system in the United States. Survey results demonstrate that employer involvement and com.mitment is increasing rapidly; broad-scale experimentation has become acceptable; knowledge of and concern for health care, rather than just medical care, is increasing; and employers find that they can reduce waste, lessen utilization, save money, and in so doing, provide better health benefits for employees. The report discusses cost containment initiatives at two levels: actions which can have some immediate or relatively short-term impact, and efforts which are long-term and essential if the problem is ever to be solved. Topics discussed are divided into three categories: areas of broad concern which can have lasting, system-changing impact; administrative controls; and benefit program changes and additions. Areas of broad concern include health planning, alternative delivery systems, health education,
rent health insurance plans of the Department of Health, Education, and Welfare and on tbe needs for drug coverage. Special attention was directed to drug insurance and the quality of care; cost containment; coverage of full pharmacy services; drug insurance and automatic dat_Lprocessing; and the policy needs of pharmacy, medicine, the industry, and consumers. Evident differences emerged on such matters as price controls, formularies, drug utilization review, reimbursement policies, and beneficiaries and drug products to be covered. There was apparent agreement, however, that the financial cost of an appropriate drug insurance program would be more than offset by savings in minimizing more costly physician visits and hospitalization. A reimbursement policy under drug insurance and supplementary comments are appended. (Author abstract modified)
quality assurance, and prospective State review. Benefit program changes and additions encompass such factors as second surgical opinions, preadmission testing, home health care, eoinsurance and deductibles, health screening, ambulatory care and surgical centers, and special illness programs. Cost containment initiatives are also examined company by company. A final section highlights hospital cost control measures. Company statements are appended, four references are included.
735. Prigs of the 28th Annual Group Health Institute, New York, New York, June 18-21, 1978.
Descn'ptor(s): Cost containment efforts, Voluntary initiatives, Outcome/evaluation of health administration, Plan design/program provisions (under health plans), Private health care plans,
734. Proceedings of the National Conference on Drug Coverage Under National Health Insurance.
Milton
Silverman
and Mia Lydecker.
National Center for Health Services Research, Hyattsville, MD 20782 DHEW/PUB/PHS-78-3208 Oct 1977, 135 pp. A vailability: Department of Health, Education, and Welfare, Washington, DC 20782.
The conference was designed to consider major research essential to support policy decisions in the field of drug coverage under national health insurance. Presentations focused on cur-
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Descdptor(s): ment efforts,
National health insurance (NHI), Cost containPharmaceutical services, Plan design/program
provisions (under health plans), Policy initiatives.
Group Health Association of America, Inc., Washington, DC 20036 1978, 488 pp. Availability: Group Health Association of America, Inc., Washington, DC 20036.
The proceedings of the 28th annual Group Health Institute, held in New York, on June 18-21, 1978, are presented. The papers focused on various aspects of concern to health maintenance organizations (HMO's) _ad prepaid group practices. The proceedings begin with general session papers reporting on labor's view toward HMO's, a challenge to revitalize HMO growth, and a discussion of HMO involvement in Medicare and Medicaid. The Carter Administration's policy on health care is examined. In addition, roundtable discussions considered such issues as appointment systems in IlMO's; critical issues in HMO health planning; financial planning, rate making, and budgeting; the development of an effective HMO board from an executive director's view; and malpractice and risk control programs. Other roundtable discussions examined preventive health systems, member retention and member services, HMO's and medicaid, and physician remuneration. Contributed papers highlighted important areas of concern to HMO's in marketing; clinical management; organization, development, and research; provider roles and clinical outcomes; financial management; urgent services; alcoholism treatment; and mental health services. Tables, footnotes, and an index are supplied.
Health Care Pr_grams
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Funding/financing of health care programs, Publicly sponsored/mandated health plans, Health care costs, Thirdparty payors, Health care/services, Providers of health care services, Outpatient facilities, Outcome/evaluation of health administration.
Descriptor(s): Prepaid plans, Participants in health care programs, Plan design/program provisions (under health plans), Health insurance industry, Premium determination/underwriting.
737. Professional Standards Review Organization
Program.
Committee on Ways and Means (U.S. House) Subcommittee 736. Proceedings. 27th Annual Group Health Institute, Los Angeles, California, June 19-22, 1977.
on Health, Washington, DC 20515 Aug 1980, 459 pp. Availability: Printed for the use of the Committee on Ways and Means.
Group Health Association of America, Inc., Washington, DC 20036 1978, 420 pp. A vailability: Group Health Association of America, Inc., Washington, DC 20036.
The testimony of those appearing before the House Subcommittee on Health's August 25, 1980, hearing on the professional standards review organization (PSRO) is presented. The purpose of the hearing was to gather testimony on the performance and effectivness of the PSRO program. Although most recent emphasis has been on the cost containment aspect of PSRO review activities, the committee also examined the quality assurance
The proceedings of the annual Group Health Institute meeting i,,cludes the edited text of contributed papers and presentations during the general sessions and round table discussions. The papers present current and practical information for dealing with the many issues facing health maintenance organizations (HMO's). Clinical/specific services, data management, and educational programs are discussed. HMO marketing issues, as well as regulatory and legal issues, are examined. The results of utilization control are also discussed. Other issues covered are the
aspect. Among the advantages of PSRO's emphasized by witnesses were the system's fair and effective appeals procedures and the areawide provision of data that facilitates physicians' decisionmaking. Other issues raised include confidentiality, the relationship between the Federal Government and the practicing physicians in this quality control effort, PSRO sanctions, and the costs of PSRO review. Those testifying included representatives from hospitals, the Association of American Physicians and Surgeons, State PSRO councils and organizations, and the Ameri..
structural quality assurance in a prepaid group practice plan and HMO facility design considerations. One session examines the issues and problems of enrolling existing plan membership in new HMO structures and outlines the Health Insurance Plan (HIP) of Greater New York's efforts to become a federally qualified HMO. A survey of HIP members found that while about one-third of the subscribers report themselves "very likely" to remain in the plan if required to pay for additional benefits, and another one-third were "fairly likely" to remain, there is the p._tcntial for the loss of about one-fifth to one-fourth of present carollmcnt. Satisfaction with the plan and with the physicians providing services was clearly a major factor in subscriber willinqness to remain with the plan despite increased costs. Round table discussions dealt with Federal employee benefits, medicaid contl-acts, and malpractice and risk control. One round table on the role of the insurance carrier described the variety of possible relationships between carriers and HMO's. Ways in which carriers can be useful to developing and operational HMO's were notcd a_ld the possibility of using brokers or of working with "multiple employer trusts" were discussed. In addition, the issuet; _)f developing premium costs for indemnity coverage as it relates tt_ HMO coverage were debated.
can Medical Association. Material submitted for the record included statements from the American College of Physicians, congressional Representatives and Senators, private physicians, hospitals, and the American Hospital Association. 96th Congress second sessibn, Serial No. 96-11Z Descriptor(s): Cost containment efforts, Present legislation/ regulations, Outcome/evaluation of quality assurance:, Outcome/evaluation of health administration.
738. Professional Standards gram Evaluation.
Review Organization
1979 Pro-
Health Care Financing Administration Office of Research, Demonstrations, and Statistics, Baltimore, MD 21235 HHS/PUB/HCFA-03041/5/80 1980, 198 pp. Availability: Health Care Financing Administration, ORDS Publications, Baltimore, MD 21235.
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This report describes the implementation of the Professional Standards Review Organization (PSRO)program through 1979, but it analyzes the program through 1978. The third in a series, this evaluation shows that for the second consecutive year, PSRO's have reduced medicare hospital use compared with inactive PSRO areas, and that, overall, concurrent PSRO medicare review actively continues to pay for itself. The 1978 estimated savings to medicare by the PSRO concurrent review of medicare beneficiaries is $21 million over administrative costs, The major utilization study presented in this report demonstrates that PSRO impact is not uniform across the nation. Also reported here is the first major study of PSRO impact on physiclan compliance with quality of care criteria. The study found that when PSRO's identified variations from accepted standards, compliance with those standards improved significantly over time. A utilization study analyzing procedures and diagnoses for which PSRO impact seemed most likely is also reported, with four out of five test cases evidencing such impact. In addition, an attempt is reported to compute medicaid hospital utilization rates using four PSRO's as case studies. The analyses indicate that existing medicaid data sources are not sufficiently well developed to permit adequate assessment of PSRO's in that sector, The examination of operational costs indicates that these are still rising for the program, partly due to the increased conduct of profile analysis, areawide medical care evaluation studies, and other forms of review. Footnotes, 115 tables, and three appendices containing PSRO implementation status, a glossary of abbreviations and acronyms used in this volume, and a glossary of terms are included. (Author abstract modified)
pay. The average company now provides basic hospital-surgicalmedical expense coverage for all employees and their dependents. Major medical coverage is provided for office emloyees in 95 percent of the companies. For companies with nonoffice employees, 86 percent haw: this coverage. Long-term disability insurance is provided for managers by 72 percent of the profile companies, for office-clc'rical employees by 62 percent, and for nonoffice employees by 28 percent. About 85 percent of the companies have pension plans, but a minority have chosen to relate retirement costs to profits through deferred profit-sharing plans. Eight out of 10 pension plans are noncontributory for both office people and nonoffice people. Virtually all companies provide group life insurance coverage, and three out of four attach accidental death and dismemberment riders. Layoff and severance benefits are not much more widespread than in 1964. A little over half (56 percent) of the companies have severance pay plans and the incidence of supplemental unemployment benefits plans is below 15 percent. However, time off with pay has increased for all classes of employees. Many companies have reduced the requirements for 3-week and 4-week vacations by 5 years, but these are still typically given after 10 and 20 years of service. On the average, companies have added two paid holidays since 1964, so that nine l_Lolidaysare now typical. Fully one-third of the companies have 10 holidays or more, up from 19 percent in 1964. Detailed charts show the status of each major employee benefit. Chapter notes are included.
Health
Descriptor(s): Commercial health insurance plans, Source of premium payment, Private health care plans, Plan design/program provisions (under health plans).
Care Financing
Research Report
Series.
Conference
Board Report
No. 645.
Descriptor(s): Medicare, Medicaid, Present legislation/reglflations, Outcome/evaluation of health administration, Hospital services, Health care costs. 740. Profile of Health-Care Coverage. The Haves and HaveNots.
739. Profile of Employee Benefits. Mitchell Meyer and Harland Fox. Conference Board, Inc., New York, NY 10022 1974, 103 pp. A vailabi/ity: Conference Board, Inc., New York, NY 10022.
Maureen Baltay. Congressional Budget Office, Washington, DC 20515 Mar 1979, 72 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 0524)70-04880-0.
This analysis of the employee benefits programs of a large, diverse sample of companies provides profiles of typical benefit packages and identifies potential new trends in 10 major industries. Major benefit classifications are profiled, including health insurance, disability income, retirement income, group life insurance and other death benefits, severance pay, and time off _ith
In 1978, more than 90 percent of all Americans either had health insurance or were eligible for public programs that give some protection against f'mancial losses associated with medical care. However, from 5 to 8 percent of all Americans did not have such protection. To evaluate alternative health insurance proposals, it is important to know the size and character of the uncovered
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Health
Care Programs
population. The uncovered are mostly from lower income families (incomes below $10,003) and are young. Unemployed persons and young adults are more likely than others to be uncovered. The overwhelming majority of the uncovered are members of families rather than single persons. To evaluate the adequacy of coverage requires detailed information on four faetors: financial resources of the family, health status of the merebers and the likelihood of their incurring health care expenditures of certain types, family preference concerning risk and the value placed by them on health care as compared with other goods, and types of coverage available to a family. Policy implications of the patterns of coverage are complex: (1) any plan that relies exclusively on employers to provide insurance will not encompass all of the uncovered population, (2) using any single dimension to define the population to be covered will help only some individuals and will give double coverage to some who already are covered, and (3) changes in existing programs such as medicaid could substantially reduce the uncovered population. Finally, if all uncovered workers and their dependents had employer-provided coverage, and if all the self-employed were covered, the number of uncovered would be cut in half. Foot-
total expenditures. Furthermore, 39 percent of all health expenditures in 1975 passed through the profit sector. From 1962 to 1975, health expenditures in the profit sector increased 327 percent, compared to 277 percent growth for all health expenditures. Moreover, profit sectors have accelerated their growth rate since the beginning of medicare and medicaid in 1967. While the profit sector will never completely encompass the health care system, continued growth of profit sectors will cause their priorities to dominate the activities of the overall health industry. The results will probably be a distortion of basic human needs, enhancement of the profit sector's political power, and new government regulations which increase costs, product standardization, and monopolization. Finally, decisions on types of research to be pursued and products to be produced will be determined by market conditions as perceived by profit-minded corporations rather than by socially accountable institutions or individuals. Figures, footnotes, and eight references are included.
notes and tables are provided, and additional ed.
programs,
Descriptor(s): Policy initiatives, health care programs.
tables are append-
Medicaid, Non-participants
Descnptoffs): Characteristics of U.S. health care system, Economic/commercial influences, Funding/financing of health care Health care costs, Facilities providing
health care.
in 742. Program for Elective Surgical Second Opinion. Surgical Faq_rience of Program Participants, 1976-1977. Jerome Joffe and Mark Schaehter.
741. Profits in Medicine.
Gelvin Stevenson. 1978, 14 pp. Availability: International 54 1978.
A Context and an Accounting.
Blue Cross and Blue Shield of Greater New York Health Affairs Research Dept., New York, NY 10016 Nov 1980, 17 pp. Availability: Blue Cross and Blue Shield of Greater New York, New York, NY 10016.
Jnl. of Health Services v8 n l p41-
The influence of the profit-making sector of the U.S. health industry is analyzed. The U.S. health industry is a mixture of private for-profit, private (voluntary) nonprofit, and public seetors. Profit-making enterprises have a monopoly on material production and are involved in all areas except medical schools, while voluntary and public institutions coexist in all areas. The profit sector is the trend setter because of economic necessity, often creating problems which the nonprofit sector must solve, The profit sector has expanded into new areas; in contrast, the public sector has only increased its role in financing, especially for medicare and medicaid. Calculating actual growth and size of the profit sector is complicated by a lack of necessary data and by difficulties in separating profit from nonprofit categories of payment in the data available. However, estimates set the 1975 profits of the profit sector at $3,321 million, or 2.8 percent of
This report focuses on the surgical experience of those who used the Program for Elective Surgical Second Opinion (PRESSO), the largest private sector second surgical opinion project in the United States. PRESSO is eounected to Blue Cross and Blue Shield of Greater New York, uses a dosed panel of board certifled surgeons, gives full payment for the consultation of it second opinion, and promotes voluntary use of the program for its more than 5 million diglble persons. The report also measures the surgical rates for the confirmed and nonconfirmed participants separately. Of the slightly over 1,500 participants whose consultations occurred from 1.5 to 4 years ago, somewhat under half have not had surgery. This includes 73 percent of the nonconfirmed, but also 34 percent of the confirmed cases. Acc_eptance of the nonconfirmation decision was highest among those who had been recommended for vascular and cardiac surgery (100 percent), proctology (91 percent), and breast surgery (89 percent). Adherence to a nonconfirmation was lowest among
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gynecological patients (63 percent). Nonsurgical rates were highest in the younger age groups. The total and age specific variation between male and female participants in their nonsurgical rates was small. As expected, the lowest nonsurgical rate (56 percent) was found for patients recommended for further diagnostic study. The highest nonsurgical rate (82 percent) was found for conditions judged benign or where no pathology was found. These findings reinforce the status of a nonconfirmation as an appropriate technique when surgery is recommended. When surgery was confirmed, adherence to the consultant's recommendation to undergo surgery was greatest among abdominal patients (81 percent) and least among orthopedic (55 percent), ophthalmologic (55 percent), and proctological (50 percent) patients. Among the confirmed, acceptance of the consultant's recommendation was greatest among the youngest age group (79 percent), while the acceptance rate was the lowest fi_r those aged 65 and over (39 percent). Over a third of the nonconfirmed surgery cases were performed within 30 days of the second opinion consultation, and slightly over four out of five within 6 months. However, the relatively short elapsed time fi_r the 81 percent of the nonconfirmed cases does not suggest inordinate delay in performing necessary elective surgery. Finally, of all the surgeries, slightly over one-third were performed by a physician other than the first opinion surgeon. Tables and footnotes are provided.
and "grand strategies." Small strategies, such as improving consumer information, dispelling the "medical mystique," understanding insurance, and instituting health education in the public schools, have limited affects, but they can be implemented locally and do not necessarily require legislative change. The "'grand strategies" require action :at the national level because they call for fundamental changes in medical care delivery. Four grand strategies are Health Maintenance Organizations (HMO's), Consumer Choice Health Plan (CCHP), private health insurance reforms, and structaral reforms. With the exception of HMO's, many plans have not been tested fully and some initial regulatory activity would be required. The mandate from Congress to begin to consider competitive forces is clear. Health planning agencies are in a unique position to rationalize the dual mandates. Imperfect as it may be, regulation appears to be the only tool available in the short run, but neither cost containment nor competition can be achieved in the short run without the political and financial support of Congress. Thirty-six references are provided.
Presso Report
744. Promoting Health. Consumer Education and National Policy.
No. 3.
Descriptor(s): Impact of third-party coverage, Service benefit plans, Medical/surgical services, Voluntary initiatives, Cost containment efforts.
743. Promoting Competition in the Health Industry. The Role of Health Planning. Institute for Health Planning, Madison, WI 53705 Health Resources Administration, Hyattsville, MD. May 1980, 42 pp. A vailability: Institute for Health Planning, Madison, WI 53705.
The phenomenal growth of health insurance and government programs over the past 40 years has isolated consumers from the costs of illness. Two possible solutions to the high costs of health care are regulation and competition. In 1979, Congress amended Titles XV and XVI to the Public Health Service Act to reaffirm the need for regulatory controls, but at the same time focused greater attention on competition. Possible approaches to increasing competition in health care include both "small strategies"
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Descriptor(s): Health care cost trends/projections, Cost containment efforts, Impact of third-party coverage, Policy initiatives.
Anne R. Somers. National Inst. of Health, Bethesda, MD. Fogarty Center. American Coll. of Preventive Medicine, Washington, DC. 1976, 264 pp. A vailability: Aspen Systems Corp., Rockville, MD 20850.
This report of the Task Force on Consumer Health Education presents the results of their exploration of the best ways to disseminate information on the value of preventive health care measures. The task force also explored ways to apply knowledge to prevent or modify the course of diseases. The report first discusses the relation of health status to lifestyle and the timelihess of the current challenge to consumer health education. Part two summarizes and analyzes existing programs, practices, and problems of health education. The concluding part of the presenration contains the task force recommendations. The first two recommendations require a major emphasis on health promotion and on consumer health education as a part of overall policy. The nine additional recommendations are designed to implement an effective national strategy of consumer health education. They include the requirement that all hospitals, HMO's, neighborhood health centers, and other community health facilities, both public and private, provide consumer health education;
Health Care Programs
that all third-party payers, both public and private, be required to reimburse providers for the net costs of patient education; and that Federal support be provided for regional and State networks of consumer health education programs. Additional recommendations concern administration, finance, increased manpower development, consumer participation, and reviews of Federal policies and programs with a harmful impact on health. Appendices contain a list of witnesses and guests at task force meetings, the Federal health budget for 1975, and texts of statements made on a variety of topics by task force members. An index is provided.
Abbre_ated version of this paper presented at a session in the Health Resources Administration's 1976- 77 Colloquium Series, Dept. HEW, December 3, 1976 in Rockvile, MD.
Report
746. Proposals for the Regulation of Hospital Costs.
of the Task Force on Consumer
Descriptor(s): initiatives.
Health Education.
Descriptor(s): Policy/changes re health care, Third-party payors, Comparisons of health care programs, National health insurance (NHI), Publicly sponsored/mandated health plans, Economic/commercial influences.
Preventive services, Voluntary initiatives, Policy American Enterprise Inst. for Public Policy Research, Washington, DC 20036 Jun 1978, 76 pp. A vMlability: American Enterprise Inst. for Public Policy Re-
745. Proposals for National Health Insurance in the USA. Origins and Evolution, and some Perceptions for the Future. I. S. Falk. 1977, 31 pp. Availability: Milbank Memorial Fund Quarterly/Health Society v55 n2 p161-191 Spring 1977.
and
This article reviews the origins and evolution of National Health Insurance (NHI) and proposes an alternative program based on cooperation between the public and private sectors. Government participation in health care is described under the following historical programs: (1) the 1798 Marine Hospital Service Act, designed to provide for the temporary reliefand maintenance of sick or disabled seamen; (2) the first major campaign in the U.S. for the enactment of Government-sponsored health insurance (1912 to 1920), with programs to be developed State by State; (3) the activities of the Committee on the Cost of Medical Care (1928), a self-created, private organization committed to a cornprehensive 5-year program "to study the economic aspects of the care and prevention of illness;" (4) the Social Security Act (19321935); (5) proposals after the Social Security Act (1936-1950); (6) medicare and medicaid; and (7) proposals for an NHI program from 1966 to 1976. The article critiques designs for NHI proposed under the Nixon and Ford administrations and by the American Medical Association or the insurance industry charging that they start with a commitment to private insurance and its current patterns. Such patterns are seen as contributing to the present difficulties. Instead, the "Health Security" approach is advocated. Health security is a partnership of the private sector for the provision of health and medical services by all who are qualified to participate and of the public sector for the financing of those services, with augmented consumer participation in both. References are provided.
search, Washington, De 20036. This legislative analysis describes and examines the rise in hospital costs, summarizes five hospital cost containment bills, and discusses these bills in terms of their impact on total hospital costs, efficiency, and equity. The report notes that in 1977, the United States spent about 40 percent of the $160-billion expenditures for health care on hospital care and that hospital expenditures are growing faster than any other health care expenditure except those of nursing homes. The report outlines the causes of these rising costs, including rising capital expenditures, inflation, and the changing character of hospital services; recent governmental efforts to control costs by using supply, utilization, and reimbursement controls; and some results of the 1971 to 1974 Federal Economic Stabilization Program. Five major proposals for hospital cost containment are described: the Administration Bill, the Senate Human Resources Committee Bill, the House Commerce Subcommittee BiU, the Ways and Means Subcommittee Bill, and the Talmadge Bill. A two-part analysis is then presented: an analysis of the provisions that regulate hospital revenues and an analysis of the provisions that regulate hospital capital expenditures. In addition, the interrelations between the two types of controls are discussed in a section on capital expenditure controls. A final section evaluates the Consumer Choice Health Plan which is modeled on the Federal Employees Health Benefits Program. Notes are provided for each chapter, and 11 tables are given.
American
Enterprise Inst. Legislative Analyses
No. 29.
Descriptor(s): Health care cost trends/projection s, Cost containment efforts, Hospital services, Present legislation/regulations, Policy initiatives.
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747. Proposals to Restructure the Financing of Private Health Insurance.
748. Proposed Framework for Health and Health Care Policies.
Committee on Ways and Means (U.S. House) Subcommittee on Health, Washington, DC 20515 Feb 1980, 273 pp. A vailability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 052-070-05237-6.
Anne R. Somers and Herman M. Somers. Robert Wood Johnson Foundation, Princeton, NJ. Health Resources Administration, Hyattsville, MD. 1977, 56 pp. Availability: Inquiry v14 n2 p115-170 Jun 77.
These are the proceedings of the Subcommittee hearings on H.R. 5740, the Health Cost Restraint Act of 1979, and on other proposals to restructure the financing of health insurance and encourage cost restraint through the use of incentives to stimulate competition and greater cost consciousness. Through changes in the tax law, the medicare and medicaid programs, and existing health maintenance organization (HMO) legislation, this bill would create incentives for employers to provide lower cost alternative insurance plans from which individuals could select. It would also promote greater competition among the various types of available insurance programs and encourage the further development and marketing of alternative health care delivery systems. The subcommiittee heard from invited Administration witnesses and panels of recognized experts on the fields of health economics, tax policy, and health delivery systerns. Witnesses include a tax analyst from the Department of the Treasury; the Department of Health, Education, and Welfare Assistant Secretary for Health Planning and Evaluation; and the director of the Congressional Budget Office. Witnesses also came from the American Enterprise Institute for Public Policy Research, the American Federation of Labor and Congress of Industrial Organization (AFL-CIO), and the Health Industry Manufacturers Association. In addition, A.C. Enthoven and C.C. Havighurst spoke. Other witnesses included representatives of Tufts University School of Medicine, the Washington Business Group on Health, and the Maryland Health Services Cost Review Commission. Tabular data and journal articles on ambulatory care components and Japan's high cost insurance program are provided. (Author abstract modified)
A comprehensive discussion of health and health care in the United States emphasizes the impact of medical practices, current government policies, and escalating costs on the maintenance of individual health_ Because many social, economic, and biological factors influence health status, a national health promotion policy is needed which places primary responsibility for personal health on the individual but provides essential environmental protection, health information, and access to health care when needed. Initially, three major conditions which affect national and individual health are examined: knowledge development, the environment, and individual behavior and lifestyle. A. discussion of the policy framework for personal health services discusses economic relations between doctors, patients, and hospitals; correlations between quality and efficiency; limits in resources; overcapitalization of the health care industry; and the role of health care in the national economy. Major problems involved in achieving universal access to services are reviewed, including Federal programs, insurance coverage patterns, manpower, health care facilities, and mechanisms for monitoring the quality of care. Malpractice, medicaid abuse, and technological advances are also considered. The final portion of the article focuses on controlling health care costs. Because the character of the health care industry precludes the regulatory discipline of a free and competitive market, public regulation is proposed to contain costs. Suggestions axe analyzed for the following areas: capital facilities and equipment; institutional rates; State rate review; rates negotiated by providers of services and insurers; physician reimbursement; more competition in both hospital and consumer purchases, including health maintenance organizations; utilization; and hospital organization. The paper coneludes that higher expenditures do not necessarily result in improved health care. Economy and quality can be complemen-
96th Congress second session on H.R.
tary approaches to an effective health policy. Notes are provided.
5740, Serial 96- 76.
Descriptor(s): Cost containment efforts, Policy initiatives, Competition/interaction among third-party payors, Funding/fmancing of health care programs, Publicly sponsored/mandated health plans, Private health care plans,
1-338
Descriptor(s): Policy initiatives, Present legislation/regulations, Trends in health status, Cost containment efforts, Outcome/ evaluation of quality assurance, Health care cost trends/projections.
Health Care Programs
749. Prospective
Medicine.
The cost of hospital care has been rising rapidly for more than two decades. Although it is possible to contain cost inflation
Jack H. Hall and Jack D. Zwemer. 1979, 300 pp. Availability: Methodist Hospital of Indiana, Education, Indianapolis, IN 46202.
through the mechanism of rate regulation, the effects of using this method of control on hospitals must be carefully assessed. Inflation in the hospital sector has varied directly with general
Dept. of Medical
The objective and method of prospective medicine are discussed, and a manual of prospective medicine is presented. Prospective medicine is "concerned with the identification of the individual's changing risks of disease and the recognition of his earliest deviations from a state of health. It aims to promote health and prevent disease and thus extend useful life expectancy by complementing the art of medical care with a scientific method which reduces long-term health risks." Prospective medicine builds on the fundamental assumptions that (1) everyone is subject to the risk of death; (2) the risk of death for each race, sex, and age group can be described by an average or mean risk; (3) the average risk for the group can be quantitatively adjusted to the probable risk for the individual; and (4) by treating these categories or precursors, the individual's risk can be reduced and the probability of survival increased. In practice, prospective medicine involves a risk-oriented patient history and clinical examination, the calculation of the patient's comprehensive present and projected risks, using the Geller-Gesner tables and the development of a health compliance program for risk reduction, A hypothetical case report on a 41-year-old white male is presented to trace the steps used in a risk assessment from the point of patient entry to the point of health intervention and patient compliance. The risk factor manual presented is designed for the estimation of long-term personal risks. Comparative risk data are presented in the Geller-Gesner tables. Source materials are listed.
Descriptor(s):
Preventive
services, Trends in health status,
750. Prospective Rate Reimbursement and Cost Containment. Formula Reimbursement in New York.
inflation over the past several years and has exceeded general inflation by a significant order of magnitude. The implementation of cost containment proposals such as wage and price controis on a national level and prospective reimbursement in New York can be analyzed as natural market experiments to test hypothesized behavioral processes. W 142 = The the hypothesis tested maintains that a constraint on price will lead to a constraint on cost through the mechanism of lower surpluses and less cost-inducing changes in the input intensity of the services provided. The long-term trends in prices, costs, and inputs in the hospital sector in New York have been much the same as the long-term national trends. The prospective rate reimbursement by formula that has evolved in New York amounts to a cost containment mechanism that involves price controls in general and includes additional specific constraints on capital inputs. The mechanism came into effect in 1970. With regard to affecting hospital behavior, data indicate that from 1970 to 1974, the trends in average lengths of stay in hospitals were consistently downward nationally and in several comparable States, but not in New York. It is reasonable to conclude that prospective rate reimbursement has had an impact in New York. However, there is a serious problem indicated by the consistent deficits in New York since the introduction of the mechanism in 1970. Given the prevalence of retrospective cost reimbursement by third ]parties, health care cost inflation will occur if hospitals are able to increase their inputs. Eleven tables and 13 references are included.
Descdpto_s): Methods of payment determination, Cost containment efforts, National economic conditions, Third-party payors, Hospital services, Inpatient facilities, Reimbursement, Evaluations/outcome of health care programs.
751. Prospective Rate Setting.
Ralph E. Berry. Department of Health, Education, and Welfare, Washington, DC. 1976, 14 pp.
William L. Dowling. 1977, 159 pp. AvMlabih'ty: Aspen Systems Corp., Rockville,
Availability:
This volume compiles and condenses information concerning the concept and practice of prospective rate setting as a way to contain hospital costs. About 35 prospective rate-setting systems are now operating: 22 operated by Blue Cross Plans, 9 by State agencies or commissions, and several by State hospital associations. The volume discusses the goals of prospective rate-setting
Inquiry v13 n3 p288-301 Sep 76.
Discussions in this article include prospects for cost containment in the hospital industry, the potential impact of rate regulation on hospital behavior and quality of care, and the New York experience with formula-based prospective rate reimbursement,
MD 20850.
1-339
systems and the various ways such systems are designed, organized, and sponsored. Two rate-setting systems are then described to illustrate most of the elements of rate setting found in the other systems. In the Rhode Island system, budgets are negotiated on a one-to-one basis between Blue Cross and each hospital, These negotiations are conducted within a statewide "maxi-cap" or aggregate cost increase ceiling for all hospitals for the coming year. In the Washington system, rates are set by a public utility commission, and each hospital's budget is judged in comparison with the budgets of its peers. Other articles in the book summarize the fndings of five Social Security Administration-sponsored evaluations of ongoing prospective rate-setting systems; report how administrators view the cost-saving possibilities and realities of a prospective rate-setting system; and advise managers on financial and administrative changes they may need to make to function under prospective rate setting. A final article discusses the information required for rate setting and for planning. Tabular data and chapter references are given. An appendix lists reports and papers from a Harvard project on information for hospital rate setting (1975-76). (Author abstract modified) Repnnted
from Topics in Health
Care Financing.
DesctCptor(s): Cost containment efforts, Inpatient facilities, Present legislation/regulations, Methods of payment determination, Evaluations/outcome
752. Prospective Perspectives.
of health care programs.
Reimbursement
in Rhode Island. Additional
Harvey Zimmerman, Jay Buechner and Helen Thornberry. 1976, 14 pp. Availabdity: Inquiry v14 nl p3-16 Mar 77. This paper discusses the risks associated with drawing conclusions from the results of the quantitative studies of a 1971 to 1972 prospective reimbursement experiment in Rhode Island. Summary data on cost-control experiments can lead to erroneous inferences and decisions concerning the feasibility of individual budget negotiations and the potential of this type of rate setting for cost control. The first section of the paper includes a description of the participants in the Rhode Island experiment and the history of the movement toward a cost-control program (background, pilot project, incentives, peer review, negotiations, wage and price controls, and evolutionary development). The second section presents the methods used to evaluate the costcontrol aspects of the program (cost-function regressions, regression data problems, exogenous factors, impact of incentives,
1-340
regression results, comparison of costs and revenues, hospitals' financial positions, and quality of care), the problems encountered in this evaluation, the results of the several studies performed, and the validity of the conclusions indicated by these results. The obstacles encountered in evaluating the Rhode Island program were more fundamental and more pervasive than those usually encountered in evaluations. In the first place, this was a true experiment because the structure of the program was constantly being altered even as the program was operating. In the second place, the imposition of wage and price controls in the middle of the experimental period constituted an exogenous shock that was of such magnitude and of so unusual a nature that even when considered alone it would have made conclusions based on the quantitative results tenuous at best. Despite these difficulties, the participants themselves were sufficiently encouraged by their experience during the 1971 to 1972 program to institute a second phase beginning in fiscal 1975, and medicare and medicaid opted to join. Many aspects of the present system have beendesignedfromexperiencesinthefirst experiment, and the evolutionary development of the original program may turn out to be more valuable than any possible dollar savings resulting from the operation. Thirteen references and two tables are provided.
Also see "'Re-examining the Rhode Island Experience
with Pros-
peetive Reimbursement" and "'Prospective Reimbursement through Budget Review. New Jersey, Rhode Island and Western Pennsylvania. "" Descriptor(s): Health information/data systems, National economic conditions, Third-party payors, Claims administration, Methods of payment determination, Present legislation/regulations, Outcome/evaluation of health administration.
753. Prospective Reimbursement System Based on Patient Case-Mix for New Jersey Hospitals 1976-1981. New Jersey State Commission of Health, Trenton, NJ 08625 Health Care Financing Administration, Washington, DC. 1981, 245 pp. AvMlabih'ty: Health Care Financing Administration; Publications, Washington, DC 20201.
ORDS
This manual for New Jersey hospital administrators discusses a prospective reimbursement system based on patient case-mix 1976 to 1981. The passage of S. 446 provides an explicit framework for developing and implementing standards concerning the payment for health care which ensure fairness to the public and to institutions by establishing a panel to consider the circum-
Health Care Programs
stances of individual hospitals and a mechanism to apportion the hospital's approved budgets equitably among payers. In addition, the law furnishes a basis for consistency among planning, licensing, and payment functions. Discussion of the bill covers rate design, simulation of patient care costs; institutional costs, and payment illustration, as well as standards, timing, and goals. A chapter on diagnosis related groups (DRG's) explains how these patient groupings are designed to be both medically meaningful and similar to hospital resource consumption (measured by patient days or dollars). The manual notes that DRG's are the building blocks of the case-mix reimbursement system. In addition to providing full documentation on the derivation of the rate from 1976 cost information, the section on cost sets forth the steps of the case-mix model and illustrations on how to go through the allocation tables provided to individual institutions on August 21, 1978. The concluding section on future developments provides some detail on anticipated improvements, such as labor cost equalization. Footnotes and tables are provided. The DRG cost model, format for submission of bills, institutional cost variables, and a letter regarding costing differences are appended. (Author abstract modified) Health
Care Financing
Grants and Contracts
Report
Setfes.
Descriptor(s): Cost containment efforts, Inpatient facilities, Present legislation/regulations, Reimbursement, Methods of payment determination.
754. Prospective
Reimbursement
Through Budget Review.
New Jersey, Rhode Island and Western Pennsylvania. Fred J. Hellinger. 1976, 12 pp. AvailablTity: Inquiry
v13 n3 p309-320 Sep 76.
This paper discusses results of evaluations of the prospective rate systems in Rhode Island, Western Pennsylvania, and New Jersey. In general terms, prospective reimbursement provides an alternative to cost-based reimbursement. Payments to health care facilities are based upon preestablished rates for a given period of time under such programs. Enormous increases in hospital costs and in Blue Cross rates that occurred in the latter part of the past decade provided impetus for the adoption of all prospective rate experiments. From examination of the experiences of the budget review programs in New Jersey and Rhode Island, it is concluded that these prospective rate systems, with rates set through a hospital-by-hospital budget review, were ineffective in controlling hospital costs. Results from the evaluation of the budget review and formula-determined prospective rate
system in Western Pennsylvania indicate that experimental hospitals registered smaller increases in costs for departments that are not dominated by physicians -- e.g., dietary, laundry, and maintenance -- than the control hospitals. However, these results are not conclusive, as only five hospitals participated in the Blue Cross of Western Pennsylvania experiment, and these hospitals were self-selected. Presently, there are many emerging prospective budget review systems that are developing cost and productivity screens in order to eliminate the necessity of reviewing every hospital budget. Such screens represent an administratively feasible approach to implementing a prospective rate system based upon the budget review concept. Six tables and 1/ reference notes are provided. (Author summary modified) Also see "'Re-examining the Rhode Island Experience wit,_ Prospective Reimbursement" and "Prospective Reimbursement in Rhode Island. Additional Perspectives."
Descriptor(s): Cost containment efforts, Third-party payors, Service benefit plans, Inpatient facilities, Reimbursement, Methods of payment determination, Comparisons of health care programs.
755. Prospects and Problems in Health Services Resem:ch. David Mechanic. John Simon Guggenheim Memorial Foundation, New York, NY. Robert Wood Johnson Foundation, Princeton, NJ. 1978, 13 pp. Availability: Milbank Memorial Fund Quarterly/Health and Society v56 n2 p127-139 Spring 1978. The health services research field focuses on the production, organization, distribution, and impact of service on the status of health, illness, and disability. It concentrates attention on improving the distribution, quality, effectiveness, and efficiency of medical care. Although health services research is not a unique field, it is vulnerable to instability in financing and to uninformed criticism because it has no organized professional constituency to promote it. And it continues to be handicapped by unrealistic expectations, inflated demands, and erratic modifications of its research agendas by funding agencies. Health services research, unlike most basic research fields composed of a community of scholars who share many assumptions and methodologies, speaks more directly to policymakers and administrators who typically face pressing practical problems. It is unrealistic to expect that a modest research investment will provide solutions to political dilemmas of health care, but a well-structured health
|-._4-I
services research program is essential to future health care policy and to adequate monitoring of a massive national investment, Such a program can supply facts to administrators, evaluate complex studies, test hypotheses, provide policy analysis, and help solve problems of technology transfer. A more precise delineation of the incentives, cultural conditions, and technical support required to encourage rapid deployment of useful innovations is needed. Health services research is a timely but valuable endeavor that provides a basic understanding of the way the health sector functions and its impact on the population. Six footnotes are provided.
Descriptor(s): Policy/changes mercial influences.
re health care, Economic/corn-
goals, as the examples of medicare and medicaid illustrate. The growing bureaucratic efforts to cut costs through meticulous reporting, formal review, and substitution of drugs for care will tend to dehumanize health care. Furthermore, the intrinsically expansionistic character of the system will eventually cause a renewed growth of costs, continuing the cycle of bureaucratic, legislative reform and cost containment followed by cost expansion. Only basic changes in the system seem likely to lead to real improvement in the cost, distribution, and quality of health care. One reference in included.
Presented at a Symposium University of Connecticut
on New Directions in Health Care, Health Center, May 18, 1977.
Descriptor(s): Characteristics of U.S. health care system, Economic/commercial influences, Policy/changes re health care. 756. Prospects
for Health Services in the United States.
Eliot Freidson. 1978, 13 pp. Availability: Medical Care v16 n12 p971-983 Dec 78.
757. Providing More Information ness. Norman
Four ideal models implicit in the countless schemes for organizing health care and health care trends in the immediate future are discussed. The models include the capitalistic, free market approach which stresses pursuit of individual interests without constraint by organized controls; the rational-legal bureaucracy, which is based on deliberate planning and control of work by an elite group of government officials; the collegium of workers in which workers assume responsibility both for the nature of their products and for public welfare; and cooperative equalitarianism, which is a vague socialist system emphasizing cooperation of all, preeminence of social need, and equality of workers. Each of these ideal models is vulnerable in the context of the real world. The American health care system is primarily a mixture of two models, the collegium of workers and the free market system. Within this combined system, competing interests have built up pressures. While the profit-making manufacturers promote the value of constantly changing products, the health institutioas, health occupations, and private interest groups emphasize the value of health and of their own services without agreement on means of financing or distributing services. All elements of the system are intrinsically expansionistic, and the public is prone to seek ever increasing services. The emerging framework of health care appears to be moving away from the free market and worker-controlled models in favor of bureaucratization of manufacturing, health institutions, and health workers. Such a change could ensure accountability and control. But bureaucratic frameworks are generally used by participants to advance their own ends and financial goals rather than policy
1-342
on Work Injury and I11-
Root and David McCaffrey.
1978, 6 pp. Availability:
Monthly Labor Review v101 n4 p16-21 Apr 78.
This article briefly describes the new Supplementary Data System (SDS), a program that will provide the Bureau of Labor Statistics (BLS) with additional information about work-related accidents and illnesses. The new program requires States to code cases uniformly and to provide coded information in a standard format. In addition, State processing of first reports of injury or illness means that the SDS places no new informational burden on the employer. These th'st reports are the basic source document for SDS, and all jurisdictions, except Louisiana, require that a first report be filed. States now collect four types of common information for SDS the first identifies the employer and permits classification of the case by industry and geographic location; the second lists the employee's age, sex, salary, and occupation; the third provides an analysis of the injury or illness; and the fourth identifies the workers' compensation insurance carrier, the expectation of disability, and other information. The SDS will help in occupational safety and health efforts by (1) sharply defining occupational health and safety problems, (2) channeling professional investigation toward injury and illness clusters, and (3) serving as a resource in the administration of State workers' compensation programs. Thirty-one States provided data for 1977. Datatbr 1978 will also be available from New York, Mississippi, Pennsylvania, and Washington. With the addition of these four States, reporting jurisdictions will account for two-thirds of the total nonagricultural payrolls. The article
Health Care Programs
cautions that SDS statistics are not substitutes studies, Tabular
for detailed case
nor is SDS a substitute for the BLS annual data and 10 footnotes are provided.
Descriptor(s): pensation.
Health information/data
survey.
systems, Workers tom-
Peter McMenamin, Bruce Steinhardt and Alien Dobson. Health Services Administration, Rockville, MD. Office: of Planning, Evaluation and Legislation. Dec 1977, 52 pp. Availability: National Technical Information Service, Springfield, VA 22161, PB-284 943. This final volume of an eleven-volume
758. Provision of Long-Term Care Services by Community Hospitals in Virginia. Lawrence D. Prybil. 1980, 23 pp. Availability: Hospital and Health Services Administration n4 p80-102 Fall 1980.
v25
Obstacles that have tended to prevent or impede community hospitals in Virginia from providing long-term care services are examined in this study. It was determined that only 17 of 90 community hospitals in Virginia were operating licensed longterm care units as of November 1979. Through onsite vists and followup telephone interviews, information was obtained outlining the reasons that led to establishing or assuming responsibility for long-term care units and the experience gained in operating them. In most cases, the original decision to become involved in providing the care seemed to be a corporate response to a clear need for such services in the communities served by the hospitals. Problems related to reimbursement from third-party payers, principally medicare and medicaid, represent the most common obstacles encountered in the operation of these units. Some institutions encountered other difficulties as well, such as maintaining adequate physician coverage for the long-term care patients. Despite problems, almost all of the administrators considered their long-term care units to be highly successful, and no administrator has planned to reduce unit size or cease operations, Six hospitals have firm plans for unit enlargement. Eight cornmunity hospitals in Virginia were identified which had operated long-term care units but had closed, sold, or convened the facilities. In two situations, inadequate reimbursement from medicare or medicaid prompted closing. Seven tables and approximately 50 footnotes are included. (Author abstract modified) Descriptor(s): Inpatient facilities, Long term care facilities, Funding/financing of health care programs, Impact of thirdparty coverage.
759. PSRO. An Evaluation of the Professional Standards Review Organization Programs, Volume II. A Cost-Benefit Context for PSRO Utilization Control Activities.
report on an evaluation
of the Professional Standards Review Organization (PSRO)program analyzes the impact on Medicare hospital reimbursements of potential changes in hospital use induced by PSRO review. Data from individual hospitals in 18 PSRO areas are combined with data from volumes 8 and 10 of the report to estimate utilization reductions needed to reduce Medicare hospital reimbursements by an amount equal to the expenditures for PSRO review in each area. These estimates are then compared to the estimated use reductions reported in volume 3 of the report. A PSRO is considered to break even if the estimated reductions in medicare part A expenditures due to use reductions just equal the estimated incremental expenditures for shifting from use to PSRO concurrent review of medicare beneficiaries. Findings show that the use reductions (in hospital days of care per 1,000 enrollees) needed for PSRO's to break even, and hence to contribute to cost moderation, are quite small. Even using the low estimates of the value of a day saved, the PSRO's in the sample could break even with a uniform aggregate reduction in use of only 2.05 percent. The maximum reduction that any single PSRO would have to achieve was less than 5 percent; hence, the prospect of PSRO contributions to cost moderation appear favorable. On the other hand, study results show that even if effective, PSRO's cannot add much to cost containment efforts. The incremental cost of changing from utilization review to PSRO amounts to less than 1 percent of all Medicare expcnditures. Even if the full costs of PSRO are considered, the result is unchanged, since total PSRO costs are only 1.33 percent of medicare hospital expenditures. Achievement of full cost containment through PSRO review would have required benefitcost ratios on the order of 16 to 1 in 1976. Tabular data are provided. (Author abstract modified) Descriptor(s): Cost containment efforts, Present legislation/ regulations, Outcome/evaluation of quality assurance, Demand/utilization of health care programs, Hospital services, Cost/benefit analyses.
760. Public Capabilities and Health Care Effectiveness. plications from a Comparative Perspective.
Im-
Arnold J. Heideaheimer. 1979, 16 pp.
1-343
A vailabihty: Jnl. of Health Politics, Policy and Law v4 n3 p491-506 Fall 1979.
This article examines interrelationships between "centers" and "peripheries" within political, professional, and health care systerns. Health care delivery modes are seen as being shaped by interactions between networks on three intersecting planes: the political plane, the health care resource plane, and the professional status plane. The article discusses a series of theses which relate public authorities' capabilities and problems of access, quality, and complementarity of services. Examples are selected from the experience of the United States and West European countries. Topics for comparative analyses of health care systerns include the maintenance of general practitioners; the problems of developing health centers, health maintenance organizations, and similar instruments of primary care delivery; better monitoring to prevent excessive and hurtful use of surgcry, prescriptions, and other treatment methods; the diffusion of improved health care techniques by dismantling organizational and role barriers; and the planning and regionalization of health care systems. The article notes that regionalization in the United States has meant not only the development of three tiers of complementary health facilities but also, through the creation of 212 PSRO's and 211 HSA's, the creation of new jurisdictions which are generally larger than cities and counties but smaller than States. Forty-five notes are provided. (Author abstract modified) Prepared for the tional-SubnationM straints," Fogarty Health, Bethesda,
International Conference on "Changing NaRelations in Health. Opportunities and ConInternational Center, National Institutes of MD, May 24-26, 1976.
Descliptor(s): Supply/availability of services, Comparisons regarding foreign health policies, Comparisons of health care programs.
This article examines the effect that selection of different theoretical perspectives can have on the identification of problems and on the formulation of prescriptive policies in the health field. It also focuses on the different values that are promoted by different policy perspectives and considers alternative modes for implementing value choices. Development of health policy goals necessitates a choice among normative premises -- an accommodation of conflicting values. Briefly, problem identification and policy prescription differ ,depending on the theoretical perspective adopted. There is a trend toward establishing substantive health policy goals and implementing them through prescriptive bureaucratic and regulatory techniques. The possible use of decentralized forms of decisonmaking that rely on procedural roles for government and that emphasize incentives and other marketoriented strategies should be reconsidered. This mode of institutional design can be adapted for implementation of substantive health policy objectives because of the effects of symbolism on sensible government choices in this field, because of the problems of ascertaining and measuring the process by which good health is promoted and maintained, and because of the difficulties attached to defining health and the political consequences of that definitional issue. Three important health policy issues -- cost, quality, and access -- focus on the difference in analysis and prescription that derive from varying theoretical and political viewpoints. When it comes to governmental support for medical services, the problems of balancing the goals of cost, quality, and access are especially difficult because of the difficulties of aggregating individual social welfare functions. So, even if allocative efficiency were all that were at stake, government's path would be far from clear. Indeed, there is a strong argument for placing greater reliance on a decentralized, pluralistic system. When income transfer is itself made an affirmative goal, which directly conflicts with the goal of cost containment, the problems become much more complex. Improved communication about fundamental values, policy prescriptions, and programmatic implementation is an important step in clarifying issues. Over 135 footnotes are appended. (.Author abstract modified)
Descriptor(s): Supply/availability health care, Evaluations/outcome
of services, Policy/changes of health care programs.
re
761. Public Choice in Health. Problems, Politics and Perspectives on Formulating National Health Policy. 762. Public Health and the Law. Issues and Trends. James F. Blumstein and Michael Zubkoff. Vanderbilt Inst. for Public Policy Studies, Nashville,
TN.
L. Lynn Hogne. 1980, 427 pp.
Dartmouth Medical School, Hanover, NH. Dept. of Cornmunity Medicine. Vanderbilt Univ., Nashville, TN. Research Council. 1979, 32 pp.
Availability:
Availabih'ty: Jnl. of Health Politics, Policy and Law v4 n3 p382-413 Fall 1979.
This anthology of articles and cases on public health and the law was developed to meet the need for a useful collection of materi-
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Aspen Systems Corp., RockviUe, MD 20850.
Health Care Programs
als for courses on the legal aspects of health care administration, hospitals, and public health. The book is intended for students in health care and health sciences administration programs, law schools, and medical schools as well as for a broad readership, Six significant areas of interaction between law and the health care delivery system are covered. The section dealing with eco• nomic and regulatory concerns includes contributions on cost containment regulations, government regulations on health care, and an argument for controlling costs through the strengthening of the private sector's hand in the health field. The section discussing administrative issues in the regulation of health care delivery focuses on such topics as professional licensure, minority access to mainstream hospital care, and State law and policy on physician assistants. The role of the law in protecting the public's health analyzes, among other issues, the Swine Flu Immunization Program and Federal regulation of vinyl chloride.
examined; for 38 of those cities that had public hospitals, the relationships of levels of public hospital services to local demographic, government fiscal, and tax structure conditions were analyzed. The article concludes that the need for public hospital services is unequally distributed and is often in inverse proportion to available government resources. Further, governments in the areas of greatest need were unable to cope with the need either because of the low income of the area or because the local distribution of political power made it politically impossible for the local government to tap existing resources adequately. A suggested solution, now being advocated for all cash assistance and medicaid programs, is to judge certain problems as statewide or nationwide and to not allow geographic mismatches of resources and problems to interfere. Eight footnotes, 4 tables, and 15 references are given. Study materials are appended.
Contributions on the role of the law in defining and regulating behavior include an analysis of mental health law and the development of a fair alcohol policy. The section on the role of ethics and law as related to health presents four contributions on the euthansia issue. The final section dealing with regulation of public health research by institutions and government includes a discussion on institutional review boards and an article on new drug research. Chapter references and notes, a table of cases, and an index are furnished.
Earlier re, on of this paper delivered at the American Public Health Association Medical Care Section session "'Effect of Fail-
Descriptor(s): Present legislation/regulations, Cost containment efforts, Mental health services, Policy/changes re health care..
764. Public Insurance in Private Medical Markets. Problems of National Health Insurance.
ing Ones on Health Deh'very';
October 19, 1976.
Descriptor(s): National economic conditions, Inpatient facilities, Policy initiatives.
Some
H. E. Frech and Paul B. Ginsburg. Johnson Foundation, Inc., Racine, WI. 763. Public Hospital and its Local Ecology in the United States. Some Relationshil_ Between the "Plight of the Public Hospital" and the "Plight of the Cities".
1978, 93 pp. Availability: American Enterprise Inst. for Public Policy Research, Washington, DC 20036.
William Shonick.
This article contributes to the national health insurance (NHI)
National
issue by addressing the interaction of public insurance and the private health care market and by asking what type of benefits the Government (or private insurers acting for it) should provide for consumers in the private medical market. The argument for out-of-pocket expenses to restrain demand and costs of health care is expanded to include the impact of copayments or their absence on the entire health care system. Following a general discussion of the complexities arising from public insurance interrelationships with private markets is a presentation of the basic NHI model showing that full coverage service benefits are incompatible with private provision of services. Various types of cost sharing are analyzed, and both coinsured service benefits and indemnity benefits are shown to be inflationary. Regulation of fees and reimbursements, particularly the matter of setting fee schedules, is then explained. It is contended that regulations limiting fees to usual, customary, and prevailing levels will au-
Center for Health Services Research, HyattsviUe,
MD. 1979, 38 pp. Availability: 396 1979. International Jnl. of Health Services v9 n3 p359-
This article discusses the parallel plights of both the public hospitals and the cities in the United States and identifies the dependence of public hospital service levels at different study sites upon the degree of urban plight in those localities. Urban plight is viewed as a function of four dimensions of local ecology: fiscal condition of the local government, the degree of need for services by the population, the relative political power of the forces contending for more services versus those pressing for lower local taxes, and local tax revenue patterns. Fifty-five large cities were
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tomatically result in inflation if there is complete coverage of the entire population. Health maintenance organizations (HMO's) are discussed as a particularly efficient alternative way of combining public insurance with private provision of services because the provider and insurer are joined into one organization. HMO's are seen as a viable alternative to cost sharing, with the potential to provide competitive, nonprice rationing of health care that remains sensitive to consumer preferences, and should therefore be considered in the design of a national health insur•ance program. Appendices contain an economic analysis of health care, and graphical and mathematical analyses pertaining to specific chapters. Footnotes are provided in the text.
American
Enterprise
Inst. Studies in Health Poh'cy, 201.
Descriptor(s): National health insurance (NHI), Prepaid plans, Policy initiatives, Third-party payors.
765. Public Regulation
of Health Care Providers.
1976, 368 pp. A vMlability: Practising Law Institute, New York, NY 10019.
This course handbook is intended to serve as a supplement to the Practising Law Institute's program on the public regulation of health care providers. It contains outlines of the topical material for each of the course lectures along with supporting .data, supplementary illustrative documentation, glossaries, and other information pertinent to the study topic. The course begins with the history of title XVIII and title XIX of the Social Security Act and its regulations, followed by detailed analysis of the documentation and regulation of both part A and part B of the title XVIII legislation. The topic of public regulation of health care providers is dealt with in terms of the State's role in regulation under title XIX and the regulation of institutions as well as of individual providers. Audit, reimbursement, and appeals under part A of the medicare program is a topic which is introduced with a general description of the medicare program and illustrated with a listing of Provider Reimbursement Review Board decisions and a comparisons by subject matter of the Intermediary Board's and Provider Reimbursement Board's decisions. The topics of recoupment for overpayment and surveillance conclude the course. The appendix contains an advocate's guide to the medicare program, a description of how medicare is administered, and material from the civil litigation action involving Massachusetts General Hospital and Francis W. Sargent. Also provided are the program schedule and faculty names and a list of the Commercial Law and Practice Course Handbook Series.
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CommerciM Law and Practice, Course Handbook 149.
Series, No.
Descriptor(s): Medicare, Methods of payment determination, Present legislation/regulations, Providers of health care services.
766. Public Venus Private Administration of Health Insuranee. A Study in Relative Economic Efficiency.
William Hsiao. Blue Cross Association, Washington, DC. 1978, 9 pp. Availabih'ty: Inquiry v15 n4 p379-387 Dec 78.
The major purpose of this study was to determine which type of administration, public or private, can most efficiently perform the intermediary dutie_ of a health insuranc_ plan, The measure of economic efficiency chosen for the study is the average cost per unit of output; in administering health insurance, the longrun marginal cost is approximately equal to the average cost. Methodology involved a direct comparative analysis of administrative costs by function under two organizational forms. The two plans were selected on the basis of their similarity of characteristics, such as size of insured population, that affect administrative costs. The medicare program and a large privately insured group, the Federal Employees Health Benefit Program, (FEHBP) were chosen. Data for 1971 and 1972 were collected and analyzed with regard to the following functional categories: beneficiary services, enrollment, premium collection, claims review, claims payment, financial control, quality assurance, auditing, professional relations, statistical, general management, planning and analysis, and office services. Study data came primarily from internal budget documents and accounting records. The basic approach involved identification of the major administrative components, evaluation of information relating to the functions of each component, allocation of budget expenses to each function, grouping of expenses for each function and calculation of the percentage of the total of all functional expenses, and application of this percentage against the total incuffed administrative expenses to yield the total expenses by each functional category. Empirical results show that the unit cost of administering health insurance is significantly less for the private insurance organization. It is suggested that the private organization is more efficient because of competition, higher wage scales for Federal employees, differing incentive mechanJsms, and emphasis in the public program on controlling the costs of medical services rather than administrative expenses Three tables and nine references are included.
Health Care Programs
Descriptor(s): Private health care plans, Publicly sponsored/ mandated health plans, Outcome/evaluation of health administration, Cost/lxmefit analyses, Claims administration,
767. Quality Assurance in a Prepaid Group Practice. Richard N. Winickoff, G. Octo Barnett, Mary Morgan and Kathy L. Coltin. 1979, 10 pp. Availability: Jnl. of Ambulatory Care Management v2 n3 p 19-28 Aug 79. The Harvard Community Health Plan (HCHP) a Boston, Mass., prepaid group practice, has developed a 10-step quality assurance process. The primary goal of institutional quality assurance programs is to monitor quality of care to assure that providers themselves have defined the care adequately and to detect and correct discovered deficiencies. The principles upon which the program is based are applicable to operational quality assurance programs in any setting. In several projects, HCHP has demonstrated significant improvement in measures of quality as a result of specific interventions, but strong evaluative components are necessary to measure beneficial effects. Three vital elements are broad participation in the program by providers, a staff to carry out the programs, and a medical information system which allows tracking of clinical problems. HCHP uses a computerstored ambulatory record called COSTAR. The importance of broad participation of providers cannot be emphasized enough, although the development of criteria and evaluation are important elements of a successful program. Ten projects are described, 10 steps to the development of quality assurance projects are outlined, and the principles upon which such a program can be based are discussed. One table and 34 references are provided. Descriptor(s):
Outcome/evaluation
paid plans, Health information/data
of quality assurance, Presystems.
768. Quality Assurance in Health Care. Richard H. Egdahl and Paul M. Gertman. Robert Wood Johnson Foundation, Princeton, NJ. 1976, 355 pp. Availabih'ty: Aspen Systems Corp., Rockville, MD 20850. The volume reprints 14 background papers presented at the seminar on quality assurance in hospitals held in November 1979. The papers are divided according to five distinct but inter-
related topics. The first topic, current quality assurance mechanisms, includes a four-step long-term research strategy, which would facilitate the effectiveness of quality assurance efforts. Another topic centers on the coordination of interest and activity among the three major interest groups in quality assurance -- the Federal Government, the States, and private parties. The third topic dealing with the management of data and the question of public access to quality assessment information presents contributions on future needs and options in the information field and on the subject of confidentiality. Public licensure of health professionals and the delineation of physicians' hospital privileges are also discussed. The development of licensure and specialty certification axe analyzed and a case against maintenance of the current type of licensure and credentialty system is made. The concluding section is devoted to the cost and financing mechanisms of hospital quality assurance programs including a delineation of basic cost/benefit methodology for evaluating quality assurance programs. As a result of the seminar, policy changes were suggested to the Department of Health, Education, and Welfare in the fields of cost control; research and development; Professional Standards Review Organization's expansion of the mandate; uniform data collection and analysis systems, data confidentiality; and resource allocation and decisionmaking. A selected bibliography with about 175 citations is appended. Chapter notes, tabular data, and an index are included. Descriptor(s): Inpatient facilities, Policy initiatives, Outcome/ evaluation of quality assurance, Evaluations/outcome of health care programs, analyses.
Present
legislation/regulations,
Cost/benefit
769. Quality Health Care. The Role of Continuing Medical Education.
Richard H. Egdahl and Paul M. Gertman. Robert Wood Johnson Foundation, Princeton, NJ. 1977, 245 pp. Availability: Aspen Systems Corp., Rockville, MD 20850.
The volume presents 19 background papers to a conference exploring the link between continuing medical education and quality health care. The conference was held in Boston in June 1976 and contains the recommendations resulting from the conference. The essays cover voluntary efforts in continuing medical education, including the American Medical Association's Physician's Recognition Award program and the Kaiser-Permanente system of quality assurance. Other papers deal with the trend toward concepts of periodic recertification and relicensure, based not only on mandatory participation in continuing educa-
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tion but also on actual reexamination.
Additional
contributions
benefit. The article concludes that if PSRO's fail to achieve their
evaluate data on whether continuing education improves physician competence and the quality of patient care. The financial aspects of continuing medical education activities, including cost-benefit calculations and the availability of income tax de-
objectives, the pressure for more radical solutions will be difficult to resist. A table and 53 notes and references are included. (Author abstract modified)
ductions to physicians, are also examined. Final essays are devoted to the definition of policy issues; current policies of continuing medical education; efforts and future directions of such education. Also presented are the Boston University Health Policy Institute staff views on the relation between continuing medical education and the quality of medical care; as well as the comments made by conference participants on some facets of the issue. Conference participants call for a clear distinction between minimum standards of acceptable physician performance and standards for the delivery of high quality care. Furthermore, particular effort must be made to improve the potential of the Professional Standards Review Organization mechanism as an educational vehicle. Diagrams, charts, notes, graphs, and an
Descriptor(s): Present legislation/regulations, come/evaluation of quality assurance.
index are included.
This report shows that the rise in hospital costs reflects a change in the character of the service that hospitals provide and that this
Descriptor(s): Outcome/evaluation initiatives, Physicians, Cost/benefit tives,
of quality assurance, Policy analyses, Voluntary initia-
770. Quality of Mediesd Care. Avedis Donabedian. 1978, 9 pp. Availability:
Science v200 n4344 p856-864
26 May 78.
This article classifies the major approaches to assessing medical care processes and outcomes, describes the major features of Professional Standards Review Organizations (PSRO's), and discusses their possible effects. A classification system is presented for quality assessment use that includes (1) studies mainly of structure, such as staff organization and equipment; (2) studies mainly of process, based either on direct observation of practice or on medical records; (3) outcome studies based on the incidence and prevalence of illness and disability, the incidence of mortality, and measures of longevity in a population; (4) studies that combine process and outcome to show system effects, such as the " trajectory method" which selects one or more diseases or conditions and follows patients throughout the time they receive care; and (5) evaluation of strategies that includes criteria maps and testing of strategies. The article briefly describes factors leading to the legislation establishing PSRO's, the scope and administrative structure of PSRO's, and the various concerns that PSRO legislation has generated, including fear of Federal control or fear of additional PSRO-imposed costs with little
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Physicians,
Out-
771. Rapid Rise of Hospital Costs. Council on Wage and Price Stability, Washington, Jan 1977, 68 pp. Availability: Council on Wage and Price Stability, ton, DC 20506.
DC 20506 Washing-
change has been induced largely by the growth of insurance. Costly medical care does not correspond to what consumers or their physicians would regard as appropriate if their choices were not distorted by insurance which encourages the provision of more expensive products than consumers wish to purchase. Hospital costs per patient day have continually increased at a rate substantially greater than the rate of increase of consumer prices in general. Even though hospital wage rates have risea more rapidly than wages in other parts of the economy, wage increases are responsible for only a small part of the overall increase in the cost of hospital care. Despite these observations, the problem of inflation in hospital costs is fundamentally different from rising costs in other sectors of the economy. Understanding hospital cost inflation therefore requires understanding why hospitals now provide a much more sophisticated and expensive service than they did even 5 years ago. Although the consumer pays the full cost of the expensive care through higher insurance premiums, at the time of illness the choice of more expensive care in terms of out-of-pocket cost appears modest. In this way, the current method of financing hospital care denies patients and their physicians the choice between higher and lower cost hospital care. I'he long-run solution is not to reduce or limit the growth of medical spending, but to achieve the correct rate of spending growth by providing incentives for choosing less costly care. Physician peer review alone cannot control the quality of medical care; choosing the correct quality of medical care requires involving the individual family in the decision of how much to spend for medical care. Discussion of national health insurance should recognize that the challenge today is to find new methods of financing health care that protect families while making the future development of health care more responsive to the true preferences of people. Seventeen tables and footnotes are provided.
Health Care Progra,ts
Descriptor(s): Demand/utilization of health care programs, Cost/benefit analyses, Medical technology impacts, Impact of third-party coverage, Poficy initiatives, National economic conditions,
a factor to ensure that the organization will become self-supporting at an early stage. There was general agreement that collection of copayments should be at the point of service, not on a billed basis, because of the small size of such payments. No references are given. From
772. Rate-Making
Process for Developing Plans.
Arvid W. Schwartz. 1980, 7 pp. Availability: Group Health Association of America, Inc., Washington, DC 20036.
Because the financial feasibility of health maintenance organizations (HMO's) is still a topic of lengthy debate and because a few malplanned HMO's still become targets of criticism for having exhausted their financial resources before achieving financial serf-sufficiency, this article reports on the rate-setting practices of three successful HMO's. The first organization has been in existence since 1937. It is consumer owned, with a membership of some 110,500 people, and it is governed by a board of 9 trustees elected by the membership. Two active membership committees -- the benefits and the finance committees -- are involved with the rate-making process. The rate-making process is structured around two crucial dates - April 30 and July 31 -- when change in benefits and rates for the succeeding year must be submitted for Federal employees, a substantial part of their membership. Beginning in January, all departments compile their annual budgets. During this time the executive planning committee and the benefits and finance committees work independently on recommendations to be made in April on their respective areas of responsibility. These recommedations are reconciled by the board of trustees, and benefit changes are announced. The total budget is then coordinated, with final review of potential shortfalls between cost and current rates to be made up by rate increases. In July, the total membership gathers for a rate hearing meeting. The second organization represented is a multispecialty staff-model group health plan servicing 142,000 members through 8 full service medical centers. Their rating procedure establishes community rates based on a history of plan costs, membership figures, and future changes. For separate loadings, contract variations in the areas of benefits, eligibility rules, and timely payments are identified. The third organization is a community-based nonprofit health maintenance organization of the family practice model. During its preoperational phase, premium rates were developed by using cost and utilization assumptions borrowed from other HMO's. Since becoming operational, the organization's own actual costs and aetuaJ utilization rates are being used. The plan continues to adjust the premium rates based on experience, inflation, and
"Skills
Development
for the HMO
1980"s, "' p 37-43, 1980, edited by Eugenia
Managers
of the
WarhoZ
Descriptor(s): Prepaid plans, Plan design/program provisions (under health plans), Premium determination/underwriting, Outcome/evaluation of health administration.
773. Rates of Surgical Care in Prepaid Group Practices and the Independent Setting. What Are the Reasons for the Differences.
James P. LoGerfo, Robert A Efird, Paula K. Diehr and Williana C. Richardson. Washington Univ. Dept. of Health Services, Seattle, WA 98195 National Center for Health Services Research, Hyattsville, MD. Bureau of Health Planning and Resources Development, Rockville, MD. 1978, 7 pp. Availability:
Medical Care v17 nl pl-7 Jan 79.
The Seattle Prepaid Health Care Evaluation Project compares the medical care received by enrollees in a large prepaid group practice (PGP) to that received by those in a prepaid independent practice (IPP) setting. The project, begun in February 1971, was designed to provide fully prepaid comprehensive medical benefits to low-income persons who were not eligible for medicald or medicare, yet had adjusted family incomes no greater than $2,000 above Federal poverty guidelines. Enrollees had a choice of either a large, well-established, consumer-owned prepaid practice with salaried physicians and about 200,000 members, or an independent practice plan consisting of virtually all non-Federal, non-PGP physicians and hospitals in King County. On the average, about 1,300 families were enrolled at any time. The patterns of surgical care for hysterectomy, cholecystectomy, appendectomy, and tonsillectomy/adenoidectomy were assessed. Overall, there were 215 such procedures with an exposure-adjnsted rate that was five times higher in the IPP than in the PGP group. After elimination of 43 percent of procedures in the IPP and 22 percent in the PGP which did not meet specified criteria for either necessary, appropriate, or justifiable surgery, the exposure-adjusted rate differential was 3.9 times higher in
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the IPP. The differences in the rates were mainly attributable to hysterectomy and tonsillectomy/adenoidectomy. The finding of more surgery in IPP was not new, but unlike some of the previpus studies, the enrollees in this project were quite comparable in prior illness, age, and symptoms. Even after elimination of
A Halsted Press Book. This book derived from a paper dehvered to the InternationM Ex'onomics Association meeting on the "Economics of Health and Medical Care"held in Tokyo in April 1973.
unnecessary surgical procedures, significantly higher numbers of surgeries persisted in the IPP. The question remains, however, as to whether the higher incidence of surgery in IPP was a result of inappropriate care, or whether the lower number of surgeries in PGP was a result of underprovision of care. Twelve references are provided. (Author abstract modified)
Descriptor(s): Comparisons regarding foreign health policies, Demand/utilization of health care programs, Supply/availability of services.
Descriptor(s): clans.
Prepaid plans, Medical/surgical
services, Physi-
775. Re-examining the Rhode Island Experience with Prospective Reimbursement. Fred J. Hellinger. 1977, 4 pp. Availability: Inquiry
774. Rationing
Health Care.
Michael H. Cooper. 1975, 126 pp. Availability: John Wiley and Sons, New York, NY 10016.
This text presents an overall economic review of the nature and problems of the 26-year-old British National Health Service (NHS). The first three chapters discuss the variables which influence and determine health care resources demand and supply the individual's assessment of a desire for better health; needs, or demands actually requiring medical attention; and supply, in which the State must decide how much of the current scientific and technical possibilities it is going to make available. Statistics are given on NHS health expenditures, provision of services, capital expenditure, and manpower supplies. Additional chapters discuss the economic implications of the rationing process under the British NHS; the impact of the rationing process in such areas as appointments systems, hospital admissions, and length of hospital stay; and the lack of effective planning and control leading to persistent regional inequalities. The future of NHS is examined in terms of present and future financing and the need for reexamining priorities, such as use of renal dialysis, and changes in health delivery, such as the accelerating trend of general practitioners to lean toward health centers. Expected changes in patient demand -- especially for a more active role in treatment decisions -- are discussed. Despite its shortcomings, NHS compares favorably with all other known systems. However, regular relicensing of physicians to limit gross variations in medical practices and better research and data into indicators of need to help alleviate shortages are recommended. Economic charts, tabular data, a subject index, and a bibliography of about 150 citations are given,
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v14 n2 p189-192 Jun 77.
This commentary is written in rebuttal to a critique of the author's article, a report oil three evaluations of rate-setting programs in western Pennsylvania, New Jersey, and Rhode Island. Specifically, the commentary refutes a criticism which states that the failure of the rate-setting experiment in Rhode Island is not yet factually supportable:. In giving a brief description of the empirical work performed by the evaluators commentary notes that the cost-function equations contained a dichotomous ratesetting variable that was .set equal to one for hospitals in Rhode Island and zero for control group hospitals. Other independent variables included a case-mix measure, a teaching variable, and an occupancy rate variable. The average cost per patient day and stay were employed as dependent variables. The empirical work showed that the coefficient for the rate-setting variable was never statistically significant. Thus, the hypothesis that the rate-setting program had no impact on hospital per diem or per stay costs could not be refuted. In addition, the statistical findings suggested that even if the coefficient had been significant, rate-setting would still have resulted in an average cost per patient day of only about 3 percent less than would have occurred in the abo sence of a rate-setting program. The commentary concluded that the rate-setting program had not effectively controlled the pace of hospital cost inflation. One table and 11 references are included.
Also see "Prospective Reimbursement in Rhode Island AdditionM Perspectives" and "Prospective Reimbursement through Budget Review. New Jersey, Rhode Island and Western Pennsylvania. " Descriptor(s): Comparisons of health care programs, Outcome/ evaluation of quality assurance, Inpatient facilities, Methods of payment determination.
Health Care Program_
776. Realities of Rural Primary Care.
This report contains an overview of a market study for a competitive medical care system in Denver, Colo., recent health plan activity since that study, and an assessment about the potential impact of two related events: the failure of Choice Care in Ft.
William P. Ferretti. 1978, 10 pp. Availability: Ambulatory Care Management Feb 79.
v2 nl p29-38
Federal polieymakers need to recognize several realities concerning rural primary care. The unfavorable distribution of primary care physicians to citizens will continue for some time. In many areas, although third party payers will reimburse providers for health services delivered in rural clinics by nurse practitioners and physician assistants, they are prohibited by State legislative restrictions. More favorable legislation is needed. Young primary care physicians do not want to practice in isolated, rural areas, and creating opportunities for them to practice in groups and to increase earnings, possibly linking solo practices to larger group practices situated in less remote areas should help alleviate this problem. Without hospitals, primary care practices and many small rural hospitals cannot survive. The most promising alternative for the small rural hospital is linkage to a multihospital arrangement, developing political and managerial expertise, National Health Insurance is not likely to improve access to primary care services, and in fact, will probably not attach high priority to primary care. At best, planning primary care services is guesswork. Accurate predictive information depends upon stable and defined populations, and a defined subscriber population is difficult to identify until after the practice has been established, unless delivery of HMO services is involved. Rural primary care practices, which are often small, could benefit from developing shared management services which would also allow for uniform data collection and financial reporting, a great planning benefit for allocation of primary care resources. Lack of capital funds makes the development of primary care services difficult, but initially, programs and services could be emphasized rather than facilities. Eleven footnotes are provided.
Descriptor(s): Supply/availability of services, Present legislation/regulations, Third-party payors, Providers of health care services.
777. Recent Alternative Delivery System Development in Denver.
Linda Krane Ellwein. InterStudy, Excelsior, MN 55331 Aug 1980, 16 pp. A vailabih'ty: InterStudy, Excelsior, MN 55331.
Collins and the demise of the Colorado hospital rate review program. An outline summarizes the predisposing conditions for development of a health care system and presents a brief evaluation of the Denver health care market. The report concludes that the rapidly growing and relatively prosperous population provides a natural market for health maintenance organizations (HMO's), but that a truly competitive market will not develop unless major employers and unions are willing to offer new Alternate Delivery Systems (ADS's) as they form. A second section briefly describes each competitive health plan in Denver: Kaiser Foundation Health Plan of Colorado, Comprecare, HMO Colorado, Arapahoe Health Plan, Sloans Lake Medical Group, and the Organization of Independent Physicians. The section gives an overview of ADS activity in Denver, including pLan characteristics, enrollment trends, and premium levels. In the final section, the failure of Choice Care in Ft. Collins is viewed, at least in the short term, as having a negative effect on ADS activities in Denver, but the demise of the Colorado rate review program is viewed as beneficial. Hospitals in Colorado can now make a variety of contractual agreements with health plans, and HMO's make an attractive market for hospitals because their regular payment system makes cash flow more predictable. Tabular data and a list of persons interviewed are provided. Descriptor(s): Prepaid plans, Demand/utilization of health care programs, Source of premium payment, Evaluations/outcome of health care programs, Competition/interaction among thirdparty payors.
778. Reducing Medicaid Expenditures Through Family Responsibility. Critique of a Recent Proposal. Joanne P. Acford. 1979, 21 pp. Availability: American Jnl. of Law and Medicine v5 wl p5979 Spring 1979.
This report evaluates the viability of a "Family Responsibility Plan," proposed by the Massachusetts Department of Public Welfare (DPW), under which resident adult children with taxahie incomes over $20,000 per year would be required to contribute to the cost of nursing-home care for their parents receiving medicaid. The report states that family responsibility proposals, such as the Massachusetts plan, contravene the language, intent,
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and legislative history of the Social Security Act and the Department of Health, Education, and Welfare (DHEW) regulations, and that in order to implement the plan, DPW must rely upon the waiver provision of the Act that permits the Secretary of DHEW to approve experimental programs that circumvent the Act's prohibitions. Further, even if these conditions are satisfied, the plan may be challenged because of its legal deficiencies, such as interference in personal matters and family relationships. The plan also raises public policy concerns because its potential savings may be outweighed by its risks of harm. The plan may have a detrimental impact on family relationships, may injure elderly recipients psychologically, and may lead to medically inappropnate decisions. The report recommends positive financial in-
tional services. The paper on the costs of nursing home services argues for a rental plan for the reimbursement of capital resources as an alternative to the current system of capital reimbursement. A discussion of patient-related reimbursement analyzes the statistical and the engineering (service-time-cost relationships) approaches to determining the effects of patient differences upon operational costs of a long-term institution. The regulatory issues and options essay views the medical nursing model of long-term care: as giving way to the social welfare model, where the basic components are housing and social care. Tabular data and notes are included with individual chapters. The volume contains an index.
centives as alternatives to the family responsibility approach including (I) providing financial assistance for home health care; (2) extending medicaid coverage to home health services for elderly persons living in group homes, halfway houses, or shelters; (3) allowing tax deductions for children who contribute to the support of elderly parents; (4) providing Federal grants or tax credits to children who add or convert living space to allow a parent to reside in their home; and (5) ending existing eligibility disparities that allow higher medicaid eligibility for the institu-
Praeger Special Studies.
tionalized.
780. Regiomflization
Footnotes are given.
Descriptor(s):
Medicaid, Policy initiatives, Mandated benefits.
779. Reform and Regulation in Long-Term Care.
Valerie LaPorte and Jeffrey Rubin. Rutgers Univ. Bureau of Economic Research, New Brunswick, NJ 08903 Department of Health, Education, and Welfare, Washington, DC. Office of the Assistant Secretary for Planning and Evaluation. 1979, 216 pp. Availability: Praeger Publishers,
New York, NY 10017.
This collection of papers on the long-term care population and public policy brings together four comprehensive studies of the issue and its background, along with position papers and commentaries of seminar participants. The papers discuss the design of service programs, the financing of long-term care, the monitoring of facilities and programs by government regulatory agencies and auditors, and the cost impact of regulation upon the provider and the economy in general. The paper on options for Federal financing of long-term care analyzes the shortcomings of medicaid and proposes a model based on vendor payments for institutional care, to be financed like acute health services, with concurrent grants to the States for the provision of noninstitu-
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Descriptor(s): Long term: care facilities, Medicaid, Methods of payment determination, Present legislation/regulations, Policy initiatives, Funding/fmaacing of health care programs.
and Health Policy.
Eli G-inzberg. Health Resources Administration, DHEW/PUB/HRA-77/623 Apr 1977, 192 pp.
Hyattsville,
MD 20782
A vMlability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 017-022-00578-6.
The setting, Federal experience, and policy regarding regionalization and health care are discussed in a series of papers. A paper discussing the meanings of regionalization in health care notes that although "regionalization" is a term used to describe varying types of health care delivery, it implies some ordering or reordering of health resources and services within an area. From a positive perspective, the: term is generally used to characterize programs altering the fanctions of and relationships among health providers within an area in order to achieve better access to health care, a higher quality of service, lower costs, greater equity, and more responsiveness to consumer needs and desires. The regionalization of professional services is discussed, and some common forms of the regionalization of medical services in various countries are described. The Federal experience in regionalization is described and evaluated under the topics of planning for facilities, community mental health programming, closed systems, regional medical programs, improved access through regionalization, emergency medical services, quality improvement through categorical programs, and health manpower. After examining the British and Canadian experience in health
Health
Care Programs
care regionalization and discussing voluntary regional planning, certificate-of-need regulation, financial support mechanisms, and regionalization and national health insurance, policy direc-
Proccxxtings of The Academy
t'ions are considered. In outlining policy directions, lessons learned thus far are identified, and the policy issues discussed are governance versus planning, entrepreneurship versus social con.trol, private-public partnership, provider and consumer choice, and regionalization and federalism. References accompany each presentation.
Descziptor(s): Publicly sponsored/mandated health plans, Cost containment efforts, Present legislation/regulations, Methods of payment determination, Comparisons regarding foreign health policies.
Descriptor(s): Supply/availability of services, Providers of health care services, Comparisons regarding foreign health pollties, Funding/financing of health care programs, Present legislation/regulations, Health care/services.
of Political Science v33 n4 1980.
782. Regulating Hospital Costs. The Development Policy.
of Public
David S. Abernethy and David A. Pearson. 1979, 228 pp. Availability: AUPHA Press, Washington, DC 20036. 781. Regulating Health Care. The Struggle for Control.
Arthur Levin. Henry J. Kaiser Family Foundation, Palo Alto, CA. Pew Memorial Trust, Philadelphia, PA. Allied Chemical Foundation, New York, NY. Bank of America Foundation, San Francisco, CA. Exxon Corp., Washington, DC. City Investing Co., New York, NY. 1980, 244 pp. A vaiJabih'ty: Academy of Political Science, New York, NY/ Z10025.
An overview of health care regulation, health care costs and constraints, the impact of regulation on the health care system, alternatives to regulation, and the foreign experiences in health care policy are discussed. The overview of health care regulation examines the political environment of regulation as well as regulation and legislative intent. Topics discussed in relation to health care costs and constraints are medical education, the cost of hospital regulation, Federal regulation and pharmaceutical innocation, the regulation of health insurance, and Federal-State conflicts in cost control. The discussion of the impact of regulation upon the health care system considers the impact of regulation on health care quality, a case study of the regulation of nursing homes, cost-benefit analysis, and the regulation of health technology. Alternatives to regulation are examined in papers dealing with the fostering of competition in health care, cousumer health education, voluntary accreditation, and hospital cost containment. The discussion of the foreign experience in health care policy includes an assessment of Canada's experience in regulating health care. A selected bibliography of approximately 20 references and an index are provided,
This book is a descriptive and qualitatively analytical discussion of the policy struggle in Congress over the Hospital Cost Containment Act. Against a background of severe inflation in health care costs, an understanding of this conflict provides a perspective on the probability that health care inflation will ever be brought under control. Available statistical indicators are presented to identify the dimensions of the problems. Various theories explaining inflation in the health care industry are discussed, followed by an examination of previous efforts to control health care inflation. Theories of inflation are emphasized since the confusion and lack of understanding of why health care costs are inflating have contributed significantly to the difficulty surrounding passage of the Hospital Cost Containment Act. The efficacy and fairness of previous control efforts are examined, and it is concluded that previous proposals had a sizeable impact on judgments made by Congress regarding the value of the act. Progress of the 1977 legislation through Congress, participants, their motivations, and the effects of their decisions are described, providing an example of how this Nation decides between cornpeting goals and conflicting viewpoints. Although the Act did not pass during the 95th Congress, it already has had a definite impact upon the health care delivery system. In addition, the Act demonstrates the recognition of the need to reallocate health care resources. Nevertheless, a combination of strong opposition, weak public support, and a lack of credible information led to the demise of the Hospital Cost Containment Act in 1978. An index, tabular data, and chapter reference notes are included. A guide to the bills is appended.
Descriptor(s): Cost containment efforts, Inpatient facilities, Policy initiatives, Present legislation/reguiations.
1-353
783. Regulating Hospital Labor Costs. A Case Study in the Politics of State Rate Commissions.
Carl J. Schramm. 1978, 11 pp. Availability: Jnl. of Health Politics, Policy and Law v3 n3 p364-374 Fall 1978.
With the advent of various attempts to control hospital costs by direct State regulation, labor input costs have become a target of particular attention. This focus is due in part to the unique discretion administrators can exercise over labor factors and in part to the large absolute part of hospital resources devoted to labor costs, conservatively estimated to be about 55 percent of the total budget. This paper examines the impact of State efforts in prospectively setting rates on collective bargaining outcomes in the hospital sector. Specifically, bargaining in New York, Maryland, and Connecticut is examined in view of the role played by State agencies as third parties to the bargaining process. The paper draws upon recent advances in the theory of multilateral bargaining. The relative importance of labor costs to experienced hospital inflation is also explored as a measure of the extent of influence of rate agencies on hospital bargaining. Resuits indicate that State Government attempts at controlling costs have, in all cases, required the regulatory bodies to consciously exert influence on the collective bargaining process, Further, while attempts seem to be within the paradigm of multilateral bargainihg, significant distinguishing features can be seen in the role hospital regulatory bodies play in the bargaining process. These variations from the multilateral paradigm may impede the long run ability of rate review efforts to control bargaining outcomes with respect to wages. Thirty-nine reference notes are included.
(Author
Descriptor(s): Cost containment health care programs, Inpatient regulations.
abstract
modified)
Drawing on the experience, of other industries, the article argues that Government regulation of health costs is an ineffective way of lowering health care costs. For example effective price controls in the field market for natural gas were established in 1960 when the Federal Power Commission (FPC) introduced a system of area-rate regulation. The establishment of the system followed a period approxtmately 15 years after World War II during which the price of natural gas increased dramatically. The declining price of natural gas in the early 1960's created the illusion that natural gas regulation was successful. After several years, however, a painful shortage of natural gas confirmed earher predictions of the necessity of price controls. Regulation had created substantialdisincentives for producers of natural gas and forced users to do without or to purchase more expensive substitutes. The situation in U.S. health industry may be analogous to that of the natural gas market around 1960. Just as in natural gas, prices have been increasing now for over a decade and have created political pressures for price control. Though it is impossible to predict the future, data indicate that the rate of increase in medical prices is slowing down; reasons for such deceleration include a possible decrease in the inflation rate (a key factor in rising costs), an increase in physician supply, the market response to higher health paces, and attempts of the private health care industry to cut medical costs. The article concludes that, in view of the experiences of other industries, the Government should proceed with extreme caution in abandoning the possibility of establishing less restricted markets in health care. The article includes bibliographical footnotes.
Tins article is based on a speech delivered at the eighteenth annual Canadt'an-AmeH, zan Seminar in Windsor, Ontario, November
1976. AEI Occasional Series Repnnt
Descriptor(s): Present legislation/regulations, trends/projections, Cost containment efforts.
No. 85.
Health care cost
efforts, Funding/financing of facilities, Present legislation/ 785. Regulation and the Quality of Dental Care.
784. Regulating the Cost of Health from Experience.
Care. Can We [earn
Peter Milgrom. Commonwealth Fund, New York, NY. National Center for Health Services Research, MD.
Hyattsville,
1978, 251 pp. Robert
B. Helms.
American Enterprise Inst. for Public Policy Research, Washington. DC 20036 Apr 1978, 11 pp. A vailabihty: American Enterprise Inst. for Public Policy Research, Washington, DC 20036.
1-354
Availability:
Aspen Systems Corp., Rockville,
MD 20850.
The major thesis in this l:ext is that regulation of the structure and process of dental care affects the quality of care. The activities of governmental and nongovernmental health service organizations in the area of quality control, utilization review,
Health
Care Programs
fmancing, planning and location of facilities, professional and paraprofessional manpower production, and licenses and credentialing are examined. The text investigates the degree to which these different regulatory activities are effective or ineffective and whether they have secondary, predicted, or direct effects on health care. The chapters devoted to government regulation of dental practice examine regulation of dental education and licensing issues as well as direct monitoring efforts through the Professional Standards Review Organizations Law and related disciplinary acts. The discussion of judicial regulation of quality in dental practice focuses on the legal doctrines, special liabilities, and malpractice insurance. Professional self-regulation elforts are examined with emphasis on the committees and processesof involved in dental societyandregulation. Third-party financing dental care is discussed, it is concluded that third parties are not doing much monitoring of care. There is limited consumer input on boards, and dental service corporations have tried to control practitioners through litigation rather than professional regulation. The major problems of dentistry are identified as those of occasional fraud, underutilization, lack of access, and difficulty in monitoring care which is ambulatory, Furthermore, there is a serious lack of data in the field, and for this reason, there is no definitive formulation of standards or established monitoring systems. Existing regulation and review of care relates primarily to fraud and utilization rather than quality. Serious shortcomings are the fragmented system of standards across the country, and the fact that disciplinary acts are rarely enforced, while the judicial malpractice system is merely punitive. Prepayment dental plans are seen as a positive phenomenon, encouraging comprehensive and preventive care, and extending it to whole classes of people formerly denied treatment. Prepayment plans also further consumerist attitudes that influence quality care. The most immediate needs are for a data base regarding quality of dental care and for better mechanisms of organizing and disseminating information. Included are chapter references, tabular data, an index and a bibliography of over 70 references. A case study of prepaid dental care is appended.
Jan/Feb
80.
If group practice managers are to have an impact on how group practice will be regulated in the future, they need to understand current health care delivery regulatory programs. Capital expenditure and service controls have become the principal instruments of Federal and State efforts to contain the rapid escalation of health care costs. State certificate of need (CON) statutes and section 1122 of the Social Security Act which denies reimbursement for capital costs exceeding $100,000 are two types of controis. The CON legislation alone will not contain total investment in hospitals, and while capital expenditure controls reduce bed supplies, they also increase costs in areas such as equipment. Another regulatory program directed at reducing health care costs is prospective rate setting. This allows external authority to determine in advance what hospitals can charge or the amount they will be reimbursed by third-party payers. It is not yet clear that prospective rate setting has been effective in controlling health care costs, but the operation of hospitals in States with Government rate setting has been profoundly affected. The administrator often becomes more influential in deeisions about the array of services offered and has more leverage in negotiating with department heads and medical staff. Traditionally, Government regulations in health care have been concerned only with quality of care, but professional standards review organizations have been restricted by a dual mandate to ensure appropriate use of hospital services (a cost containment goal) and to assure medical quality, a goal which in effect increases costs. The future is likely to bring greater involvement between group practice managers and Government regulators. Clearly, better coordination of the various regulatory methods is necessary for regulation to be truly effective. Like hospital administrators, group practice managers will have to become more involved with determining services to be offered, type of equipment to be purchased, and efficient clinic management. Eighteen footnotes are provided. Article is third in a series of three, covering the topics of Politics,
Descriptor(s): Impact of third-party coverage, Dental services, Allied health professionals, Present legislation/regulations, Out-
Planning
come/evaluation
Descriptor(s): Cost containment efforts, Present legislation/ regulations, Funding/financing of health care programs.
of quality assurance.
and Regulation
of Health
Care Delivery.
786. Regulation of Health Care Delivery. Thomas C. Dolan and Gayle C. Lane. Center for Research in Ambulatory Health Care, Denver, CO 80222 Kellogg (W.K.) Foundation, Battle Creek, MI. 1979, 4 pp. Avnilabih'ty: Medical Group Management v27 nl p22-24,28
787. Regulation of Health Care in the United States. James D. Isbister and Nancy McGaw. 1978, 19 pp. Av_dlabih'ty: Jul. of Health and Human tration vl nl p11-29 Aug 78.
Resources Adminis-
1-355
Regulation of the health care system has historically been voluntary in nature and aimed at the institutional aspects ofcare with physician control. Times have changed, however, and physicians
1973, 90 pp. Availability: Virginia Law Review v59 n7 p1143-1232
and other providers are no longer exclusively in control. Major influences can be activities categorizedof asthe the government, marketplace, reimbursement voluntary control, regulatory
This article suggests tha_: administration of certificate-of-need will not be effective in achieving cost control objectives because
practices of third party payers, and the actions of health planning agencies. The debate over making health care respond to market economies revolves around those who wish to control health care and those who would use regulation to make health care more closely approximate an ideal competitive market, Voluntary controls set by health care providers do not remain the most important determinants of the quality of care provided by individual practitioners and health institutions. Historically,
of the almost unavoidable slippage involved in translating a persuasive rationale for regulation into a workable regulatory program. Further, it warns that inflationary pressures may, like a balloon, bulge out at another place even if growth in one direction is effectively prevented. Finally, it argues that the laws' limited benefits may be obtainable only at the cost of repressing
State governments played the most important governmental role in regulating provision of health care. many other forms ofthegovernment regulation, bothNow, directhowever, and indirect, are work atpayment Federal, programs State, andoflocal levels. The thirdat party medicare and government's medicaid are pervasive and comprehensive government regulation,to The tendency to work throughforms the of third party mechanism control costs continues to grow despite the prevalent argument that this mechanism has failed. Health planning in the United States has taken a variety of forms, but until recently it has tended to be fairly correcting in athe specific ceived problem andlimited, placingdirected few realat controls handsperof health planners. The 1975 National Health Planning and Resources Development Act granted agencies some regulatory clout and for the first time accomplished an integration of planning, regulation, and implementation functions, providing the opportunity to initiate change. Comprehensive health planning in theory should draw together all the pluralistic parties interested in health care and develop wise plans for equitable and effective care. The theory is now being tested. Many forms of regulation have come into being and there is likely to be much more experimentation with regulatory controls in the future. The history of regulatory development is provided, along with 11 references.
Oct 73.
useful market forces, particularly those calling forth badly needed innovations and stimulating efficiency. The paper suggests fundamental reforms to ccmtrol rising medical costs: HMO development; government provision of universal health insurance with a high annual deductible, perhaps 10 percent of income; encouragement of health insurers to pay per diem indemnities to their insureds rather than actual hospital charges; and active price competition among health insurers. Other proposed remedies include a system of incentive reimbursement for hospitals, legislation to aid inadequate or unneeded providers to exit from the market, and utilization review. The article also recommends improving existing certificate-of-need programs by having certification-of-need lodged in an agency which bears direct political responsibility for the oost of health care as a purchaser of care under medicaid and State employee health programs. Coverage of the law should be limited to hospitals only, HMO hospital facilities should be exempted totally from the need requirement, and strict standards of openness in policy formulation and implementation should be ,_tablished. Additional recommendations include mandatory reliance on real planning, definition of the need commitment so as not to shelter noncost-related pricing or to prevent entry by providers giving less comprehensive care, and a fixed expiration date for the law. A total of 262 footnotes is provided. Descriptor(s): Cost containment efforts, Inpatient sent legislation/regulations, Policy initiatives.
facilities, Pre-
Descriptor(s): Competition/interaction among third-party payors, Present legislation/regulations, Voluntary initiatives, Impact of third-party coverage, Publicly sponsored/mandated health
plans.
789. Regulatory Enviromnent for Physician
Compensation.
James L. Head. 788. Regulation cate of Need.'.
of Health Facilities and Services by 'Certifi-
1978, 16 pp. Availability: Topics in Health Care Financing v4 n3 p75-90 Spring 1978.
Clark C. Havighurst. National Center for Health Services Research and Development, Rockville, MD. Institute of Medicine, Washington, DC.
1-356
Physicians' roles are becoming more complex as physicians must reconcile cost factors wiCh quality of care. They must become more aware of medical care costs and must analyze the effective-
Health Care Programs
ness of their own services. Traditionally, doctors have been free to work under whatever contractual arrangement can be agreed upon with hospital administration. As a result, medical care has been priced beyond the reach of a significant portion of the American people - the aged and the poor. Intending to make high-quality medical care accessible to those unable to meet high medical costs, Congress passed Public Law 89-97 in 1965, establishing the medicare and medicaid programs. Subsequent legislation expanded on these programs. Cost containment agencies have already been established in the States of Arizona, Connectieut, Maryland, Massachusetts, Minnesota, New Jersey, and elsewhere. The experience of the State of Maryland shows what can be accomplished. Maryland has experienced a rate of cost increase approximately 4 percent below the national average during 1974 to 1976, resulting in a cost saving of about $55 million. The article also discusses proposed Federal legislation, proposed State legislation, legal challenges of physician compensation, other influences on physician compensation legislation, consumer attitudes toward physician compensation legislation, voluntary cost containment, and the need for action. It is noted that the number of hospital-based physicians will continue to increase as additional subspeeialization occurs in medicine and that there will be increased Federal pressure to regulate the financial provisions of contractual arrangements. A list of 19 references and approximately 25 suggested readings are given,
Descriptor(s): Health care cost trends/projections, Cost containment efforts, Medicare, Medicaid, Inpatient facilities, Physicians, Present legislation/regnlations, Outcome/evaluation of health administration,
790. Reimbursement
Alternatives
charges, whichever is lower, with no ceiling or controls on the maximum reimbursement that any agency may receive. Of the three proposed systems, retroactive cost reimbursement with a ceiling is most restrictive, with agencies penalized for exc_ding the ceiling and no positive incentive for cost control. Prospective reimbursement should be a nearly perfect cost control mechanism, but the data indicates that it is the most costly of the reimbursement methods. Without accurate ratesetting, prospeetire reimbursement degenerates into a guessing game in which some agencies reap unacceptably large benefits and some may be penalized to the point of extinction. The prospective reimbursement plan with a ceiling and an equal sharing of surpluses and deficits, on the other hand, provides a cost control mechanism with the positive attributes of the first two systems. An incentive is provided for cost performance under the prospective rate, but the incentives and penalites are modulated to the point of being effective, but not oppressive, to either the providers or the thirdparty payers. The proposed reimbursement methods are designed to penalize only those home health care agencies that have extremely high costs. The results of this study show that costs are higher for those home health care agencies that significantly utilize contract services. It should be noted, however, that these techniques would only be successful if a large number of visits were involved, and successful implementation of any reimbursement method intended to encourage cost control requires medicare and medicaid participation. Seven references are provided.
Descriptor(s): Cost containment efforts, Impact of third-party coverage, Home health services, Reimbursement, Methods of payment determination.
for Home Health Care. 791. Reimbursement for Durable Medical Equipment.
Larry J. Shuman, Harvey Wolf, George W. Whetsell and George A. Huber. Blue Cross of Western Pennsylvania, Pittsburgh, PA. 1976, 11 pp. Availability: Inquiry v13 n3 p 277-287 Sep 76.
Theodore J. Janssen and G. Theodore Saffran. 1981, 12 pp. Avnilabib'ty: Health Care Financing Review v2 n3 p85-96 Winter 1981.
Three alternative reimbursement systems for home health care are presented: retroactive cost reimbursement with a ceiling, prospective reimbursement, and prospective reimbursement with a ceiling and equal sharing of surpluses and deficits. Thirty home health care agencies in Western Pennsylvania have been evaluated. These consist of 13 hospital-based agencies, 14 cornmunity nursing services and visiting nurse associations, and 3 clinic-based agencies. All are nonprofit and controlled by county or city health departments. Data is for fiscal years 1972 and 1973. Current reimbursement is based on allowable cost or
In 1976, a research and demonstration project to investigate the types of equipment and services being reimburssed and the use patterns of medicare recipients with regard to durable medical equipment (DME) in the home was conducted. The research was the first effort to determine the dimensions and magnitude of medicare reimbursement for this equipment. Data were extracted from the 1976 to 1977 beneficiary history files of five part B carriers in 11 geographic areas. These data included the type of equipment, rental or purchase decision, submitted charges, allowed charges, and reimbursement by medicare. Some 1.3 mil-
1-357
lion individual records from approximately 400,000 beneficiaries were tabulated and analyzed. An average of 11 percent of the beneficiaries of the participating carrier service areas were found to have some experience with DME. Only 52.3 percent of all submitted charges of claims for DME were reimbursed; 92 percent of these were $100 or less for line items claimed. A relatively large proportion of users of relatively small amounts of DME was associated with service areas in California, Florida, and Idaho, while carriers elsewhere evidenced a much smaller population using a larger number of items. Oxygen, oxygen therapy equipment, and related life support equipment appeared to constitute a sizable portion of DME expenditure. In general, the study confirms that DME reimbursement amounts are larger and the procedures for DME provision more complex than formerly thought. Various characteristics of the data collected for the project are detailed in tabular and graphic form. Three references are given. (Author abstract modified)
ance Company against Blue Cross of Western Pennsylvania in 1973. The article describes the implications for Blue Cross discounts of rate review legislation; implications of collective rate negotiation by State and local hospital associations; the effects of HMO ownership on hospitals to reduce utilization; and longterm implications of reducing third-party payer reimbursements to hospitals by offsetting charitable contributions against such charges or costs. Twenty-nine references are included.
Descriptor(s): Cost containment efforts, Commercial health insurance plans, Service benefit plans, Prepaid plans, Hospital services, Competition/interaction among third-party payors, Methods of payment determination.
793. Reimbursement for Physicians' Services. Descriptor(s): Participants
Medicare,
Reimbursement,
in health care programs,
792. Reimbursement
for Hospital
Health
Therapeutic
care costs, services.
Jeffrey A. Prussin and Jack C. Wood. 1975, 13 pp. Availabib'ty: Topics in Health Care Financing Fall 1975.
Services. This article on reimbursement
Jeffrey A. Prussin and Jack C. Wood. 1975, 20 pp. Topics in Health Care Financing Avnilabili(y: Fall 1975.
v2 nl p13-32
This article on reimbursement for hospital services includes topics on the definition of hospital care, alternative modes of coverage, methods of hospital reimbursement, Blue Cross discounts, health maintenance organizations, and other considerations in hospital reimbursement. The article discusses the different modes of coverage furnished under commercial insurance cornpany plans, Blue Cross plans and health maintenance organizations (HMO's). Different methods of hospital reimbursement are also discussed including assignment of the patients' benefits fights to a hospital under commercial insurance plans and various Blue Cross reimbursement methods based on charge-based and cost-based formulas. The article states that the valued and indemnity methods used by commercial insurance companies for claims payments do not create a strong insurer interest in the actual cost or charges for hospital services. In contrast, the Blue Cross uncontrolled charges method of payment, while inflationary, creates a stronger incentive for third party payers to control hospital charges. The article also discusses suits filed against Blue Cross by private insurance companies and others attacking discounts on Blue Cross payments and specifically details the Supreme Court's decision in the ease brought by Travelers Insur-
1-358
v2 nl p33-45
for physicians'
services includes
a definition of physician services, alternate modes of coverage, methods of physician reimbursement, and other related considerations. The article notes that third party payment systems classify physician services into covered and noncovered categories depending on location,, type, and patient condition. In addition, third party payment systems sometimes recognize the broadened role of allied professionals and generally distinguish between ancillary services rendered on an inpatient or an ambulatory basis. The article describes alternative modes of coverage, including commercial insurance company plans, Blue Shield plans, and health maintenance organizations (HMO's) and assesses their methods of physician reimbursement. Commercial insurance company plans are viewed as doing nothing to contain the costs of health care services, control service quality or improve accessibility. The Blue Shield method of paying the physicians' usual, customary, and reasonable charges 0dCR) is viewed as having a solid potential for containing physicians' fees but as not being used to its maximum potential; the fee schedule method does not contain health care costs and might even contribute to fee inflation. The article also assesses physician financial incentives under the prepaid group practice (PGP) model HMO and the foundation for medical care (FMC) or individual practice association (IPA) model HMO. Two factors which might affect the relationships between physicians and private third party payers are also discussed briefly: physician unionization and the applicability of antitrust laws to physicians. Four references are included.
Health Care Program._
Descriptor(s): Third-party payors, Commercial health insurance plans, Service benefit plans, Prepaid plans, Medical/surgical services, Methods of payment determination.
795. Reimbursement Policy Under Drug Insurance. Administrative Expediency or Economic Validity. T. Donald Rucker. 1978, 12 pp. A v_lability: American Jnl. of Pharmacy and the Sciences Supporting Public Health v150 n4 plO7-118 JulfAug 78.
794. Reimbursement
Management.
William O. Cleverley. 1977, 16 pp. Availability: Topics in Health Care Financing/Improving Profitability v4 nl p13-28 Fall 1977.
Most health care organizations need to employ a full-time reimbursement specialist to ensure maximum reimbursement from third-party cost payers. Reimbursement options for improving reimbursement from medicare and other third party payers are for the most part related to the underlying cost accounting model employed to derive estimates of costs. This article examines the three separate but related activities of cost accounting: valuation, allocation, and output or object specification. The end result of the cost allocation process is to assign all costs or values determined in the valuation phase of costing to revenue or direct departments. Two phases of activity are involved. First, all resource values to be recorded as expense in a given period are assigned or allocated to the direct and indirect departments as direct expenses. Second, once the initial cost assignment to individual departments has been made, a further allocation is required to assign the expenses of the indirect departments to the direct departments. During the output or object specification phase of costing, it is necessary to separate the patient-related from non-patient-related outputs and services and to separate patient-related outputs and services by payer responsible for
This paper focuses on the cost of prescription products and pharmacy services to develop a model reimbursement policy for prescription drugs under a national insurance program. A compensation program should help patients obtain medications which are likely to improve or maintain their health status and minimize the use of scarce national resources essential for achieving this goal. Certain economic considerations must then be addressed, including the effect of insurance benefits on basic supply and demand relationships and a vendor payment system that discriminates between efficient and inefficient providers, negating the effects of sales promotions. An optimum reimbursement policy should incorporate flexibility to react to changes in economic conditions and national priorities and should employ precise administrative tools to carry out its functions. Other components of the model include a comprehensive set of incenrives for all providers, rapid processing of vendor claims, neutrality, and a valid payment system that accurately reflects varying expense levels among different providers. A reimbursement model must also meet specific administrative objectives, beginning with a high degree of program integrity. The option of using indirect controls to implement reimmursement policy should be explored, and providers should be treated equitably. Regulations must be simple and practical. A complete monitoring system is needed to evaluate implementation and improve communication between providers and administrators. Reimbursement strategies that should be avoided are identified. Tables and 19 references are provided.
payment. Because there is a growing tendency of many health care organizations to become involved in a wide variety of commercial activities (usually designed to be profitable), it is important to keep adequate records that will permit utilization of the
Paper presented at the NatYonM Invitational Conference on Drug Coverage Under National Health Insurance, Waslu'ngton, DC, October 6, 1977.
cost offset method. A third party payer or the intermediary might need to approve this new management plan before these reimbursement methods can be implemented. In addition, the effect of these changes should be evaluated prospectively to determine the long-run effects on reimbursement. Selection of a more sophisticated reimbursement treatment may preclude return to a less sophisticated one later. Moreover, overzealous efforts to maximize current reimbursement may, in the long run, be a detriment to the provider. Figures and tables are included,
Descriptor(s): Reimbursement, Pharmaceutical services, tional health insurance (NHI), Policy initiatives.
Na-
796. Relationship Between Diagnostic Information Available at Admission and Discharge for Patients in One PSRO Setring. Richard Burford and Richard F. Averill.
Descriptor(s): Claims administration, health administration.
Outcome/evaluation
of
1979, 13 pp. Availability: Medical Care v17 n4 p369-381 Apt 79.
1-359
Professional standards review organization (PSRO) operating guidelines recommend the use of professional activity study (PAS) length of stay (LOS) norms for conducting concurrent review. The primary focus of concurrent review is the identification and elimination of unnecessary hospitalization. Two types of review are involved: admission certification and continued stay certification (CSC). Admission certification certifies the medical necessity of each admission and establishes a diagnostic specific LOS norm. CSC examines patients whose LOS exceeds the norm assigned at admission in order to determine the necessity of continued hospitalization. These norms, determined by aggregating discharge abstracts from PAS hospitals in the same U.S. census region, are assigned to patients based only on information known at admission. This study investigated the relationship between patient information available at admission and the information available at discharge in light of its effects on the concurrent review process. Analyzing 52,210 patient records from 68 hospitals in 1 PSRO setting, it was found that changes in patients' primary diagnosis resulted in changes in their PAS diagnostic category for 41.3 percent of the patients. A change in PAS diagnostic category after the assignment of the review norm resulted in missed and unnecessary reviews as well as early and late reviews. These findings indicate that there are serious operational problems with the current method of performing concurrent review. The most feasible solution to the problem would be to routinely examine selected patients early in their LOS (after 2 or 3 days) in order to confirm the patients' diagnoses and assign the correct LOS norm. Although the confirmation of admitting diagnosis is not as expensive a process as a CSC review, it will add to the cost of CSC and further reduce its already questionable cost effectiveness. CSC is a very labor intensive and expensive process which this study and others have shown to be prone to serious operational constraints. Rather than expending much of the resources of the PSRO program in an all encompassing program of continued stay review, it may be more effective to limit the CSC process to those diagnostic areas where the other portion of the PSRO program, such as profile analysis, have demonstrated a need for the intensive concurrent examina-
National Center for Health Services Research, Hyattsville, MD. 1979, 16 pp. A vailability: Medical Care v 17 n9 p937-952 Sep 79.
tion of patients. Twelve references are provided.
798. Repeated Hospitalization for the Same Disease. A Multiplier of National Health Costs.
(Author ab-
stract modified) Descriptor(s): Health information/data vices, Present legislation/regulations, come/evaluation
systems, Hospital serPolicy initiatives, Out-
of health administration,
Diagnostic
services.
797. Relationship Between Utilization of Mental Health and Somatic Health Services Among Low Income Enrollees in Two Provider Plans. Paula K. Diehr, Stephen J. Williams, Stephen M. Shortell, William C. Richardson and William L. Drucker.
1-360
This article describes a study designed to examine the characteristics of users as compared to nonusers enrolled in two provider plans of mental health services and to examine the possibility of lower use of somatic health services attributable to the availability of mental health services. Two low-income enrollee groups were studied: one included enrollees using at least one mental health service and the other included those using some somatic health services but not mental health services. Results indicated that mental health servic_,_ users were different from nonusers based on sociodemographic, health status, and prior use measures. Further, mental health users consumed more somatic services than other enrollees, even controlling for background variables. The visit and admission rates for the mental health service group were 2.4 times that of the group not using mental health services, and total inpatient and outpatient costs were three times as high. On all three comparisons, approximately 60 percent of the difference was accounted for by mental health use and by differences in sociodemographic and health status characteristics. Although the remaining 40 percent could not be explained, the higher use rates may have occurred for conditions where medical care is discretionary. Graphs, eight tables, and 42 references are provided. (Author abstract modified) Also See "'Mental Healt_ Services. Utilization by Low Income Enrollees in a Prepaid Group Practice Plan and in an Independent Practice Plan." Descriptor(s): Medical/surgical services, Demand/utilization of health care programs, Mental health services, Prepaid plans, Participants in health care programs.
Christopher Moore.
J. Zook, Sheila F. Savickis and Francis D.
Henry J. Kaiser Family Foundation, Palo Alto, CA. Robert Wood Johnson Foundation, Princeton, NJ. Harvard Medical School, Boston, MA. Peter Bent Brigham Hospital, Boston, MA. Medical Foundation, Boston, MA. William F. Milton Fund, Boston, MA. Walnut Medical Charitable Trust Fund, Boston, MA. 1980, 18 pp. A vailability: Milbank Memorial Fund Quarterly/Health Society v58 n3 19454-471 1980.
and
Health Care Programs
The fiscal and clinical nature of repeated hospitalizations for the same disease are examined in this study. It is suggested that hospital recidivism has three principal implications for public health policy. First, if there are predictable, high-c._t groups of repeater patients with particular illnesses or traits, public health policies targeted at such groups might achieve major economies, Second, medical recidivism has implications for the design of major-risk health insurance. Third, unusually high rates of readmission by certain hospitals, doctors, or communities mightindi-
This report of the Interagency Task Force for the Department of Health, Education, and Welfare (DHEW)addresses all of the major recommendations that were developed in the April 1978 "Report to the President from the President's Commission on Mental Health." The report focuses on the following areas: social and community supports, services, financing, mental health personnel, protection of basle rights, knowledge development, prevention, and public understanding. In its discussions of insurance for mental health care, the President's Commission on
care possible provider accountability or overuse of medical resources. Study data were developed from a random sample of 2,238 medical records in 6 contrasting hospital populations. Billing data were obtained from a random sample of 30 percent of the indexed hospitalizations in each hospital, except for the Veterans Administration hospital where bills are not computed, Repeated hospitalization for the same disease was defmed by a diagnostic classification system containing 19 categories. Repeated hospitalizations were determined through reading of the medical record, including all previous admissions at that hospital and all physician notes. Analysis revealed that patients with repeated hospitalizations for the same disease were found frequently in each hospital population. Of the total sample, 52 percent were in this classification. In addition, repeated hospitalizations for the same disease accounted for approximately 60 percent of all hospital charges. Illnesses that accounted for the most repetitive hospitalizations were spinal cord injury, renal failure, cancer, congenital defects, blood diseases, benign lung disease, and chronic degenerative vascular disease. Unhealthy personal habits such as alcohol abuse, drug abuse, extreme obesity, or heavy smoking were associated with a high rati 9 of repeated hospitalization. Four tables, a few footnotes, and 16 references are included,
Mental Health (PCMH) highlighted existing contradictions in national policies regarding mental health care and pointed out discriminatory practices against mentally ill persons in the medicare and medicaid programs. The task force proposed that the DHEW Secretary prepare legislation to increase allowable reimbursement under medicare for outpatient treatment of mental conditions to $750 per year and reduce the coinsurance to 20 percent; remove medicare's 190-day lifetime limit on inpatient care in a psychiatric hospital so that coverage would be tlhe same as that for all other illnesses in short-term general hospital settings; and modify the Child Health Assessment Program proposal to mandate inclusion of mental health services for children. Additional proposals would require States to reimburse ambulatory health services under medicaid at a minimum of 70 percent of medicare prevailing rates, would prohibit States from establishing limits (other than medical need) on the number of visits to a physician (including a psychiatrist) reimbursable under medicaid, and would establish an eligibility income level for medicaid of at least 55 percent of the poverty level. In addition, the DHEW Secretary should initiate a series of major interagency research and demonstration projects on facility provider status under medicare and medicaid for organized community mental.health care settings, including community mental health centers and partial hospitalization programs. Additional projects should be conducted on intermediate care facilities for mental health. Further, medicare payments for partial hospitalization services should be regularized. Five appendices contain an index of DHEW officials responsible for implementation proposals, members and staff of the DHEW task force, detailed specifications for the Community Mental Health Systems Act (February 8, 1979 draft), and material on PCMH Task Force budget development.
Descriptor(s): Demand/utilization of health care programs, Trends in health status, Health care costs, Third-party payors, Hospital services, Inpatient facilities, Policy/changes re health care.
799. Report of the HEW Task Force on Implementation of the Report to the President From the President's Commission on Mental Health.
Descriptor(s): Medicare, Medicaid, Mental health services, Present legislation/regulations, Policy initiatives, Limitations on coverage.
Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD 20857 DHEW/PUB/ADM-79/848
800. Report on Coalitions to Contain Medical Care Costs.
Dec 1978, 239 pp. Availability: Alcohol, Drug Abuse, and Mental Health Administration, Rockville, MD 20857.
Jon M. Kingsdale and Pamela L. Haynes. Government Research Corp., Washington, DC 20036 Oct 1979, 89 pp.
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Availability: 20036.
Government
Research Corp., Washington,
DC
A telephone survey undertaken in 1979 revealed a growing number of private sector coalitions, including business, provider, labor, and/or insurer interests, that were forming to encourage or undertake community and statewide health care cost containment activities. An intensive study was made of four medical cost containment coalitions -- the Michigan Bed Reduction Coalition, the Greater Cleveland Coalition on Health Care Cost Effectiveness, the Maryland Health Care Coalition, and an informal alliance of business leaders, Blue Cross, health planners, and health providers in Cincinnati. Certain characteristics appear to be associated with active coalitions. Among these are well-defined objectives and specific means of achieving these as well as an informal organization so that structure and procedures do not hinder activity. Strong leadership and support from community leaders were common as was a membership of a scope and size consistent with accomplishing coalition objectives. Coalition members had some knowledge of the health care delivery system, and the coalitions had linkages to the public sector. Most organizations had collected data to profile and evaluate the existing health care system and initiatives to change it. In addition, the study found that the community-specific and employer-specific data needed to identify high-cost providers and services, determine cost-containment interventions, and evaluate their effectiveness often do not exist in a form coalitions can use directly. Thus, efforts should be made to gather supply data from providers and other agencies that use such data. Private sector coalitions to contain medical care costs can serve an important function in educating purchasers and, in some cases, providers about health care finance. A survey instrument and data tables are appended. (Author abstract modified) Descriptor(s): Cost containment efforts, Voluntary initiatives, Health information/data systems.
1978 and makes recommendations for improvements. The commission found that despite impressive improvements in the mental health care system, millions of Americans remain unserved underserved, or inappropriately served. These Americans may go untreated because of geographic or financial barriers or because of their age, sex, race, cultural background, or the particular nature of their disease. Often available services are limited or not sufficiently responsive to individual clients' needs. The recommendations made by the commission focus on eight areas of importance: (1)community supports, (2)a responsive service system, (3) insurance for the future, (4) (i.e., a comprehensive strategy for financing mental health care), (4) new directions for health personnel, (5) protection of the basic rights of clients, (6) research in the mental health field, (7) prevention of mental problems, and (8) improvement of public understanding of the problem. Specific recommendations include developing networks of high quality mental health services throughout the country, coordinating mental health services more closely, estabfishing a national priority to meet the needs of people with chronic mental illness, and making available services and personnel for populations with specific needs, such as children, adolescents or the elderly. In addition, the commission recommended that any national health insurance program and all existing private health insurance programs and public programs financing mental health care provide benefits for the treatment of mental disorders in a least restrictive setting, provide reimbursement for mental health services involving direct care of the patient, provide minimal patient cost sharing for emergency care, and give consumer freedom of choice. Annotations are provided which expand upon the recommendations, describe methods of implementation, and presem: additional recommendations. Also See "Report of the HEW Task Force on Implementation of the Report to the President from the President's Commission on Mental Health. " Descriptor(s): Mental health services, Policy initiatives, Evaluations/outcome of health ,:are programs, Funding/financing of health care programs.
801. Report to the President From the President's Commission on Mental Health. Volume I.
President's 20500
Commission
on Mental Health, Washington, DC
1978,94 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 040-000-00390-8. The President's Commission on Mental Health presents the resuits of its l-year study of the country's mental health needs in
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802. Research and Demonstrations 1978-1979.
in Health Care Financing,
TrudJW. Galblum. Health Care Financing Administration Office of Research, Demonstrations, and Statistics, Baltimore, MD 21235 HHS/PUB/HCFA-03044 1979, 78 pp. A vailability: Health Care Financing Administration, Publications, Baltimore, MD 21235.
ORDS
Health Care Programs
This report describes the intramural and extramural projects of the Office of Research, Demonstrations, and Statistics (ORDS) of the Health Care Financing Administration (HCFA). The current status of each project is included. To promote the HCFA objective of finding the most cost-effective methods of providing quality health care to its beneficiaries, ORDS has identified nine areas of primary interest, along which the report is organized, They include beneficiary studies and statistical activities, health systems organization, hospital reimbursement, industrial organization and reimbursement, integrated data systems, long term care, physician reimbursement, program evaluation, and quality and effectiveness. Information on the design and results of ORDS activities in each of the nine areas is included for the broad audience concerned about health care financing and delivery issues. A chapter on hospital reimbursement outlines 11 reimbursement demonstrations, including the National Hospital Rate-Setting Study, The New York Case-Mix Study, and the Georgia Prudent Buyer Reimbursement scheme. Program assistance and reimbursement and cost research axe examined with emphasis on factors affecting hospital costs and the development of rate-setting methods (through case-mix studies, hospital classification systems, and application and simulation of alternative rate-setting models). Reimbursement and coverage issues for
nants of prices of medical inputs, and cost-benefit analysis. The research is divided into the categories of "positive" and "normative." Positive studies are those designed to describe or predict how the health care system, or aspects of it, actually c,perate. Normative studies are intended to provide statements as to how the health care system should operate. The following issues are considered under the topic of production function studies, costs, and thesupply of health resources (positive study): the concept of a production function for health, the private and social costs of health care, and types of health inputs (hospitals, physicians, nonphysician labor, drugs, and nonmedical inputs). In considering the types of production processes and empirical methods for studying them (.positive study), survey examines the issues of prevention versus treatment, controlled experiments, and statistieal regression analysis. Other subjects analyzed from positive studies are the demand for health and the interaction of demand and supply in determining the prices of medical care. The normative economic issues discussed are prices and incentives, financing, costs, and benefits. The overall purpose of economic research in the health field is noted to be the measurement of illness and health care in quantitative terms in order to aid policy decisions. Tabular data and 107 references are provided.
long-term care focus on hospice demonstrations, nursing homes, and community care for dependent adults. In addition, swing bed experimentation, waiver of hospitalization requirements for medicare skilled nursing facilities (SNF) coverage, and longterm care reimbursement and regulations research are discussed. Footnotes are included.
Article is a revision of a background paper prepared for the lnter-RegionM Seminar on Health Economics, World Health Organization, Geneva, Switzerland, July 2-16, 1973. Institute for Research on Poverty Reprint Series, No. 197.
Descriptor(s): Funding/financing of health care programs, Poll cy initiatives, Cost containment efforts, Outcome/evaluation of quality assurance, Hospital services, Reimbursement, Methods of payment determination.
803. Research in Health Economics. A Survey.
Burton A. Weisbrod. Wisconsin Univ. Inst. for Research on Poverty, Madison, WI 53706 Department of Health, Education, and Welfare, Washington, DC. 1976, 19 pp. A vailability: Wisconsin Univ., Inst. for Research on Poverty, Publications Dept., Madison, WI 53706. This survey of research in health economics considers such areas as the concept and estimation of the "production function" for health, the distinction between private and social costs, determi-
Descriptor(s): Economics of third-party payors, Health care/ services, Funding/financing of health care programs, Providers of health care services, Economic/commercial influences, Health care costs.
804. Responses of Canadian Physicians to the Introdu¢._ion of Universal Medical Care Insurance. The First Five Years in Quebec.
Charles Berry, J. Alan Brewster, Philip J. Held, Barbara H. Kehrer and Larry M. Manheim. Mathematica Policy Research, Inc., Princeton, NJ 08540 National Center for Health Services Research, Hyatts_ille, MD. Feb 1980, 21 pp. Availability: National Center for Health Services Reseaxch, Publications and Information Branch, Hyattsville, MD 20782.
Results are reported from a study designed to determine the effects of Quebec's (Canada) universal and comprehensive physi-
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cian insurance on (1) physicians' location and practice mode and (2) the organization and behavior of physicians' private practices. Claims files of the Quebec Health Insurance Board as well as other national and provincial data sources were used. In cooperation with the Federation of General Practitioners of Quebec, a telephone survey of a stratified random sample of 1,900 general practitioners in the province was conducted to obtain current data on their practices. Data were gathered on factors such as staff and physicians' hours spent in providing primary care. Geographical units within the province were delineated in an effort to ascertain mobility and location of physicians. Sixty-five of these medical market areas were defined, Economic models and appropriate statistical methods were used to analyze the data in relation to the physician supply, physician mobility, use of services, and cost. The analysis includes the following conclusions about Quebec medicare and implications for the United States: (1) the Quebec medicare system appears to be approaching one of the primary objectives of a universal health insurance program: reasonably uniform access to medical care across income and location groups; (2) the physician-population ratio in Quebec has been rising rapidly, albeit at different rates in different market areas, without depressing average gross payments per physician at constant fee levels; (3) in a fee-forservice medical system with zero copayment by the patient, the definition of medical procedures and the enforcement of the rules governing billing for such procedures are important items in controlling program costs; and (4) the observed movement of general practitioners to areas in Quebec where payments per general practitioner are relatively high suggests that financial incentives may provide policy options for affecting the distribution of physicians,
Issues related to the role of families in financing and caring for their members with long-term care needs are discussed. These issues are examined from the perspective of whether the Federal Government should require some type of financial or in-kind contribution from designated kin of relatives receiving long-term care services under medicaid as either partial payment or as a condition of eligibility for the programs. In the past 13 years, total expenditures for nursing-home care under the medicaid program have increased drastically and show no signs of abating. Government, therefore, has become aware of the need to control this rapid increase. Demographic elements appear to mitigate against increased family responsibility in this area. Further, differences in the nature and extent of family financial responsibility and caring show the potential variability in families' capacity to give care. Such capacity is contingent on the balance between patient need and family resources. Therefore, both the general social forces and specific policy initiatives that will sustain that balance should be identified. Inducements to institutional care might be limited by using an approach in which funds for nursing home care can be used for noninstitutional care if the cost of the latter is not over some fixed percent of the cost of the former. Also, current efforts to control nursing home use can be efficient if free tuned and closely correlated with expansion of home care services. A minimum incentive for families would be public recognition that those who elect to care for their relatives need periodic respite from what is often a taxing physical burden. Some variation of coinsurance or deductible concepts might be applied to long-term care programs, and the potential for more suitable income tax credits or tax deductions should be explored. The growth of Federal expenditure may also be reduced by altering the current trend of transferring State and local costs to Federal programs. Technical notes are provided on
NCHSR Research Digest Series, Report No. NCHSR 80-18. Summary of"Study of the Responses of Canaak'an Physicians to the Introduction of UniversMMedical Care Insurance. The First Five Years in Quebec. '"
major long-term care programs and family responsibility and on the California experience with personal care allowances. About 60 references, a few footnotes, a graph, and some tabular data are included.
Descriptor(s): Physicians, Comparisons regarding foreign health policies, Evaluations/outcome of health care programs, Supply/ availability of services, Medical/surgical services,
Descriptor(s): Medicaid, Home health services, Long term care facilities, Deductible/eoinsurance, Funding/financing of health care programs, Policy initiatives.
805. Responsibility Eiders.
806. Responsibility
of Families for Their Severely Disabled
James J. Callahan, Lawrence D. Diamond, and Robert Morris.
Janet Z. Giele
Health Care Financing Administration, Washington, DC. 1980, 20 pp. Availability: Health Care Financing Review vl n3 p29-48 Winter 1980.
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of the Individual.
John H. Knowles. 1977, 24 pp. Availability: Daedalus
v106 nl p57-80 Winter
1977.
Aspects of personal responsibility for preventive health care are discussed. The sociocultural effects of urban industrial life pro-
Health Care Programs
duce stress, a sedentary existence, bad habits, and unhealthy environmental influences. The individual can maintain his/her health, however, by the observance of simple, prudent rules relating to sleep, exercise, diet and weight, alcohol use, and smoking. The long-term use of drugs should also be avoided, Persons should be aware of the dangers of stress and the need for stress-relievingprecautiousduring periods of sudden change, such as bereavement, divorce, or new employment. Selective medical examination and screening procedures should be pursued. While these simple rules can be understood and observed by the majority of white, educated, middle-class Americans, it is much more difficult for minority groups which include large numbers of the impoverished and the illiterate, whose fear, ignorance, desperation, and superstition conspire against even the desire to remain healthy. In this instance, social policies related to improvements in education, employment, civil rights, and income, along with health services, must precede significant developments in personal preventive health care behavior. On the other hand, the individual is largely powerless to control disease-provoking environmental contaminants -- whether they are drugs, air and water pollutants, or food additives - except as he/she becomes knowledgeable enough to participate in public debate for support of appropriate governmental controls. In this area, citizens must depend largely on the wisdom of experts, research results, and the national will to legislate controls for our own protection over the long-term. Ten references are provided,
State management of medicaid are then addressed. This paper, focusing on Federal medicaid controls and incentives, examines the factors which make the States' medicaid programs so susceptible to economic fluctuations. This is discussed in the context of the 1974-75 recession. The chapter on alternative approaches to Federal financing addresses the funding issues. The issue of the resource allocation incentives generated by open-ended matching grants is then considered. The paper suggests that programs in many States may have expanded beyond levels which are satisfactory to the citizenry of the States. Four alternatives to the current financing system are examined. These alternatives include widening of the matching rate-structure, implementation of a system of closed-end matching grants, implementation of block grants, and federalization of medicaid. Finally, changes in medicaid regulations are proposed. It is recommended that the Federal Government impose a :limit on total hospital revenues and increase its financial share for longterm care services. States should be required to institute and operate a surveillance and ut'dization review system, should be allowed to experiment with limiting benefits by diagnosis, and should be required to issue to medicaid clients photo identification cards. In addition, the freedom of choice provision should be deleted. All nursing homes certified for either medicaid or medicare must participate in both programs. An appendix, 50 reference notes, and 11 tables are provided. (Author abstract modified)
Descriptor(s): Economic/commercial influences, National economic conditions, Preventive services,
Descriptor(s): Cost containment efforts, National econotnic conditions, Medicaid, Plan design/program provisions (under health plans), Funding/financing of health care programs, Present legislation/regulations, Policy initiatives.
807. Restructuring
Federal Medicaid
Controls and Incentives.
John Holahan, William Scanlon and Bruce Spitz. Urban Inst., Washington, DC 20037 UI-986-12 National Center for Health Services Research, Hyattsville, MD. Ford Foundation, New York, NY. Jun 1977, 96 pp. A vailabib'ty: Urban Inst., Washington, DC 20037.
This paper is the fourth of a four-part series on alternative strategies for controlling the costs of State medicaid programs. The series is a systematic examination of State options which are permitted by Federal regulations and which would improve the efficiency of the programs. Cost containment issues and options regarding medicaid eligibility, benefits, provider reimbursement, and utilization controls are set forth. Possible changes in Federal regulations and financing mec_nisms which might improve
808. Rethinking Employee Benefits Assumptions. David A. Weeks. Conference Board, Inc., New York, NY 10022 1978, 97 pp. Availabih'ty: Conference Board, Inc., New York, NY 10022.
This book describes a review of employee benefits assumptions that was conducted at The Conference Board's New York City meeting. One speaker projected a future scenario to include some form ofminimnm health-insurance standards, a limit to the level of pay replaced by social security checks, mandatory vesting of pensions in the event of death, pension credit portability, restrictions on fund investments, and an expansion of the corporate role in unemployment benefits. Several speakers addressed the major problem of reconciling the contributions of executives and highly paid employees with their rewards and at the same time,
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providing for some redistribution of wealth to noncontributing members of society. While one session concentrated on problems associated with retirement, another focused on the major conterns ofbenefit planners in the health field. Attempts at eontrolling costs through a marshaling of company and community resources at General Motors were discussed, as well as the involvement of General Mills with prepaid group-practice plans, One speaker claimed that planning benefits will increasingly depend on the ratio of cost to benefit that is obtainable for a group of employees, but that these ratios will no longer be favorable in the case of increases in levels of basic employee benefits, A preferable approach will center around new ways to increase the number of optional coverages and benefit levels available to an employee to allow the individual to tailor his or her own benefit package. Another speaker predicted that maintaining benefit levels in the face of rapidly rising costs will strain future collective bargaining and will lead to increased Federal involvement in employee benefits. Finally, two different approaches to limiting future benefits were suggested: a series of planning guidelines to compare benefit proposals and a benefits design for
ratios of the elderly to the working-age population varying from 1 to 4 to 1 to 2.6 in the year 2035; (4) increasing proportions of the "old-old" (age 75 and over); and (5) more single women and minorities among the elderly. In addition, medicare and medicaid are both costly and do not adequately meet the needs of the elderly. The proposed six-point program includes income maintenance, medicare reforms including long-term care for the chronically terminally ill, greater emphasis on preventive care, and no additional cost sharing for patients who have to stay in acute hospitals for more than 60 days. The proposed program also has upper limits on deductibles and coinsurance, and proposes development of negotiated sebedules of prospective fixed fees for physicians. In addition, the following needs are taken into account: a new program for long-term care for the functionally disabled; reform of a residual or transitional medicaid; eventual incorporation of medicare, medicaid, and any new long-term program into a national health insurance system; and the development of volunteer services. Footnotes, 2 tables, and 42 references are given.
which all employees are theoretically eligible, but which only makes payments to very limited groups of employees (such as reimbursing costs of adoption). Thus, in the 1980's, more government regulation and the differing needs of employees seem to be creating even further diversity in employee benefits. Charts, tables, comments, and a list of conference participants are included. (Author abstract modified)
This paper is based in part on a presentation to the American Association of Retired Persons and NationM Retired Teachers Association, National Issue Forum, Atlnnta, GA, March 8, 1979.
Conference
Descriptor(s): Demographic features of population, Cost contalnment efforts, Medicare, Medicaid, Policy initiatives.
Board Report No. 739.
Descriptor(s): Private health care plans, Participants in health care programs, Source of premium payment, Voluntary initiatives.
810. Rethinking National Health Insurance. Theodore
R. Marmor.
1977, 23 pp. Availability: Public Interest 809. Rethinking Program.
1977.
Health Policy for the Elderly. A Six-Point
Anne R. Somers. 1980, 15 pp. Availability: Inquiry
v17 nl p3-17 Spring 1980.
This paper emphasizes the importance of rethinking national health policies and programs for the elderly and proposes a six-point program that addresses the health needs of the elderly in the last decades of the 20th century. The paper notes the following demographic reasons for rethinking national health policies: (1) increased life expectancy at age 65 which rose 1.5 years from 1965 to 1975, (2) increased number of Americans over 65 from 4 million in 1900 to 24 million in 1979,(3)projected
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n46 p73-95 Winter
Step-by-step introduction of child health insurance and catastrophic coverage are proposed as an alternative to immediate comprehensive national health insurance (NHI). The article states that American politicians have tended to exaggerate the severity of the crisis in the medical care system, hindering realistic appraisal of competing NHI proposals. Real health care problems include the lack of catastrophic illness coverage for many families, runaway medical inflation, a disorganized medical care distribution system, and questionable or inefficient medical practices. NHI has come to be viewed as a rapid solution to these problems. However, the form of national medical insurance has been the subject of extensive debate. Alternatives range from the Medieredit proposal of the American Medical Association to the universal Kennedy-Corman plan, catastrophic expense programs, and mixed strategy calling for increased Government
Health
Care Prod;rams
requlation and partial Federal subsidy of the present medical care system. Unfortunately, the political debate over these proposals tends to emphasize their differences rather than their probable results. The Canadian and British experiences with NHI suggest that such health insurance is likely to be more successful in improving access than in containing costs. In the author's view, the most reasonable solution to the particular American set of problems would be to continue the tradition of
legal reforms are designed to reduce the number of :suits, the likelihood of success of suits, or the size of settlement awards. The Medical Malpractice Commission has noted that no central collection of data occurs for malpractice. The Commission has suggested that the National Association of Insurance Commissioners work with the insurance industry to establish such a system, and action has been taken in that direction. The Medical Malpractice Commission recommends that alternative methods
phasing in health programs by age and income groups. A cornprehensive health insurance program for all preschool children and pregnant women with capitation reimbursement would be a
of solving claims should be instituted and prefers voluntary binding arbitration to use of screening panels or to compulsory nonbinding arbitration. The American Medical Association has
relatively low-cost means of expanding health care coverage and improving equality of access. Annual total cost would be about seven million dollars, the program would be supplemented by a national catastrophic plan, and all medical care expenses would be eligible for tax credits, although the amount of out-of-tx>cket liability would vary according to income. Tables are supplied,
acknowledged that State medical boards have not effectively disciplined incompetent physicians, and it now supports State legislation which would protect State medical boards from lawsuits by disciplined physicians. Exhibits detailing methodology and summarizing selected malpractice claims are provided, along with 50 annotated footnotes.
Descriptor(s): National health insurance (NHI), Policy initiatives, Comparisons regarding foreign health policies,
Descriptor(s): Economic/commercial influences, Non-employment related plans, Policy initiatives, Health care cost trends/ projections, Health information/data systems.
811. Review of the Medical Malpractice
Problem in the
United States.
Health Insurance Association 20006 Oct 1975, 28 pp.
812. Rising Cost of Catastrophic Illness.
of America,
Availability: Health Insurance Association ington, DC 20006.
Washington, DC
Gordon R. Trapnell and Frank E. McFadden. Trapnell (Gordon R.) Consulting Actuaries, Falls Church, VA 22044
of America, Wash-
National Center for Health Services Research, Hyattsville, MD.
In the past 15 years, the cost of malpractice insurance premiums has increased at a 25-fold rate, leaving little doubt that the United States is faced with a severe medical malpractice problem. In some States, premium costs have increased several hundred percent in a single year, and doctors have begun to practice defensive medicine, leading to further increases in costs which may actually dwarf the rise of insurance rates. Insurance firms are withdrawing from the malpractice market, with only 22 firms writing virtually all primary malpractice insurance. Most proposals for alternatives to primary malpractice insurance call for the establishment of joint underwriting associations, or for provider owned companies which could draw from State or Federal government reserve funds in case of depletion. Suggestions for combating sharply rising premiums and claims costs include changing tort laws, limiting legal contingency fees, iraproving provider performance, and substituting arbitration for jury trials. Many legal reforms have been suggested to alter the trend to increased costs, although the American Trial Lawyers Association has not proposed any significant changes. Suggested
Dee 1977, 538 pp. Av_labilit¥: Trapnell (Gordon R.) Consulting Actuaries, Falls Church, VA 22044.
Results are reported from research that developed time series analyses of catastrophic illness ((2I) so as to (1) provide a basis for understanding the increasing cost of treating major illnesses, (2) provide a profile of the changes in spending for CI by its principal causes, and (3) show the contribution of major disease categories to these trends. The results also have major implications for public policy by providing a basis for estimating the rate of increase in the cost of catastrophic provisions of health insurance plans, including those in proposed national health insur. ance programs. The study defines CI to be an illness or series of illnesses that results in annual health care charges for an individual in excess of a specified threshold amount. The charges may be expressed in nominal dollars or dollars used to represent purchasing power, the quantity of medical factor inputs, the quantity of medical services, the number of units of average spending for medical care, or another aspect of medical care. In
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order that research results can be applied to as many specific problems as possible and to show the distribution of health care costs by amount, a number of threshold levels are analyzed, ranging from $2,500 to $15,000 in $2,500 increments. Findings show that the cost of CI is increasing rapidly, both in terms of the ability of individuals to pay and the consumption of national medical resources. The trend is shown to depend on the level of • the threshold chosen to define CI; CI increases faster at higher threshold levels. The causes of this increase are the general level of price inflation, the additional increases in the prices of medical care factors, an increasing level of use of health services, a trend toward relatively greater use of more expensive services, new types of treatment involving complex technology, and the aging of the population. The per capita cost of CI, defined with a fully dynamic threshold, was found to increase faster than medical spending in general. The significance of the results for public policy is discussed, and suggestions for further research are offeted. Detailed tables and discussions of methodology are appended. A glossary and bibliography of over 100 references are provided.
Descriptor(s): Health care cost trends/projections, Economic/ commercial influences, Policy/changes re health care.
professor of law at Duke University; an American Enterprise Institute adjunct scholar; and a member of the health subeommittee, Committe on Interstate and Foreign Commerce, U.S. House of Representatives.
AEI Forum Series. Conference Charles Daly, Moderator.
held on April 26, 1979. John
Descriptor(s): Cost containment efforts, Voluntary initiatives, Economics of third-party payors, Present legislation/regulations, Policy initiatives.
814. Rising Hospital Costs Can Be Restrained Payments
by Regulating
and Improving Management.
Comptroller General of the United States, Washington, DC 20548 Sep 1980, 210 pp. A vailabib'ty: General Accxmnting Office, Washington, DC 20548.
813. Rising Health Costs. Public and Private Responses.
Between 1950 and 1978, health care expenditures increased from $12 billion to $192 billion -- an increase of 1,500 percent. Hospi-
Joseph F. Boyle, Hale Champion, Clark C. Havighurst and Dave Stockman. American Enterprise Inst. for Public Policy Research, Wash-
tal costs, which increased at an average annual rate of 15 percent from 1970 to 1978, composed the largest part of these expenditures and have particularly affected the medicare program. Recently, 26 States established ratesetting programs designed to help control rising hospital costs by providing for an external authority to regulate the prices that hospitals may charge and
ington, DC 20036 1979, 41 pp. Availability: American Enterprise Inst. for Public Policy Research, Washington, DC 20036.
This edited transcript of an American Enterprise Institute Public Policy Forum examines why the cost of health care is increasing faster than the cost of most goods and services and what can be done to slow the rate of increase. The panel discusses the economic incentives at work in the health care market and the prospects for providing health care more efficiently. Special attention is devoted to the effect of various policies on the difficult medical tradeoffs between cost and quality. Among the cost control measures discussed are hospital revenue limits, health planning, utilization review, second surgical opinions, the health care industry's voluntary effort, patient cost sharing, reform of tax subsidies for the purchase of health insurance, and antitrust enforcement. Panel members include a member of the Board of Trustees of the American Medical Association; the Under Secretary of the Department of Health, Education, and Welfare; a
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third parties must pay for specified services. States with such programs were more successful in controlling the growth rate in expenditures per ease during 1975-77. However, health care authorities report that hospital managers nationwide have not implemented cost-containment management techniques even though such techniques can restrain hospital cost increases. The Congress should amend the Social Security Act to permit the full participation of the Health Care Financing Administration's (HCFA) medicare program in existing prospective ratesetting programs. In addition, if Congress amends the act, the Secretary of Health and Human Services should (1) increase HCFA participation by basing medicare and medicaid payments on program-determined rates, (2) promote and encourage cost-containment management techniques, and (3) monitor the impact of prospective ratesetting programs on hospital cost increases and periodically report the results to Congress. Footnotes, tabular data, and 32 appendices are included. (Author abstract modified)
Health Care Programs
Comptroller
General's Report
to the Congress HRD-80-72.
Descriptor(s): Cost containment efforts, Policy initiatives, Hospital services, Outcome/evaluation of health administration, Impact of third-party coverage, Publicly sponsored/mandated health plans.
815. Risk Differential Between Medicare Beaefielaries rolled and Not Enrolled in an HMO.
Ea-
Paul Eggers. 1980, 9 pp. Availability: Health Care Financing Review vl n3 p91-99 Winter 1980. The risk differential between medicare beneficiaries enrolled and
816. Role of Health Insurance in the Health Services Sector. Richard N. Rosett. National Bureau of Economic Research, Inc., New York, NY 10016 National Science Foundation, Washington, DC. 1976, 548 pp. A vailabih'ty: Neale Watson Academic Publications, York, NY 10010.
New
This report examines the role of health insurance in the health services sector, focusing on the market for health insurance, effects of health insurance on the market for health services, and national health insurance (NHI). Concerning the market for health insurance, one paper studies the welfare implications of changes in the coinsurance rate of health insurance policies, and another investigates the nature and properties of the joint demand for health insurance and preventive medicine. Finally, the benefits to the public of group health insurance and the demand for reimbursement insurance are analyzed. To determine the
not enrolled in a health maintenance organization (HMO) is analyzed. Medicare provides incentive reimbursements to HMO's which enroll medicare beneficiaries on a risk option and provide care at a lower cost than expected. The incentive reimbursements are tied to an actuarial calculation of Medicare Adjusted Average Per Capita Cost (AAPCC). The AAPCC adjusts for a number of variables which affect medicare reimbursements and for which data are available: place of residence, age, sex, welfare status, and institutional status of beneficiaries. These factors account for much of the expected difference in health care reimbursements. They do not, however, account for differences in health status. Thus, AAPCC calculations of expected costs may be too high if a selected group of beneficiaries is healthier than average or too low if the selected group has a poorer health status than average. This case study examines the use behavior and reimbursement experience of a group of medi-
effects of health insurance on the market for health services, papers discuss the demand for health care among the urban poor, statistically test a model of the family as provider-protector of the health of its children, estimate price and income elasticities of medical care services, and examine physician fee inflation. Papers discussing the role of health insurance under NHI cornment on mortality, disability, and the normative economics of medicare;, the impact of medicare and medicaid on access to medical care; expenditure, use, and pricing of insured health care in Canada; and the effect of NHI on the price and quantity of medical care. Chapter references, statistical data, footnotes, and an index are included. Comments on each selection are appended"
care beneficiaries prior to their joining an HMO under a risksharing option. Their use was compared with a comparable medicare population to determine if their usage rates were greater than, equal to, or less than average. Results show that beneficiaries who joined during open enrollment had a rate of hospital inpatient use over 50 percent below the comparison group and a reimbursement rate for inpatient services 47 percent below the comparison group. These beneficiaries' use of Part B services also appears to be lower than the comparison group. These results must be interpreted with care since the information came from a single case study. Tabular data, footnotes, and eight references are provided. (Author abstract modified)
Descriptor(s): Economics of third-party payors, Competition/ interaction amongthird-party payors, Impact of third-partycoverage, Demand/utilization of health care programs, Physicians, National health insurance (NHI), Comparisons regarding foreign health policies, Deductible/coinsurance, Publicly sponsored/mandated health plans.
Descriptor(s): Medicare, Prepaid plans, Demand/utilization of health care programs, Reimbursement, Comparisonsof health care programs, Participants in health care programs.
Universities-National
Bureau Conference
Series, No..?7.
817. Role of Payment Source in Differentiating
Nursing
Home Residents, Services, and Payments. Korbin Lin and Jana Mossey. 1980, 11 pp. Avallabi_ty: Health Care Financing Summer 1980.
Review v2 nl p51-61
1-369
The foilowing issues are addressed: (1) whether publicly subsi-, dized nursing home residents are more functionally dependent or needy than their private-pay counterparts, (2) whether public residents receive the same intensity of services as private residents when needs are similar, and (3) whether payments for care for public residents are equivalent to those for private residents with similar needs. A descriptive analysis of data from a 1976 national smwey of the institutionalized elderly is presented. Consistent with findings from other studies of this population, this research shows that differences exist between public and private residents in terms of need for care, services received, and payment amounts. The retirement entitlement group was relatively less dependent, received less staff service, and paid less for care at all "activities of daily living" levels. The private-only group was slightly more dependent than the population in general, received le_s staff service than either public-only or mixed public/private resider_, and paid higher rates. While measures of need ar_5 s::_nices were limited, the anatvsis suggests some excessi_e ;_s.e of s,:r-,ices. Perhaps more significant, however, is the suggestion of inappropriate placement in long term care institutions. Tabular d'tta, a few footnotes, and 35 references are provided.
laboratory and x-ray procedures, physician-owned equipment, specialization in medical education, increased ratios of physicians to population, physician training emphasizing the technological imperative, physician unawareness of decisions, cost implications, defensive medical practice, radiologists' and pathologists' reimbursement mechanisms, and life-improvement trends in medical practice. Unfortunately, sensitivity analysis of these factors is needed to reach a decision on the most effective use of educational resources. For the time being, measures for physician education which can help control costs are inclusion of costs for laboratory and -K-rayprocedures in medical economics curriculum, emphasis iTamedical curriculum on attitudinal factors in decisionmaking, :and expansion of clinical settings for medical education to provide a more realistic patient mix. Fifteen references are supplio:l. Adapted From a presentat_._n at Lhe Invitational CorJtbrencc ,m Physicians and Cost C_;atrol, Harvard _chool o1 Pub!it Hen#h, Boston (MA), December iOTZ
Descriptor(s): Cost containment Physicians, Diagnostic services.
effoits, Health care/services,
Descriptor(s): Demand/utilization of health care programs, Health ca_e/services, Intermediate care facilities, Long term care facilities, Comparisons of health care programs. 819. Role of State and Local Governments in Relation to Personal Health Services.
818. Role of Physician Education in Cost Containment.
Robert S. Lawrence. Robert Wtx)d Johnson 1979, 7 pp. Availability: Nov 79.
Foundation,
Princeton,
Jnl. of Medical Education
NJ.
v54 nl 1 p841-847
The role of physician knowledge and attitudes in cost containment efforts is discussed. Findings of various researchers indicate that a high percentage of decisions by physicians to order laboratory tests or other investigative procedures are made on clinical grounds without consideration of cost factors. However, cost consciousness may alter physician behavior. For example, distributing results of a cost audit of physicians may temporarily reduce their ordering of laboratory tests, but modifications in behavior arc likely to be shortlived unless repetition and incentives are provided. Increased medical costs are generated by practicing physicians in three major sectors: hospital care, direct physician services, and prescription of drugs and medical supplies. Eleven inflationary cost factors directly attributable to physician_ have been identified: new medical technology, drugs,
1 ,/0
Sagar Jain. Johnson Foundation, Robert C.Wood 1980, 95 pp. Availability: American plement Jan 81.
Princeton, NJ.
Journal of Public Health v 71 nl Sup-
This collection presents the background papers and selected presentations from a conference that reviewed the current status of State and local government involvement in the organization and delivery of personal health services in the United States and considered the future direction of such involvement. An introduction summarizes the background, discussions, and atmosphere of the conference. The initial presentation outlines prospects for State and local government to play a broader role in health care in the 198ffs. This can be accomplished through extended responsibility for the health care needs of citizens with "mediealized" social problems and those who live in environments which cannot sustain private health care arrangements due to barriers of geography, language, culture, crime, etc. Additional background papers discuss the role of local health departments in the delivery of ambulatory care, primary health care for urban children and youth, and the Norlh Carolina experience with primary health care at the level of the
Health Care Program_
local health department. Roles of the States and of city governments are addressed, and current strategies for the delivery of personal health services in rural areas are assessed. Presentations of selected perspectives reveal the Federal as well as the State view of local health departments. Specific experiences are related through the examples of New York State, Cambridge, Mass., and Denver, Colo. Concluding contributions present the viewpoint of rural health services and a perspective on the relationship between long-term care and local health departments, Appendices list conference participants and contain acknowledgements. Individual papers contain footnotes, tabular data, and references, Based on the proceedings of a national symposium
ment while discouraging excessive or inappropriate coverage. If the goal of a national health insurance plan is to have a single purchaser of medical care, there is no place for the competitive private sector. The best approach would be to develop public policy that would coordinate incentives for cost containment within the competitive dynamics of the private sector. Some approaches would be the removal of distortive incentives to purchase shallow coverage, pooling of individual coverage, and a more adequate program for the poor and near-poor. Cost control could be accomplished in the short run by a national budgeting approach and in the long run by private marketoriented cost-control efforts. Tabular data and notes are provided.
held in Chap-
el Hill, NC, January 6-8, 1980.
Descriptor(s): Cost containment efforts, National health insurance (NHI).
Third-party
payors,
Descriptor(s): Present legislation/regulations, Policy initiatives, Demand/utilization of health care programs, Economic/commercial influences. 821. Rx for Health Care Economics. Competition, NHI.
820. Role of the Private Sector in National Health Insurance. Mark V. Pauly. Health Insurance Health Insurance
Inst., Washington, DC 20006 Association of America, Washington,
1979, 46 pp. Availability: Health Insurance
Inst., Washington,
DC.
DC 20006.
The role the private sector might have in a national health insurance plan is examined. There is no convincing evidence that the private sector is less efficient than the public sector in administering health insurance; it is probably more efficient. The major implicit costs of public sector administration are the inefficiency costs associated with increased taxation and the losses caused by imposition of a uniform insurance on a heterogeneous population. The inefficiency cost of increased taxation would probably be 14 to 17 percent of total premiums, more than sufficient to offset any explicit administrative cost savings from movement to public provision. Private and public cost control efforts can and should be undertaken simultaneously. Public sector administration of comprehensive universal national health insurance is unnecessary, and probably undesirable for achieving cost control, An ideal national health insurance combines comprehensive universal coverage for the poor and the near-poor with extensive catastrophic coverage (with income-related copayments and deductibles) for everyone else. Changes in the tax treatment of private insurance, especially employment-related insurance, can encourage appropriate types of coverage and methods of pay-
Not Rigid
Alain C. Enthoven. 1978, 8 pp. Availabih?y: Hospital Progress v59 nl0 p44-51 Oct 78.
The market for medical care services might be restructured to increase competition by using alternatives to the dominant system of fee-for-service physicians, cost-reimbursed hospitals, and third-party intermediaries. The most important differences in costs are differences in total per capita costs for comprehensive health care services for similar populations, and these costs can vary substantially. These variations are not necessarily related to differences in the quality of care and are imperfectly understood at this time. Utilization, physician judgments, resources, and education contribute to variations. Public policy should recognize that there is a good and legitimate reason for considerable variation and that such variation is not simply a matter of cost versus quality. It is therefore likely that several competing organized systems, each emphasizing a different mix of characteristics and designed for a different market segment, can increase consumer satisfaction over what a single uniform plan would generate. This principle has important implications for Medicare and the design of a National Health Insurance (NHI) program. An organized system financed on a capitation basis and serving a defined population might deemphasize hospitalization and apply the savings to improved access to ambulatory care. Thus, capitation-financed systems are neither a device for financing the same bundle of services, nor are they incentive schemes for lowering cost or utilization. Rather, they provide a framework whereby providers can offer very different product mixes for various con-
1-371
sumer choices. A NHI scheme or a regulatory scheme that will freeze the delivery system in its present costly and noncompetitive state should be avoided. The Federal government ought to find ways to put HMO's and other competing systems on an equal footing with respect to the per capita costs supported by tax dollars and eliminate the subsidy of more costly systems for care through Medicare, Medicaid, and the tax laws. There is much the government could do to bring about a fair market test between fee-for-service and alternative delivery systems, Twenty-one footnotes are provided, Adapted from a paper presented at the Federal Trade Commission conference on Competition in the Health Care Sector, Washington, DC, June 1977.
Descriptor(s): Cost containment efforts, Competition/interaction among third-party payors, Policy initiatives,
822. Savings to CHAMPUS formed Services Hospitals. Comptroller General 20548 Dec 1978, 28 pp. A vailabilit.v: General
Comptroller
General's Red,oft to the Congress HRD-79-24.
Descriptor(s): Publicly sponsored/mandated health plans, Inpatient facilities, Limitations on coverage, Outcome/evaluation of health administration.
From Requirement to Use Uui-
of the United
Accounting
823. Second Surgical Opiuions. What Have We Learned. States, Washington,
Office, Washington,
DC
Trudi W. Galblum. 1979, 4 pp. Availability: Forum v3 nl p14-17 Feb 80.
DC
20548. The 40-mile rule, the requirement that beneficiaries of the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) who reside within 40 miles of uniformed services hospitals obtain nonemergency inpatient care there, if available, rather than at civilian hospitals, has resulted in substantial savings to CHAMPUS and in increased use of uniformed services hospitals. Numbers of unused beds in these hospitals remain relatively high. However, the potential for greater use of available beds by program beneficiaries is limited if the Department of Defense (DOD) assessment of physician staffing problems is accurate (i.e., chronic physician shortages). DOD instructions for implementing the 40-mile rule authorize hospital commanders to alter the 40-mile radiuses around their hospitals in cases of unusual geographic or transportation problems, and thus they exempt some beneficiaries from the requirement to obtain nonavailability statements. Of the eight primary hospitals the Government Accounting Office (GAO) visited in this study, five had exempted beneficiaries in certain areas of the 40-mile radiuses for various reasons. Among these reasons are excessive waiting time and interruption of continuity of care. However, no definitive guidance is provided as to what constitutes excessive waiting time. It is recommended that the Secretary of Defense take the
1-372
following actions to improve the administration of the 40-mile rule. Procedures should be established so that approval of alterations to the 40-mile radius be done by higher DOD levels. Excessire waiting time should be clearly defined, and instructions for more strict and consistent application of the continuity of care reason should be issued. Pe_-iodic exchanges of medical capability listings between hospitals within overlapping 40-mile radiuses should be required. Finally, when availability of needed care cannot be determined from medical capability listings, case-bycase coordination between hospitals should be required. Tabular data and a list of the visiled hospitals are provided. (Author abstract modified)
Second opinion programs to reduce the amount of unnecessary surgery are surveyed. A la_admark study conducted in 1970 revealed that the United States not only had twice as many surgeons as England and Wales, but also that these surgeons performed twice as much surgery as their British counterparts. Because of its responsibility to contain the costs and promote the quality of health care for the nation, the Department of Health, Education, and Welfare announced a major initiative in 1978 to encourage Americans to seek second opinions for nonemergency surgery. While very few question the value of a second opinion for elective surgery, there remain many unanswered questions about the best way of organizing such a program and what the long-term effects would be on the cost and quality of health care. One finding consistently discovered in several voluntary programs is that the demand :for second opinions is minimal when offered as an optional benefit. About one-third of the recommended surgery in medicare demonstrations was not confirmed by consultants. The reasons most frequently cited for nonconfirmation were trial of medical management indicated, further diagnostic studies indicated, and no treatment necessary. The number of insurance companies offering some sort of second opinion program appears to be growing. In the spring of 1980, Abt Associates will complete a full-scale survey of all second opinion programs currently operating or planned. At this point,
Health Care Programs
most agree that second opinions are an advantage to the patient, Moreover, program savings probably exceed costs. But two important issues must be addressed before a final assessment about second opinions can be made. First, any direct connection be-
fields of business, economics, medicine, health planning, legislation, sociology, and political science as well as computerized data bases. (Author abstract modified)
tween second opinion programs and lower surgery rates and lower costs depends primarily upon how many persons decide to forego the surgery as a result of the second opinion. Second, voluntary programs are predominant, but mandatory programs may have a greater potential cost savings voluntary programs thus far have not attracted a significant percentage of persons recommended for surgery. Vc'hat does appear certain, however, is that enough third party payers are convinced of the cost savings of second opinion programs that such benefits in some form are here to stay.
Descriptor(s):
Descriptor(s): Medical/surgical services, Voluntary initiatives, Cost containment efforts, Plan design/program provisions (under health plans),
824. Selected, Annotated Bibliography on Health Maintenance Organizations, 1974-1978. Volume II.
Cost containment efforts, Prepaid plans.
825. Selected Bibliographic Research Guide to Health Maintenance Organizations and Prepaid Group Practice. Prakash C. Sharma. Mar 1979, 6 pp. A vailability: Vance Bibliographies, Monticello,
IL 61856.
This selected bibliographic research guide to health maintenance organizations and prepaid group practice presents approximately 75 citations arranged alphabetically by author. Most of the publications are from the 1960's and 1970's, but a couple date from the 1940's. The articles and books cited cover such topics as consumers' attitudes and satisfaction with group practice, group health cooperatives, the dissemination of health information, prepaid health plans, and health maintenance organizations (HMO's). The bibliography is not annotated.
Nina M. Lane and Anna T. Stocker. Group Health Association of America, Inc., Washington, DC 20036 Department of Health, Education, and Welfare, Washington, DCI Office of Health Maintenance Organizations. Jan 1980, 137 pp. A wilability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 01%002-00132-1. This selected, annotated bibliography on health maintenance organizations (HMO's) is intended for policymakers, administrators, scholars, and potential purchasers. The bibliography is the second volume in a two-volume series. It contains reports of findings on primary research and projects, review papers, handbooks, and any other noteworthy HMO-related materials. Items were picked for their substantiveness and inclusion of helpful appendices. The publications are arranged by 28 subject areas, Topics appear with general and conceptual areas first, followed by more specific concerns. They include such subjects as HMO performance, medicare and medicaid, issues and attitudes of physicians, financial issues, and preventive services. Indepth cross-references provide the reader with a link to related topics. Annotations present the substance of the works cited; draw attention to useful features such as tables, case studies, and further readings; and direct the user to either condensations or more detailed versions. Two appendices list 20 printed indexes in the
Pubh'c Administration
_ries
Bibliography
Descriptor(s): Prepaid plans, Participants grams, Preventive services.
No. P-203. in health care pro-
826. Selected Bibliographic Research Guide to the Medicaid Program. Prakash C. Sharma. Apt 1979, 7 pp. Availability: Vance Bibliographies,
MonticeUo, IL 61856
Nearly 100 selected references on studies related to the medicaid program are contained in this research guide. The references, published chiefly from 1965 to 1975, represent many of the old and current publications that may be used as guides for further research. Part one, which contains a listing of books, documents, and monographs, covers the subjects of public assistance payments for nursing home care, professional services to welfare in California, the impact of State and Federal policy planning on Title XIX health care programs, and specific problems of American medicine. Also included are congressional and Department of Health, Education, and Welfare materials on medicare and medicaid; and part two contains journal and periodical articles
1-373
that cover such topics as policing publicly funded health care, the effect of medicaid on the health care of low-income persons, and medi,-aid abuses. The references are unannotated and ar-
828. Selected Topics in Federal Health Statistics.
ranged
Office of Technology Assessment (U.S. Congress), Washington, DC. Jun 1979, 212 pp. Availability: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 052-003-00683-9.
alphabetically.
Public Administration
Series Bibliography
Descriptor(s):
Medicaid.
827. Selected
Studies in Medical
No. P-215.
Care and Medical Eeonom-
its. Annual Report, 1975. Blue Cro._s Association Div. of Research and Development, Chicago, 1L 60611 Nat ional Association of Blue Shield Plans, Chicago, IL 60611 Nattona[ Association of Insurance Commissioners, Chicago IL.
Federal
health data collection
activities are reviewed
and as-
sessed. The first part of 1;he report inventories the health data collection systems administered by the Department of Health, Education, and Welfare and other Federal agencies, outlines the problems of duplication and fragmentation, and addresses the possibilities of improving the coordination of these systems. The report's second section is a directory of statutory provisions that govern the collection of health data by the Public Health Service
Jun 1975, 218 pp. Availabihty: Blue Cross Association, Div. of Research and Development, Chicago, IL 60611.
(PHS) and the Health Cal:e Financing Administration (HCFA). The growth in Federal health data activities is demonstrated by the increase in the numl_er of health data projects operated by PHS, the major collector of health statistics; in fiscal 1977, PHS
This reference document is a compilation of abstracts of current research m the fields of hospital and medical economics and health cave organization and administration. The abstracts were obtained through a mail survey of nearly 3,500 persons and organizations engaged in health care research. Over 400 abstracts of current research projects are included. Categories of research t:over health economics (national health insurance, national health care, health insurance, reimbursement mechanisms, heahh expenditures, and provider charges); health planning (general survey and evaluation projects, regulation, rural, manpower, alternative health care systems, family planning, _md attitudinal studies); and organization of the delivery system, including hospital, emergency medical systems, health maintenance organizations, group practice, and community health centers. Other categories encompass service areas, such as medical records, particular treatment and facilities, and alcoholism and _.bortion; utilization; education (patient, health professionals, and health administration); population characteristics, such as elderly, youth, poor, and prison health; and health professionals, including physicians and nurses. Each entry ineludes bibliographic information; a description of the research objective, content, methodology, financing, cost, and current status; and availability of findings. Some pricing information is provided. An index of investigators is included,
administered 153 data projects, more than a one-fourth increase over the number operated the previous year. HCFA, the other principal component within Health, Education, and Welfare concerned with health issues, operated at least an additional 13 large statistical projects l:hat year. Seven agencies and departments outside of Health, Education, and Welfare conduct major health statistical activities. However, Federal Government lacks a coherent policy to organize and manage the increasing numbers of assorted data collection projects. Activities relating to the acquisition, analysis, and use of statistical data that describe the health of people and the use of medical services and resources are unstructured and decentralized. Further, no systematic and comprehensive appraisal exists of the adequacy or use of health data currently collected. Formal responsibility for the functions related to the coordination and planning of Federal health statistics should be assigned to a central coordinating body. Such a unit should have sufficient authority to impose decisions on agencies and offices, the necessary statistical and analytical capabilites to conduct a,ztivities requiring technical expertise, and adequate resources to build a core effort. Overall, the coordinating unit should dewflop an analytical framework for planning the statistical system, improve the efficiency of data collection activities, and insure data accessibility for potential users. Tabular data, 48 references, footnotes, and organizational charts are included. An index of codes cited is also provided.
Descriptor(s): Characteristics of U.S. health care system, Providers of health care services, Economic/commercial influences, Evaluations/outcome of health care programs, Private health care plaJ_:,, Facilities providing health care, Health care/services,
1-374
Descriptor(s): Health information/data systems, Present legislation/regulations, Publicly sponsored/mandated health plans.
Health Care Programs
829. Services Shared by Health Care Organizations. notated Bibliography. Hospital
Research
and Educational
An An-
Trust Health Services Re-
search Center, Chicago, IL 60611 Northwestern Univ., Evanston, IL 60201 Bureau of Health Planning and Resources Development, Hyattsville, MD. Mar 1977, 93 pp. Availability: National Technical Information Service, Springfield, VA 22161, HRP-0300301. Literature on services and closely related topics, most of it published in the United States between 1970 and 1975, is cited in a bibliography directed primarily to health planning agencies and institutional planners. The development of sharing arrangements involving institutional health and health-supported services is one of the priorities addressed in the National Health Planning and Resources Development Act of 1974 (Public Law 93-641). This bibliography is designed to assist planners in gaining knowledge which will enhance their efforts to implement or expand such service-sharing arrangements. The 624 entries have been divided into 6 categories: (1) general and overview topics (defmitions and classification schemes, case studies of shared-services programs and attempts to synthesize these experiences into principles, conference proceedings, surveys, and bibliographies); (2) specific services and facilities (medical/clinical, manpower, administrative/supportive, and education and training); (3) diseiplinary studies (tax and legal issues, organization behavior, hospital and health service economics); (4) process-oriented studies (planning, feasibility, implentation, and evaluation); (5) rural and small hospitals; and (6) technical manuals basic to hospital operations, published by the American Hospital Association. Most of the references are annotated and are crossreferenced to as many categories as the material warrants. A brief descriptive phrase indicating the name of the shared-setvices organization and/or the area of the country which is the focus of the study follows case studies which are not annotated. An index and an alphabetically arranged addendum containing 23 references are included. (NTIS abstract) Health Planning Bibliography
Series, No. 3.
Availability:
Brookings Inst., Washington,
DC 20036.
This collection of essays deals with crucial interrelated domestic and foreign policy issues such as inflation, slow productivity growth, international competitiveness, and energy supply which must be addressed simultaneously and require public confidence in the competence of government to make and execute policy. The chapter on medical care issues views the current legislative stalemate as an inevitable historical consequence of 20th century medical care financing through third-party payment. The philosophy behind both private and public third-party payment, is that medical care should be provided whenever it will help the patient, without regard to cost. In pursuit of this goal, the new forms of financing have been reinforced by programs funding for hospital construction, physician and health worker training, and expanded National Institute of Health (NIH) research. The issues of unlimited needs and limited resources are compounded in the national health insurance (NHI) bills, all of which propose to cover more people more completely. Although the Carter administration's plan and the Kennedy plan extend coverage and services, neither gives an open-ended commitment to provide services. Both plans implieity abandon the principle that services should be provided without cost. Rationing would become the necessary responsibility ofthe providers because both plans limit provider budgets as their method of controlling costs. RealisticaUy, cost control -- with or without NHI-requires acceptance of the principle that some medical services produce benefits that are worth less than their cost; otherwise, the opportunities for spending are unlimited. Because the proponents of these plans have not admitted the need to ration or its role in their plans, the debate over NHI and cost control has not yet dealt with the crucial issues. (Author abstract modified)
Eleventh volume in an annum series published Institution.
by the Brookings
Descriptor(s): Health care costs, Supply/availability of services, Present legislation/regulations, Voluntary initiatives, Policy initiatives, National health insurance (NHI), Demand/utilization of health care programs, Funding/financing of health care programs, Comparisons regarding foreign health policies.
Descriptor(s): Health information/data systems, Facilities providing health care, Economic/commercial influences. 831. Short-Ran Hospital Responses to Reimbursement Changes. 830. Setting National Priorities.
Rate
Agenda for the 1980's.
Joseph A. Pechman and Louise B. Russell. Ford Foundation, New York, NY. 1980, 563 pp.
Hirsch S. Ruchlin and Harry M. Rosen. Health Care Financing Administration, Washington, 1980, 12 pp. Availability: Inquiry v17 nl 1342-53 Spring 1980.
DC.
1-375
The short-run sensitivity of New York State hospital responses to changes in reimbursement occurring during the 1974 to 1975 and 1975 to 1976 periods are analyzed. The principal sources of data were the Uniform Statistical Reports and the Uniform Financial Reports completed annually by each New York hospital, The potential universe to be studied included all nonfederal, short-term general hospitals in the State. The final sample consisted of 264 hospitals. Data were collected on the following indicators of hospital activity: total, salary, and other-than-salary expenses per adjusted patient day; diagnostic radiology films, laboratory examinations, and electrocardiography examinations per adjusted patient day; and self-pay revenue per adjusted (serf-pay) patient day. Expenses per adjusted patient day were disaggregated into routine care and ancillary care components, The regression results show that changes in Blue Cross Plan and medicaid reimbursement rates occurring during the 1974 to 1976 period failed to elicit strong commensurate short-run changes in hospital cost and use. Average real expenditures in some areas rose in spite of the apparent decline in average Blue Cross Plan and medicaid reimbursement rates. A partial explanation for this development is that some sources of revenue remained uncontrolled and hospitals were able to offset or compensate for the Blue Cross Plan and medicaid rate reductions. Some compensating effects were an increase in the medicare reimbursement rate, cost shifting toward self-pay patients, and an increase in overall hospital volume. It appears, however, that these compensating effects were not enough to offset fully the reductions in Blue Cross and medicaid reimbursement rates, since hospital operating deficits increased over the study period. Tabular data, refer-
ganization (HMO) plans. The methodological issues discussed are the identification of variables which affect the decision to enroll in an HMO (held constant to isolate the effect of selfselection), the way in which self-selection should and can be measured, and the selection of the most appropriate statistical procedure for determining whether self-selection exists, given nonexperimental data. It is hypothesized that when faced with the opportunity to enrol]Lor stay in an HMO, or enroll in a traditional reimbursement plan, certain individual characteristics such as sociodemographic background, prior experience with the health system, a:ad attitudes will have an effect on the enrollment decision. Also, the level of medical care use in the plan will influence the dex:ision. A principal issue in the research is whether higher levels of use or lower levels of health status are attributable to the fact that persons with these characteristics are more likely to join a given plan, or that the providers in that plan encourage observed levels of use or self-reported health status. The estimation techniques used -- the simultaneous and mixed logit techniques -- permit dealing with the fact that use affects the enrollment decision (self-selection) and the enrollment decision affects the level of health care use (provider effect). The application of the estimation method to participants in the Federal Employees Health Benefits Program suggests that self-selection is not of sufficient magnitude to measure; however, the empirical methods proposed and the theoretical complications addressed will help clarify the problems and encourage further investigations with other data and for other health plans. Tabular data, notes, and 32 references are provided.
ences, and notes are provided.
Prepared for presentatioz_ at the Annual Meetings of the Southern Economic Association, Atlanta, GA, November 1979.
Descriptor(s):
Health
care
costs,
Competition/interaction
among third-party payors, Medicaid, Service benefit plans, Inpatient facilities, Methods of payment determination, Impact of third-party coverage,
Descriptor(s): Prepaid plans, Government employee plans, Participants in health care programs, Comparisons of health care programs.
832. Simultaneous Logit of Plan Membership in the Federal Employees Health Benefits Program.
833. Social Aspects of the Rate Structure of Medical practice Insurance.
Louis F. Rossiter and Deborah A. Frennd. Nov 1979, 32 pp. Availability: National Center for Health Services Research, Hyattsville, MD 20782.
Jerry S. Rosenbloom anti Gary K. Stone. 1977, 11 pp. Amilabih'ty: Jnl. of Risk and Insurance v45 nl p53-63 Mar 78.
A simultaneous logit model of plan membership is used to measure self-selection for two health care plans offered to participants in the Federal Employees Health Benefits Program. The study examines whether there is self-selection (particular types of persons enrolling and staying enrolled) in health maintenance or-
This article explores the questions of social equity arising from the current medical malpractice insurance system and how these questions are handled by insurance regulation. In addition, the article examines the question of whether the medical malpractice insurance rating classification system is justifiable, based upon
1-370
Mal-
Health Care Programs
the specific services rendered by physicians. The existing rating system assumes a clear distinction between the medical specialties and the resulting liability exposure. Equity in an insurance rating system depends upon the accuracy of the statistics supporting a given rate and the social fairness of that rate, consider, ing the needs of society itself_ The classification system in
system impinges on the poor are examined. A section on health insurance and payment methods covers the evolution of national health insurance in America, diverse voluntary health insurance plans and their comparative effects, the dynamics of different methods of paying for medical care, preventive services in health insurance, and national health insurance as a means of cost
medical malpractice insurance is complex and involves a high degree of judgement. Several tables illustrate the levels and rates of malpractice insurance for medical specialties in the State of Michigan. The lowest rates are for general practitioners and internists (both not performing surgery), while the highest rates are for orthopedic surgeons, obstetricians, and neurosurgeons, When premiums are high relative to income (20 percent to 30 percent), evidence suggests that the physician is dropping medical malpractice insurance coverage and modifying his or her
control. Papers then turn to the organization of ambulatory health services which have historically been most individualistic. The growing importance of hospitals, their increased structuring, and their impacts on the total health care system are explored. Methods of evaluating organized health programs are analyzed, along with the expanding regulation that social pre_ sures generate. With increasing organization, greater attention to systematic health planning is inevitable; various planning features are discussed in five articles. The work concludes with
practice in such a way as to reduce the risk exposure. Such methods include restricting the practice to pre£erred groups, increasing defensive medical practices, and retiring early. Further analysis of the current rating system must be made, but preliminary conclusions seem to suggest the following: (1) staffstics currently are not available to justify the specific classifications of medical specialties and (2) the medical malpractice problem is not solely a problem of specialists, but a problem of the entire profession. New approaches to medical malpractice insurance ratings could (1) reduce the number of classifications or (2) provide a sizable fixed or constant factor in all rates. Tables and footnotes are included.
some forecasts and recommendations regarding the American health care system of the future. A few topics are considered in more than one paper, such as the impact of Government on the system. Most of the papers offer general interpretations of events made at professional meetings, but several report the results of empirical research projects. Some papers include tables and footnotes; references are provided for most works. (Author abstract modified)
Desc_ptor(s): Non-employment related Premium determination/underwriting,
plans,
Physicians,
Springer Sezies on Health Care zmd Society,
Volume 3.
Zk_Iiptor(s): Characteristics of U.S. health care system, Plan design/program provisions (under health plans), Private health care plans, Outpatient facilities, Inpatient facilities, Comparisons of health care programs, Third-party payors, Policy/ changes re health care.
834. Social Medicine. The Advance of Organized Health Services in America.
835. Social Nature of Chronic Disease and Disability.
Milton I. Rcemer.
Neff F. Bracht.
1978, 560 pp. Availabib'ty: Springer Publishing Company, Inc., New York, NY 10003.
1979, 16 pp. Av&ilabih'ty: Social Work in Health Care v5 n2 p129-144 Winter 1979.
A collection of 38 papers which document the trends of social medicine in the United States is presented. Most of the papers have been published previously in diverse English-language journals. All of the papers were written or presented in the 1960's and 1970's, but most refer to trends from earlier periods as well. Eight major subject categories are considered. The work begins with several broad panoramas of trends toward organization in health care, from differing perspectives. Special programs developed to compensate for the health handicaps of poverty and various difficulties in the way that the American health care
Recent epidemiologic data on the changing scope and distribulion of chronic illness and disability in the United States is analyzed in terms of medical, social, and economic costs. Research findings regarding current gaps in health care and social service delivery systems for patients and their families are reviewed. For example, it is estimated that 50 percent of the American population has one or more chronic conditions. The chronic diseases affecting Americans - including schizophrenia (the leading diagnosis for those receiving disability payments under the age of 40) and heart disease, emphysema, and arthritis
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(for those over 40) - can cause serious disability and impairment. Approximately 2 million children are handicapped, 1.5 million have asthma, and 50,000 have sickle cell anemia. Certain rates of chronic diseases are increasing: chronic respiratory diseases, diabetes, emphysema, bronchitis, lung cancer, and chronic ischemic heart disease. Today, there are as many persons being treated in nursing homes and related institutions as in general hospital beds. There are distinct differences in the way chronic disease and disability affects the population -- differing according to age, sex, marital status, ethnicity, and education. Chronic diseases are for the most part intercurrent illnesses and in general are not characterized by an unbroken state of extreme ill health and incapacity. Clearly, the social-psychological aspects of care for the chronically ill and their families are growing in importance, yet the provision of such services strain existing budget resources. Implications for the public and recommendations for public policy and program changes are discussed. Professionals
those which are known to exist (e.g., DC 10 motor mount failures, possible food contamination). Society's view toward major problems, such as use of illicit drugs or modes of transport, determines the response to such problems. Some problems require macro intervention approaches, while others can be resolved using a combination of both approaches. Threats to effective risk reduction arLdhealth problemsolving are examined and failures that may intercept real problem analysis are described. These include failure to analyze problems adequately; failure to examine and compare relevant possible interventions; failure to become conversant with implementation pathways; and blaming of the victira rather than solution of the problem. In addition, social responsibility for planning and implementing effective risk reduction is analyzed, and current policy approaches in the United States are criticized. Two figures and 49 references are included.
must personally advocate for programs that place equal attention on care as opposed to cure, on prevention as opposed to treatment. Consumer involvement and new funding resources must become available to support program linkages between health and social service delivery systems. Helping patients alter unhealthy lifestyle behaviors will place the social-behavioral disciplines in a key position in health care delivery structures of the futures. Tables, graphs, and 25 references are provided. (Author abstract modified)
Descriptor(s):
Descriptor(s):
1977, 259 pp. A vMlability: Superintendent of Documents, Government Printing Office, Wastdngton, DC 20402, order number 017-070-00304-4.
Trends in health status, Policy/changes
re health
care.
836. Social Perspective
on Risk Reduction.
Henrik L. Blum. 1980, 21 pp. A vailability: Family and Community
Health v3 nl p41-61
May 80. This article examines the concept of risk reduction and offers a critique of risk reduction strategies advocated or implied in vailous governmental policies, both in the United States and Canada. Risk reduction can be individually based (micro risk reduction) or collectively based (macro risk reduction). Micro approaches include such actions as careful driving, installing fire and smoke detectors in homes and other buildings, doing suitable exercise, and abstaining from smoking, abusing drugs, overeating, and other hazardous activities. Macro risk reduction involves eradicating or eliminating hazards to health by safety regulations and legislation; and creating a form of surveillance or control for conceivable defects that have yet to appear or for
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Preventive services, Policy initiatives.
837. Social Security Programs Throughout the World, 1977. Social Security Administration Office of Research and Statistics, Washington, DC 20203 HEW/PUB/SSA-78/11805
This research report highlights the principal features of social security systems throughout the world and covers 129 countries. The data reported are based on laws, implementing decrees, and regulations in force at the beginning of 1977. The general social security system is summarized in tabular form. The charts show the major features of each system and are arranged to facilitate intercountry comparisons. The charts are organized identically and include information on dates of basic laws and types of programs, coverage, source of funds, qualifying conditions, cash benefits for insured workers, permanent disability and medical benefits for insured workers, survivor benefits and medical benefits for dependents, and "administrative organization. Categories of social security branches covered are old age, infirmity, death, sickness and maternity, work injury, unemployment, and family allowances. The report provides a perspective on the methods that are used by different: countries both in designing and applying income-maintenance measures and as background in drafting social security legislation. It can be useful as a reference when making decisions relating to the benefit rights of foreign nationals covered under the U.S. program and providing technical assistance to other countries. (Author abstract modified)
Health
Care Programs
Descriptor(s): Present legislation/regulations, Comparisons regarding foreign health policies, Workers compensation, Publicly sponsored/mandated health plans, Plan design/program provisions (under health plans),
munication and specialization appear to be the most important. The results are consistent with the complex organization literature. Notes, three figures, three tables, and a 9 l-item bibliography are included. (Author abstract modified) Discussion Paper No. 487- 78. Paper prepared for presentation at the ninth World Congress of Sociology in Uppsala, Sweden, August 14-19, 1978.
838. Social Structure and the Diffusion of Medical Innovations in the United States, Great Britain, Sweden and France.
Descriptor(s): Trends in health status, Comparisons regarding foreign health policies, Medical technology impacts, Demographic features of population.
J. Rogers Hollingsworth, Jerald Hage and Robert Hanneman. Wisconsin Univ. Inst. for Research on Poverty, Madison, WI 53706 Department DC.
of Health, Education, and Welfare, Washington,
National Science Foundation, Washington, DC. German Marshall Fund of the United States, Washington, DC. Woodrow Wilson International Center for Scholars, Washington, DC. Jun 1978, 41 pp. Availability: Wisconsin Univ., Inst. for Research on Poverty, Madison, WI 53706.
This paper explores the relationship between several characteristics of social structure (i.e., centralization, communication, and professionalization) and the diffusion of medical innovations in Great Britain, France, Sweden, and the United States during the period between 1880 and 1970. The medical interventions ineluded in this study were low cost and highly efficacious, and thus were of greater value to low income groups. If one focuses on the role of social structural variables in influencing diffusion rates, it becomes apparent why some societies benefit earlier than others from new technologies which have considerable benefit to low-income groups. The paper demonstrates that the theoretical literature on complex organizations and communications may be integrated in order to explain the diffusion of innovations at the societal level. The dependent variables are the rate at which innovations are adopted at the societal level and the speed with which innovations are implemented throughout the society once an innovation has been adopted. To assess the rate of diffusion and the rate of implementation of heaith innovations, the research focuses on highly efficacious vaccines and measures the rate of decline in the mortality of specific diseases once a vaccine has diffused to a particular country. Scleeted diseases include smallpox, diptheria, tetanus, whooping cough, tuberculosis, polio, and measles. It is concluded that social structure does indeed influence the rate of diffusion. The impact of the structural variables is stronger on the speed of diffusion rather than on the speed of adoption. Of the three structural variables, corn-
839. Social Surveys and Health Policy. Implications for National Health Insurance. LuAnn Aday, Ronald Andersen and Odin W. Anderson. Robert Wood Johnson Foundation, Princeton, NJ. National Center for Health Services Research, Hyattsville, MD. 1977, 10 pp. Availability: Public Health Reports v92 n6 p508-517 Dec 77. Social survey data are used to assess the impact of Federal health care programs and to rank consumer preferences for future health policy initiatives. The primary data used were derived from national surveys of the noninstitutionalized U.S. population conducted by the Center for Health Administration Studies and the National Opinion Research Center in 1964, 1971, and 1975 to 1976. The data suggest that medicare and medicaid have increased access to the health care system; however, although more people are seeing physicians than ever before, large humbers believe the American health care system is in crisis. The out-of-pocket cost of medical care continues to be the greatest source of dissatisfaction among consumers. Many see national health insurance as a way of reducing unpredictable financial burdens from health care costs, but less comprehensive approaches are preferred out of fear of escalating taxes to pay for uncontrolled medical costs. The majority favor charging premiurns to those who actually receive services. Most also believe physicians would give better service if reimbursed according to units of service rather than fixed salary. A survey of physicians' attitudes toward national health insurance suggests that they favor a system administered by private insurance carriers and, assuming the poor are covered by Federal subsidy, financed by people who buy private health insurance rather than through a system of taxation. They also favored reimbursement based upon units of service. Findings from other recent public opinion polls concerniig national health insurance tend to support these same conclusions about patient and provider attitudes. Tabular data and 26 references are provided.
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This paper is based on one presented at the American Association of Public Opinion Research Conference, Asheville, NC, May 14, 1976.
Descriptor(s): Participation in health care programs, Reimbursement, Funding/financing of health care programs, National health insurance (NHI), Publicly sponsored/mandated health
major social welfare categories, health and medical programs and housing. Also contributing to the decline was the fact that the GNP rose at a faster rate in 1977 than in 1976. Six tables of statistical information and a chart are provided. (Author abstract modified)
plans.
Descriptor(s): Health care cost trends/projections, Medicare, National economic conditions, Workers compensation.
840. Social Welfare Expenditures Under Public Programs, Fiscal Year 1977.
841. Societal Responsibility
Alma McMillan. Social Security Administration,
Daniel H. Schwartz. Washington,
De 20203
1979, 10 pp. Availability: Social Security Bulletin v42 n6 p3-12 Jun 79. This paper provides statistical information on social welfare expenditures under public programs from October 1, 1976 to $eptember 30, 1977. Preliminary estimates show that $362.3 billion was spent in fiscal year 1977 under public programs for social welfare purtx_es, an amount equal to about 60 percent of all government spending during that period. This outlay represents an increase of $30.4 billion, or 9 percent more than the figure for fiscal year 1976. However, this increase falls well below the average annual increase of 14 percent for the period 1967-1976, continuing for a second year the downward trend in the size of single-year increases which peaked in 1975. In 1977, both the inflation rate and the unemployment rate were lower than in 1975, resulting in a decrease of 21 percent in expenditures under unemployment insurance and employment service programs, Spending for public aid, including public assistance, supplemental security income, food stamp, emergency employment, and manpower training programs rose only 9 percent, compared with an 18 percent increase in 1976. However, expenditures under the old age, survivors, disability, and health insurance (OASDHI) program rose nearly 17 percent to a total of $105.4 billion in 1977. Medicare expenditures accounted for one-fifth of the total OASDHI outlay in 1977, a 21 percent increase over the 1976 total. Workers' compensation expenditures showed an increase of nearly 18 percent, much of it attributable to the increase in hospital and medical benefits for work injuries. In fiscal year 1977, government at all levels expended $1,646 per person for social welfare purposes, compared with $153 per person in fiscal year 1950. In terms of constant dollars, the increase for this 27-year period is 333 percent. For the first time in more than two decades, social welfare expenditures as a percentage of the gross national product showed a slight decline, partly the result of a lower growth rate for 1977 expenditures in all but two of the
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for Malpractice.
1976, 20 pp. Availability: Milbank Memorial Fund Quarterly/Health Society v54 n4 p469-488 Fall 1976.
and
Issues in the rising cost of medical malpractice insurance are identified and discussed, and a social insurance approach is proposed as the best strategy for addressing the crisis. In iramediate terms, the availability and cost of malpractice insurance and the proliferation of suits appear to be the problem, but the fundamental issue is how to guarantee high-quality medical care and compensate patients for medical injuries. These objectives are not served by the tort system. What is needed is a social insurance system for medical injuries on either a State or national basis. This would eliminate the friction costs in the present tort system and would convert them to benefits in the compensation system. The plan could be developed gradually, beginning with a list of compensable injuries which could later be expanded. While such a compensation system for medical injuries could move forward without the adoption of national health insurance (NHI), many of the costs of a compensation system could be picked up by a NHI plan such as exists in England and Canada, where all medical costs, including those incurred by negligence, are covered. Further, under the English system, there are stringent, built-in controls on medical practice, which assure quality; this would strengthen the compensation system. The current wide disparity in malpractice premiums between Canada and the U.S. is not caused by the absence of contingency fees or jury trials, but by the coverage of medical costs under national health insurance. References are provided.
Descriptor(s): Economic/commercial influences, Cost containmerit efforts, Publicly sponsored/mandated health plans, National health insurance (NHI), Policy initiatives, Non-employment related plans.
Health Care Programs
842. Some Aspects of Ambulatory Care Under Medicaid in New York City.
53706 Apr 1980, 52 pp. Availability: Wisconsin Univ., Inst. for Research on Poverty, Madison, WI 53706.
Mark David Menchik. Rand Corp., Santa Monica, CA 90406 RAND/R-1992-NYC New York City Government, New York, NY. Nov 1977, 120 pp. A vailability.. Rand Corp., Santa Monica, CA 90406. Patient use of individual physicians, private nonprofit hospital clinics, and other providers of ambulatory services are analyzed in this study of New York City's Medical Assistance Program (medicaid). The cost of New York City's Medical Assistance
This paper discusses a methodology for examining the economic consequences of any medical care innovation, and the methodology is tested on the new drug cimetidine for the treatment of duodenal ulcers. The methodology is a simplification of the benefit-cost framework based upon reductions in costs of explicit payments for health resources. It is all but impossible to evaluate economic and social effects of any new drug, as distinguished from medical effects, within a controlled experiment framework. For the foreseeable future, inferences about socioeconomic el-
Program has risen rapidly in recent years. Critics of medicaid have accused health care providers of billing for services not rendered, providing unacceptably poor care, or supplying unnecessary treatment. The criticism has focused on profitmaking providers of ambulatory care, which consists of treatment for patients not confined to hospitals or nursing homes. In 1974, ambulatory care accounted for more than 25 percent of New York City's $1.4 billion medicaid expenditures. This study examines (1) whether claims data can be used to describe clients and services, (2) whether these data support charges of abuse, and (3) what the costs are for alternative ways of delivering ambulatory care. Generally, the claims data provided adequate information about billing and about the cost and kinds of setvices delivered; however, they did not provide sufficient inform_ation about the health status of individual patients, diagnoses, or whether a practitioner practiced alone or in a shared facility, Although the data showed that physicians with large medicaid practices perform numerous and expensive services, further research is needed before a judgment can be made about whether abuse exists. In examining alternative forms of ambulatory care, physician visits were found to cost less than clinic services, but since the comprehensive care provided by a clinic presumably reduced the need for other health services, the average total cost for ambulatory care by physicians and clinics is concluded to be about the same. Suggestions for future research are offered. Supplementary study material is appended. Tabular data, footnotes, and approximately 25 references are provided,
fects must therefore be drawn from nonexperimental settings, often using data bases constructed for other purposes. Thus, the methodology devised to cope with the problems of nonexperimental design in this study are using a hypothetical experiment, making inferences from nonexperimental data, and measuring social cost variables. The Study used the health care expenditure records of 1,206 individuals participating in the Texas medicaid program between September 1977 and July 1978. Results showed that cimetidine therapy reduced treatment expenditures compared with the average of other technologies. The drug is generally more expensive than others currently available for the treatment of duodenal ulcers. However, because use of the drug lowers surgery rates, total health care expenditures with an assoeiated diagnosis of duodenal ulcer are from 40 percent to 63 percent lower, and days hospitalized are from 15 percent to 33 percent lower than other therapies. Governments at all levels are increasingly concerned with rising medical care expenditures and hence often preoccupied with the effect of any change in the health care system, whether it be change in technology, administrative arrangements, or input prices. The methodology devised here is not equivalent to undertaking a social benefit-cost analysis. Nonetheless, it is likely that the reduction in costs does reflect net social benefits from the new treatment with cimetidine. The methodology developed here could well be used to examine the consequences of other medical innovations. Five figures, 10 tables, and 11 footnotes are provided. (Author abstract modified)
Descriptor(s): Cost/benefit analyses, Medicaid, Medical/surgical services, Outpatient facilities, Outcome/evaluation of quality assurance, Claims administration.
Discussion
843. Some Economic Consequences of Technological in Medical Care. The Case of a New Drug.
844. Some Effects of Quebec Health Insurance.
John Geweke and Burton A. Weisbrod. Wisconsin Univ. Inst. for Research on Poverty,
Advance
Madison,
WI
Paper No. 602-80.
Descdptor(s):
Cost/benefit
analyses, Pharmaceutical
services.
P. E. Enterline, A. D. McDonald and J. C. McDonald. Pittsburgh Univ., Pittsburgh, PA 15313 National Center for Health Services Research, Hyattsville,
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MD. Jan 1979, 29 pp.
77.
A series of surveys was conducted in the Montreal metropolitan area before and after the introduction of the universal health insurance plan in Quebec (Canada) November 1, 1970. The parpose was to study the plan's impact on four major aspects of health services: (1) use of physician services by the general population (two household surveys conducted from 1969 to 1970 and 1971 to 1972); (2) the workload of physicians (telephone surveys made in 1969 to 1970 and 1971 to 1972); (3) the use of emergency rooms (two periods of study included 1966 to 1970 and 1971 to 1973); and (4) a hospitalization and surgical study (hospital separation rates and surgical procedure rates for two periods of study, 1966 to 1970 and 1971 to 1974). The comparison between before-and-after findings of the same surveys gives a measure of change in the delivery of health services as a direct consequence of national health insurance. Study results indicate no overall increase in the use of physicians' services as a result of the introduction of Quebec universal health insurance (QHI), but there was a considerable redistribution of such services, with increased use by persons in low-income families. Before QHI, there was an economic gradient in the proportion of persons who consulted a physician for selected symptoms thought to require medical advice, but this was virtually eliminated after QHI. Physicians worked an average 8.8 hours a day after QHI, tompared with 10.3 hours a day before QHI. Physicians saw a larger number of patients in their offices, but reduced telephone consultations and cut home visits severely. A considerable inceease in the use of emergency rooms was observed, as well as in certain surgical operations, but there was no evidence of a decrease in hospital admissions. Thus far, the impact on health of this social legislation cannot be determined. Tabular data and references are provided. (Author abstract modified) NCHSR
Research
Digest Series, Report
No. NCHSR
From 1971 through 1975, the Social Security Administration sponsored an experimental program in Maryland with the goals of containing costs in general hospitals and thus limiting the level of hospital reimbursement Cost containment was to be achieved by industrial engineering types of review of hospital department operation. Enforcement was to be carried out by imposing "negative reimbursement" penalties in cases where there was no justification of the failure to contain costs. This paper assesses the administration and results of the program with respect to its ability to contain costs and limit hospital reimbursements. Some of the principal hypotheses tested in the evaluation were (1) that cost containment program (CCP) efforts were directly associated with raising productivity in the hospital departments reviewed, (2) that CCP efforts were directly associated with reducing or containing costs in those departments, and (3) that the data base for the experiment was valid and statistically reliable. Despite limitations to the analysis, the study found that CCP activities were, in some cases, associated with greater or rising productivity in hospitals. The hypothesis associating CCP activities with cost containment was supported clearly only for plant departmerits. The evaluation concluded that more than 75 percent of CCP's efforts were devoted to departments accounting for approximately 20 percent of total hospital costs, suggesting that positive effects of COP efforts would be difficult to detect in a period of rising costs. In addition, it was concluded that despite the high benefit-cost ratio and the possibility of replicating the experiment in a number of locations, the Maryland experiment was not sufficiently well designed or conducted to determine the effectiveness of the approach or to justify further attempts or expansion. Tables and footnotes are included. (Author abstract modified)
79-3Z
Descriptor(s): Demand/utilization of health care programs, Medical/surgical services, Hospital services, Physicians, Comparisons regarding foreign health policies, Evaluations/outcome of health care programs.
Descriptor(s): Cost containment efforts, Inpatient facilities, Evaluations/outcome of health care programs, Methods of payment determination.
846. Some State and Federal Perspectives
on Medicaid.
845. Some Issues in Limiting Hospital Cost Reimbursement. A Maryland Experience. Charles P. Hall, Stanley M. Henemier and Arnold H. Raphaelson. Social Security Administration, Washington, DC. Office of Research and Statistics. 1977, 21 pp. Availability: Jnl. of Risk and Insurance v44 n2 p267-287 Jun
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Richard E. Merritt and Ginger Hale. National Conference of State Legislatures, Denver, CO 80202 Medicaid/Medicare Management Inst., Baltimore, MD 21235 1979, 214 pp. Availability: Department of Health, Education, and Welfare, Health Care Financing Administration, Baltimore, MD 21235.
Health Care Programs
Current State experiences in the management of medicaid are examined under the topics of medicaid and cost-effectiveness, medicaid reform, State alternatives to institutional care, medicaid management and administration, State approaches to regulating medicaid expenditures, issues in medicaid reimbursement, and medicaid and national health insurance. Medicaid is a program financed by Federal, State, and local taxes to provide quality health care to eligible poor eitizeus at an affordable price. The unacceptable rate of increase in State medicaid budgets over the past several years, coupled with growing budgetary restraints, requires States to find ways to contain medicaid costs without sacrificing needed medical care for those who can least afford it. Experiences in Medicaid reform are described for New York, Connecticut, Colorado, Ohio, California, and Minnesota. Since institutional care is one of the most expensive aspects of medicaid services, alternatives which have been used by various States are described. Papers on medicaid management and administration examine the control of medicaid fraud and abuse and medicaid management improvements. New Jersey's rate-setting experience and Maryland's health services cost review are also discussed. Medicaid reimbursement issues considered are institutional reimbursement, nursing home reimbursement reform, and medicaid health maintenance organizations. Lessons learned from medicaid which apply to national health insurance proposals are discussed in the concluding section of papers. Appendixes provide a glossary of basic medicaid terms, basic medicaid data, an overview of State-legislated cost containment programs, and synopses of the medicaid quality control and utilization control programs. Descriptor(s): Medicaid, Present legislation/regulations, Policy initiatives, Methods of payment determination, Reimbursement, Cost containment efforts, Outcome/evaluation of health administration,
847. Source Book of Health Insurance Data, 1979-1980. Health Insurance Inst., Washington, DC 20006 1980, 108 pp. AvMlability: Health Insurance Inst., Washington,
DC 20006.
This is the 21st annual edition of health insurance data published by the private health insurance industry in the United States. It provides the latest available statistical information on major forms of health insurance: hospital, surgical, physician's expense, major medical, disability, and dental insurance. Also ineluded are data on medical care costs, morbidity, and health manpower in the United States. The information has been cornpiled from reports of insurance companies and other health in-
surance plans, government agencies, and hospital and medical associations. The presentation begins with an overview of key health insurance statistics, followed by data on the extent of private health insurance coverage, health insurance benefit paymerits, and health insurance premium income. Federal, State, and local government programs are described. Medical care costs are analyzed under a variety of categories, including national and personal health care expenditures, the consumer price index, and the costs of catastrophic illness and of having a baby. Trends in utilization of services and hospitals as well as health status are presented. The appendix lists historic dates and adjustments for duplication in number of persons covered. Also supplied are a glossary and index. (Author abstract modified)
Twenty-fzrst
eth_'on.
Descriptor(s): Private health care plans, Publicly sponsored/ mandated health plans, Health care cost trends/projections, Health care/services, Supply/availability of services, Funding/ firmneing of health care programs, Demand/utilization of health care programs, Trends in health status.
848. South Carolina Voluntary Effort, 1980-81. Sep 1980, 20 pp. A vailability: South Carolina Voluntary Health Care Cost Containment Committee, West Columbia, SC 29169. This report describes the history and purpose, structure, goals and objectives, monitoring process, and recertitication program of the South Carolina Voluntary Effort from 1980 to 1981. The Voluntary Effort is a nationwide program initiated by U.S. hospital and medical leadership to slow down the rate of increase in health care expenditures. The book describes the structure of the South Carolina Voluntary Effort and the work of the five Advisory Councils: business, governmental programs, hospital, physician, and third-party payers. It outlines Voluntary Effort goals and objectives for 1980 and beyond, including improved hospital efficiency and effectiveness and restraint in hospital expenditures, improved hospital productivity, utilization review programs for hospital medical staffs, voluntary restraint of physician fee increases, and manufacturer and supplier cost containment programs. In addition, insurance carriers, other purchasers of care (public and private), business, and organized labor are asked to examine cost-effective alternatives to existing health insurance programs including consumer cost sharing. Other proposals include cost-effective studies for health care legislation, health promotion and illness prevention, and public education. A system for quarterly monitoring of South Carolina
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hospital expense insurance increases is outlined, and the minimum and optional criteria for a hospital recertification program are presented. Three appendices contain a quarterly survey form, and hospital board and medical staff resolutions in support of the South Carolina cost containment program. Descriptor(s):
Cost containment
efforts, Voluntary initiatives.
Descriptor(s):
Prepaid plains.
850. Spy in the House of Medicine.
George A. Silver. 849. Specific Issues Related to Utilization Care in HMOs.
and Content of
Linda Krane Ellwein, Lenore Kligman and Jan Malcolm. InterStudy, Excelsior, MN 55331 Apr 1980, 84 pp. A vailabihty: InterStudy, Excelsior, MN 55331. The early reviews of health maintenance organizations (HMO's) generally examined rates of admissions, hospital days, average length of stay, ambulatory visits, and use of ancillary services, Subsequent research is beginning to focus more on the nature of inpatient reductions and the organizational factors which affect HMO success. The key issue for any successful HMO is instilling cost-effective practice patterns in its physicians and then organizing resources and structuring incentives to reinforce these patterns. The critical ingredients in the group practice setting is peer interaction and cost-effective orientation. Selecting cost-effective physicians for participation in an HMO is easier for group practices than individual practice assoeia-tions (IPA's) because IPA's are usually open to most physicians in a community, often mixing costly physicians with more conservative, cost-effective ones. With limited ability to use selection of cost-effective physicians or the appropriate mix of specialties, IPAs must use formal controls or structure rewards and penalties to modify physician behavior. However, the primary care physician model of the IPA, in which participation is limited to primary care providers, has been able to achieve hospital day rates which are among the lowest for all HMO's. While much is known about gross inpatient and outpatient utilization patterns in HMO's and the quality of medical care being delivered in them, far less is understood concerning possible changes in the content of care delivered through HMO's. From the majority of studies, it is impossible to determine whether the inpatient surgical reductions are a result of a substition of ambulatory surgery, elimination within certain categories of discretionary surgery, or simply across the board reductions. There is some evidence, however, that all three phenomena are occurring in HMO's. While it is apparent that HMO physicians do behave differently, less is known about HMO decisionmaking processes, both formal and infor-mal, Most HMO's have not yet developed the resources to study their own clinical decisionmaking processes. Tables and graphs are provided.
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1976, 308 pp. Availabih'ty: Aspen Systems Corp., Rockville,
MD 20850.
This volume is a comprehensive overview of the American health care system, intended to contribute to a better understanding of its functioning, shortcomings, and potentials for improvement. It begins with a history of American medicine in its unique, new-world setting and proceeds to the issues of costs, financing, and reimbursement within the existing medical care system. Access and availability of medical care are then examined, along with the characteristic pluralism of medical practice. Role expectations and job performance of doctors are discussed in terms of medical education, patient requirements, and the impact on quality of an influx of foreign physicians. A chapter on nonphysician health-care personnel evaluates the doctorparaprofessional relationship as well as the training and licensing requirements of both. Size, scope, and ownership of hospitals and other institutions of patient care are considered, including nursing institutions and emergency care. The issue of quality care receives attention from the consumers' viewpoint and in relation to measurement techniques. A section on organization of health care services contains subtopics on the theoretical obstacles to organization, group practice, interhospital eoordination, associated practice, and the optimal size of organized health units. The analysis of the Federal investment in medical care presents an historical summary, an assessment of the effects of Government funding, and the debates over national health insurance and the investment _a research. Blood transfusions, preventive medicine, and sex education are listed as additional issues of financing and organization. A comparative chapter highlights medical care in Western Europe, makes reference to socialist systems, and relates this information to American conditions and problems. The concluding chapters are devoted to the processes of creating change iin the American system. Congressional bills are discussed in terms of the legislative and political process and regulation requirements pinpointed for physician accountability, malpractice, and quality and cost control. Innovations that promise a brighter future are delineated in the areas of costs and financing, organization, manpower, technology, administration, and emergency care:. The overriding problem of access to quality care is summarized together with possible solutions. Tabular and graphic data and an index are supplied.
Health Care Prog,ams
Descriptor(s): Characteristics of U.S. health care system, Health care costs, Publicly spousored/mandated health plans, Health care/services, Facilities providing health care, Funding/finaucing of health care programs, Providers of health care services, Present legislation/regulations, Policy initiatives, Comparisons
Descriptor(s): Publicly sponsored/mandated health plans, Present legislation/regulations, Policy initiatives.
regarding foreign health policies, Third-party payors, Supply/ availability of services, Allied health professionals.
852. State Employee Health Insurance Plans. A Survey of Coverage, .Benefits, Financing.
851. Standards for Adequate Minimum vices.
Personal Health Ser-
Thomas C. Sohelling. National Center for Health Services Research, Hyattsville, MD. Milbank Memorial Fund, New York, NY. 1979, 22 pp. Availability: Milbank Memorial Fund Quarterly/Health and Society v57 n2 p213-233 Spring 1979.
This paper discusses three interpretations of adequate minimum standards for health services -- adequacy, costs, and quality control -- and proposes that the Government set these standards in f'mancial rather than medical terms. The article evaluates the view that distributing more medical resources to the poor leaves fewer resources for everyone else and reviews the relationshi p of Federal standards to such issues as abortion, termination of medical care, the treatment of newborn defectives, and genetic screening. In addition, the paper discusses Federal standards for mental therapy and involuntary confinement, medical care versus preventive care, and the distinction between being sick and being poor. The article advocates designing a mnltiple-independent-program approach to medical services that would distinguish the supply side of the market (hospital management, medical education, etc.) from the demand side (Federal policy in the financing of insurance and medical services for the poor and disadvantaged). In addition, the paper advocates Federal financial responsibility, rather than medical responsibility, for the poor, elderly, and disadvantaged through such devices as income tax subsidies which would become tax deductions as income rises. Such an approach would separate the special medical problem of the poor from the formidably complex issues raised by the structure and behavior of the medical care industry. Footnotes are included.
Earh'er version of this paper prepared for a Round Table on "Adequate Minimum Standards for Personal Health Ser_'ces, "" in Wilh'amsburg, VA, November 30-December 2, 1977.
Martin E. Segal Co., New York, NY 10019 1980, 19 pp. Availability: Martin E. Segal Co., Consultants and Actuaries, New York, NY 10019. This survey table describes State employee health insurance plans in effect as of January 1980. Benefits listed are not inclusive; many plans offer other benefits, such as extended care and retirement benefits. Listed for each State axe the group health insurance plans applicable to all covered employees or major segments of the employee population. Group health plans, such as Kaiser, are by their nature limited to a geographical area and are shown only where the covered area includes a significant percentage of State employees. The employee and dependents category includes the employee and spouse under age 65 and all children. Some States have intermediate contribution grades. Where applicable, these are shown. Referring to full hospital benefits, full service means provision of semiprivate room and board (or its local equivalent) and other usual hospital services without additional charge to the insured. Concerning major medical, the percentage given is the percentage of covered charges reimbursed by the insuring organization for usual medical care. The deductible amount is for each person. When polities have a family limit on total deductible amounts, such as $100 per year per person, this information is given. Almost all surgical benefits include certain surgical procedures on or around the mouth, but these are not the procedures generally covered under a dental benefits provision. Dental benefits in group insurance generally cover treatment of decayed teeth, extractions, replacements, etc. A brief compilation of supplementary survey findings is supplied following the State entries. Footnotes are included. (Author abstract modified) Descriptor(s): Health care/services, Government employee plans, Comparisons of health care programs, Participants in health care programs, Plan design/program provisions (under health plans).
853. State Health Legislation Report Vol. 8 No. 3. State Comprehensive and Catastrophic Health Insurance Legislation. American Medical Association, Chicago,
IL 60610
1-385
Sep 1980, 25 pp. Availability: American 60610.
Medical Association,
Chicago IL
Private health insurance has become the primary mode by which most persons pay for the costs of medical care. However, not all persons have adequate coverage; some have preexisting health conditions which make adequate coverage unreasonably expensive and some cannot afford any coverage at all. Since 1974, eight States have enacted legislation providing for comprehensive and for catastrophic health insurance coverage for residents who would otherwise be unable to purchase adequate coverage privately. The laws vary substantially in their basic elements, such as the segment of the population covered, the manner in which coverage is provided, and the type and extent of such coverage, The various approaches taken by the States are compared, and each State plan is subsequently discussed in detail. The eight State programs studied are those for Connecticut, Hawaii, Maine, Minnesota, Rhode Island, Wisconsin, Alaska, and New York. A chart comparing the following seven elements of the various plans is supplied: availability, deductible, funding, copayment, administration, preexisting condition exclusions, and minimum lifetime benefit. Desc_qptor(s): Third-party payors, Publicly spousored/mandated health plans, Mandated benefits, Comparisons of health care programs, Plan design/program provisions (under health plans).
Because start-up changed plicating art, not
these programs are only 10 years old at the most and times vary, coml)arisons are difficult. Programs have as operations become more sophisticated, further comcomparison. In reality, hospital cost containment is an a science. Of the variety of methods for measuring
effectiveness, examination of three costs appear to be particularly useful: total expenses, which reflect the total resources citizens must devote to hospital care; expense per day, a calculation that is useful for measuring resources devoted to a single day of hospital care; and expense per admission, which shews changes in the costs of a hospital stay. State interest in the protection of its citizens' health is traditional. In addition, States have a major financial stake in the success of cost containment programs because of their contributions to medicare and as purchasers of health care for State employecs. Furthermore, States are in the best position to investigate the needs of individual hospitals and assure coordination of eost control programs with other forms of State regulation. Health Care Cost Seminar held by the Hawaii Legislature Department of Social Services and Housing.
and
Descriptor(s): Cost containment efforts, Present legislation/ regulations, Comparison.,; of health care programs, Inpatient facilities.
855. State of Hawaii Prelmid Health Care Act (Chapter 393, HRS) and Related Rules and Regulations. 854. State Hospital Cost Containment
Programs.
Russell W. Hereford. National Conference of State Legislatures, Denver, CO 80202 Health Care Financing Administration, Washington, De. Oct 1980, 22 pp. A vailabih'ty: National Conference of State Legislatures, Denver, CO 80202.
Seventeen States now operate hospital cost containment programs, indicating the increasing concern at the State level over the high rate of inflation in the hospital sector. Five areas should be considered in examining these programs: the voluntariness of compliance with program findings, the method of review (formula or budget), measurement of effectiveness in reducing costs, responsibility for program administration, and the payers covered. The eight voluntary programs described are for Arizona, California, Florida, Maine, Minnesota, Oregon, Virginia, and West Virginia. The nine mandatory programs in Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, Rhode Island, Washington, and Wisconsin are also detailed,
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Hawaii State Dept. of Labor and Industrial Relations Disability Compensation Div., Honolulu, HI 96812 Jan 1980, 38 pp. A vailabib'ty: Hawaii State Dept. of Labor and Industrial Relations, Disability Compensation Div., Honolulu, HI 96812. Hawaii's prepaid health plan regulations are discussed. The prepaid plans provide Hawaiian residents with a measure of financial protection against medical emergencies by requiring most employers to subscribe to and pay one-half the premium for a prepaid plan as delineated by law. The first section details who is and is not eligible for the plans, in what locations the eligible may be employed, and required health care benefits. A second section on mandatory coverage outlines coverage of regular employees by group prepaid health care plan, liability for premium payment and health care costs, coverage of temporarily disabled employees, and the effect on this legislation of collective bargaining. A section on administration and enforcement details the powers of the Department of Labor and Industrial Relations and
Health Care Programs
penalties for infractions by employers. A section on premium supplementation outlines the establishment of a fund to reimburs¢ certain kinds of employers for prmniums, entitlement, and claims to the fund. An outline of regulationspertainingto the prepaid health plan legislation covers definitions, types of allowable plans, requirements of health care contractors, benefits and claims procedures, penalties, and reports to be filed with the State by employers and contractors. An appendix outlines two existing, acceptable prepaid plans: Hawaii Medical Service Association and the Kaiser Foundation Health Plan B.
other hand, if all States had to bear a heavy burden of program costs, some might be driven to use such strict control that the objectives of the Federal program would be subverted. It: seems likely, therefore, that a national health insurance program would create strong pressures to minimize State discretion. Notes for each chapter and 12 tables are provided.
Descriptor(s): Publicly sponsored/mandated health plans, Medicaid, Funding/financing of health care programs, Present legislation/regulations, Reimbursement, Eligibility requirements.
Descriptor(s): Prepaid plans, Participation in health care programs, Present legislation/regulations, Mandated benefits.
857. State Regulation of Health Services Utilization. From Michigan. 856. State Policies Constraints.
and Federal Programs. Priorities
Lemons
and Bruce Stuart. Urban Inst., Washington, UI-1208/1
Peter Pass¢ll and Leonard Ross. 1978, 33 pp. Availability: Praeger Publishers,
New York, NY 10017.
De 20037
Citizens Research Council of Michigan, Ann Arbor, MN. Jun 1979, 94 pp. Availability: Urban Inst., Washington, DC 20037.
The chapter on health care in this book examines the division of health care resources between States and the Federal Government. Currently, States have considerable freedom from Federal constraints in making health care policy. They have such a wide range of discretion concerning eligibility and types of benefit that State medicaid expenditures per capita vary by a factor of 15. States are allowed to adopt or reject patient copayments, to regulate the rates paid physicians and hospitals, and to establish new modes of health care delivery. Through the process of appointment and review, a State administration could, in theory, exercise strong influence over the health systems agencies and professional standards review organizations. The real limitations on State authority are political and economic. As a program designed for the poor and linked to the welfare systems, medicaid, for example, does not emily lend itself to reforms that would be acceptable to the general population. The Federal Government could assist States by creating incentives for reform and by establishing a program of careful experimentation and analysis. The Federal Government should undertake the management of a process that leads from State experimentation to federally mandated change. National health insurance would pose a distinctive set of problems in Federal-State relationships, Most of the proposals now under discussion would allocate substantial responsibility to the States in such matters as physician and hospital rate regulation and health facility construction. Unless the States were made responsible for a significant share of program costs, they would have little incentive to take the political risks involved in innovation and cost control. On the
The State of Michigan's experience with designing a health services utilization control policy is discussed in this paper. In broadest terms, the design process is similar for agencies at either the Federal or State level. Although the breadth of intervention will differ, the same analytic framework is appropriate. The framework described herein consists of the six interrelated components of surveillance, standard setting, assessment, targeting, intervention, and evaluation. Surveillance documents the current status and observable trends in medical utilization and delivery patterns by program or source of financing. Standard setting establishes the relevant Federal, State, departmental, or agency objectives with regard to utilization and delive:ry patterns. Assessment and targeting represent the related processes of comparing actual patterns to desired outcomes and assessing priorities for intervention. Intervention itself comes into play with the implementation of specific techniques designed to move the system toward the desired outcome. Evaluation is ttle final step and is intended to provide an ongoing analysis of the system's internal effectiveness and external interfaces with other public program objectives. This paper describes the design requirements for each of these components in terms general enough to accommodate various applications. One specific application, the choice of utilization control options for the State -- is offered as a case study. Case study results were not encouraging for other States facing the problems of rising utilization rates and higher costs. Conflicting objectives, few substantive pressure points, and numerous individual interests
1-387
contribute to the design problem. At present, Michigan has no specified policy of utilization control, either for its own programs or for services sold privately in the State. Nevertheless, although a coordinated control policy is ruled out for the near future, the intermediate steps of building surveillance, assessment, and targeting capabilities offer potential benefits in their own right and place the State in a better position to develop an appropriate program when it becomes essential to do so. Four tables and 81 footnotes are included,
Descriptor(s): Health care costs, Third-party payors, Demand/ utilization of health care programs, Health care/services, Present legislation/regulations, Publicly sponsored/mandated health plans.
and special abilities, cognitive development and socialization, adjudication and prevention of delinquency, and adolescence and work. Also described are long-term trends in family research and emerging tendencies in family research, such as increasing muhidisciplinary research on marriage and family behavior, reemphasis on family transactions within social networks, and attention to the pluralism of family patterns in the United States. The report finds that health insurance coverage is lower for blacks than for whites and lowest for Hispanics. It also mentions the eligibility requirements and provided services of the Medicaid program. Charts, tab!Les, chapter references and bibliographies, chapter summaries, and chapter footnotes are provided.
Descriptor(s): Demographic features of population, Trends in health status, National economic conditions, Medicaid, Participation in health care programs.
858. Status of Children, Youth and Families, 1979.
John A. Calhoun, Edith H. Grotberg and W. Ray Rackley. Systems Research and Development Corp., Research Triangle Park, NC 27709 DHHS/PUB/OHDS-80-30274 Department of Health and Human Services, Washington, DC. 1980, 251 pp. Availability: Department of Health and Human Services, Ofrice of Human Development Services, Administration for Children, Youth and Families, Research, Demonstration and Evaluation Div., Washington, DC 20201.
This report is the third in the biennial series of reports on the conditions of children, youth, and families in the United States. A survey of demographic and economic trends is followed by discussion of life cycle development which focuses on intrauterine development, the first 2 years, ages 2 to 6, ages 6 to 12, and prepubescent and adolescent years. For each phase, information is presented on growth and development, family growth and development, and factors affecting growth and development, The status of children is documented with data on numbers and distribution, economic environment of the child, and health and nutrition. Discussion on the status of youth highlights changes in the youth population from 1970 to 1979, health of adolescents and young adults, conditions and trends in education, youth employment, and special youth problems. In addition, a discussion of the status of families considers employment and income of families, women in families, health status, and programs affecting families. Research devoted to child abuse, day care, the school as a socializing agent, and "compensatory education" are also addressed. Topics considered in an examination of the status of research on youth include somatic and mental health, intellect
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859. Status of Competition in the Health Industry.
Paul M. Ellwood, Jan Malcolm and John K. Tillotson. InterStudy, Excelsior, MN 55331 Jun 1979, 15 pp. A vnilability: InterStudy, Excelsior, MN 55331.
This progress report on the.,competitive health system movement focuses on three areas: the development and growth of competitive health maintenance organizations (HMO's) in recent years; different types of HMO's; and the evidence that the market can work in health care. Tables and figures summarize the growth of the HMO movement over the past 2 years; show changes in the number of operational HMO's from 1970 through 1979; indicate the distribution of HMO's by State in 1970, 1975, and 1979; and show 16 metropolitan areas with 4 or more HMO's as of April 1979 and metropolitan areas with significant HMO enrollment as of August 1978. The report assesses three major models of physician organization within HMO's: the group practice model, the individual practice association, and the primary care physician model. The report also examines evidence that the market works in health care by reviewing competitive health systems in Minneapolis, Minn., and in Honolulu, Hawaii. The report concludes that the competitive health system approach could substitute for regulation, that emerging models varying from the HMO theme show promise, and that, ultimately, a series of major political decisions on health policy must be made to support the competitive health system approach. Such policy changes should include health insurance standards in private plans, Medicare, and Medicaid that encourage consumer choice; more procompetitive forms of public regulation of both HMO's and traditional insurance; rollback of remnants of anticompeti-
Health
Care Programs
tive regulation such as price and entry controls; tax policies that reduce the current incentives to preferentially increase health benefits over wages; and equalization of employers' contribution rate for health benefits which reward employees for choosing a lower cost insurance or health delivery plan. Charts and a graph
ordinary hospital procedures, repeals Blue Cross, medicedd, and medicare exemptions from absorbing the costs of indigent care; and provides discounts to carriers for promptness of payment and for volume of business. Tabular data are included.
are provided.
Hay/Hu88_s
Descriptor(s): Cost containment efforts, Prepaid plans, Competition/interaction among third-party payors, Comparisons of health care programs, Poficy initiatives,
Descriptor(s): Present legislation/regulatious, Vohintary initiafives, Claims administration, Cost containment efforts, Plan design/program provisions (under health plans), Health care/services.
Bulletin April 1980.
860. Steps to Control Inflation in Health Care Costs. 861. Strategies for Controlling Hay/Huggins, 1980, 6 pp. Availabih'ty:
Philadelphia, PA 19103 Hay/Huggins,
Philadelphia,
the Cost of State Medical As-
sistance Programs. PA 19103.
This bulletin reviews current efforts to control health care costs in terms of steps being taken by health plan sponsors; communitywide programs by coalitions of sponsors, often aided by representatives of labor and of the health care industry itself; and governmental action at the State and Federal levels. Measures available to plan sponsors include resisting payment of excessively high claims or changinq the overall plan design, funding method, or benefit structure and expanding the program to include preventive care. Illustrative of such program alterations are second options, home health care, drug abuse care, preventive benefits, multiphasic screening, health promotion, health hazard appraisals, education and behavior modification, and physical fitness program advancement by health plan sponsors. Since few employers have the clout to implement such efforts alone, it may be to their advantaqe to band toqether with other concerned groups such as labor, the health care providers, insurers, and governmental units to pursue health care cost containment through coalition. Among the currently active coafitions is the Philadelphia Area Committee on Health Care Costs, which includes some 70 representatives of business, labor, hospitals, physicians, insurers, civic groups, and health planning agencies, Its task forces have brouqht forth recommendations on reducing excess hospital beds, controlling unnecessary hospital admissious, fostering a critical understanding of the economics of health care, identifying the least expensive means of providing care, implementing uniform reporting on health care costs and practices in the community, and other issues. A New Jersey law illustrates State activities. Passed in 1978, the legislation estabfished a program which attempts to reward hospitals for cost efficient operation, provide a more equitable apportionment of the hospital's costs for indigent care, and reward speedy claims processing by carders. The law mandates a standard charge for
Robert C. Harder and Christopher J. Smith. 1979, 11 pp. Avsilabih'ty:
Public Welfare v37 n2 p39-49 Spring 1979.
Reasons for the rapid acceleration of medical care costs and actions States have taken to prevent cost increases are discussed in this article. Recent statistics indicate that hospital costs rose 50 percent in the last 3 years and now account for more than 40 percent of all medical expenditures. Hospital costs are the major cause of medical price inflation in the United States, followed by physicians' fees, which have more than tripled in the last 10 years. These cost increases have been sustained primarily through the rise of third-party reimbursement, which _ounts for more than 70 percent of total personal health care costs. However, it is clear that more money expended for care does not mean better health care. Since the chief third-party payer is the Federal Government, rising health care costs are a national problem. It is suggested that medical care costs are increasing for a number of reasons. Health insurance encourages hospitals to charge higher prices for services and to apply more costly technology to producing these services. In addition, it is in the hospitai's best interest to please the physicians it serves by providing increasingly elaborate equipment, facilities, and services. The most immediate cost-cutting actions open to State agencies responsible for medical assistance programs are reducing services or tightening program eligibility. However, such actions hurt those who most need help. Several strategies are reconunended based on the Kansas experience, including State action to inform the medical consumer and to prevent further unnecessary construction and capital investment in hospitals. States should also promote health maintenance organizations (HMO's) throuqh removal of restrictive enabling acts or insurance, through contracting with existing HMO's for services to medicaid and State employee populations, and through legal requirements that whe-
1-389
rever nonfederally qualified HMO's are available, all companies over a certain size must offer an HMO option as an alternative to their group health insurance. Two tables, several photographs, and 43 notes and references are included in the article,
Descriptor(s):
Health
care costs, Economic/commercial
influ-
ences, Third-party payors, Private health care plans, Publicly sponsored/mandated health plans, Health care/services, Inpatient facilities, Funding/financing of health care programs, Policy/changes re health care, Physicians.
ance premiums paid by an employer are exempted from all taxes under existing tax law. As a result, the employer's contribution to an insurance program becomes a tax-free form of income to employees. Footnotes four figures, four tables, and four references are included. (Author abstact modified) Descriptor(s): Health care costs, National economic conditions, Plan design/program provisions (under health plans), Source of premium payment, National health insurance (NHI).
863. Stronger Management Needed to Improve Employee Organization Health Plans' Payment Practices. 862. Strategies for Financing National Health Insurance. Who Wins and Who Loses.
Comptroller General of the United States, Washington, 20548
DC
Bridger M. Mitchell and William B. Schwartz. Rand Corp., Santa Monica, CA 90406 Department of Health, Education, and Welfare, Washington, DC.
SCp 1979, 63 pp. A vMlability: General Acc_mnting Office, Washington, 20548.
Josiah Macy, Jr. Foundation, New York, NY.
This General Accounting Office report highlights the need for stronger management of the Office of Personnel Management and the Employee Organization Plans participating in the Federal Employee Health Benefits program. The review shows that the Office of Personnel Management needs to better assure that the plans pay benefits in accordance with their contracts. Because of ineffective guidance and overseeing, the Office of Personnel Management has allowed the plans to make claim payments without determining whether the claims represented medically necessary services and without developing sound, comprehensive systems to determine the reasonableness of changes as the contracts required. Furthermore, the plans have paid claims for services not covered and have made payments without determining if claims represented reasonable charges for medically necessary services. Payments outside the scope of the contracts unnecessarily inflate the premium cost to plan enrollees and to the Government. These conclusions are based on a review of three plans which together constitute almost 60 percent of the total benefit payments made by all the Employee Organization Plans in 1977. A records review and interviews were conducted for each plan, with emphasis on claims processing policies and procedures and criteria used to adjudicate claims. It is recommended that the Office of Personnel Management provide better guidance to Employee Organization Plans on the contractual provisions for medical necessity and customary and reasonable allowances. Increased coordination between program auditors and managers is needed, as are auditing procedures that evaluate the plans' development and application of medical necessity criteria and customary reasonable payment systems. The report contains the Office of Personnel Management responses to the review; correspondence and other documentation are appended.
1976, 6 pp. Availability: New England Jnl. of Medicine v295 n16 p866871 14 Oct 76. Basic principles underlying the financing of a national health insurance (NHI) plan examined through analysis ofthe economic impact of two major financing mechanisms and consideration of distribution of costs. One of the central features in the debate over NHI is the controversy over how to distribute the costs of the program. Because any new major program will take over an appreciable portion of payments for existing health services and will also give rise to new expenditures, the choice of financing mechanisms will have important economic consequences for all income groups. Two sources of funds are available to underwrite the costs: prepayments (premiums, payroll taxes, and income taxes), and out-of-pocket payments (coinsurance and deductibles). The extent to which taxes rather than premiums are used to finance an insurance program will be the major determinant of how large a share of the costs of health care will be carried by higher income groups. The extent to which coinsurance and deductible provisions are reduced or waived for low-income persons will have a less important, but still substantial, role in determining how the costs of a program are distributed. The employer's share of costs for the plan will be borne by the employee. This is assumed because in competing to produce goods at the lowest possible cost to ensure the highest possible profit, an employer must include the employee's fringe benefits as part of the cost of doing business. Thus, it is illusory to believe that the employer will actually bear any portion of the cost of the employee's health insurance program. In addition, health insur-
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Health
DC
Care Programs
Comptroller
General's
Report to the Congress HRD-79-87.
Desc_4ptor(s): Government employee plans, Claims administration, Outcome/evaluation of health administration.
865. Study of Dental Service Prepayment in the Private Sector. Final Report.
Nathan (Robert R.) Associates, Inc., Washington, DC 20036 Bureau of Health Manpower, Hyattsville, MD. 1978, 95 pp. Availability: National Technical Information Service, Springfield, VA 22161, HRP-0029833.
864. Structure of Health Insurance and the Erosion of Competition in the Medical Marketplace.
Joseph P. Newhouse. Rand Corp., Santa Monica, CA 90406 RAND/P-5906 Department of Health, Education, and Welfare, Washington, DC. Jul 1977, 19 pp. A vaJlability: Rand Corp., Santa Monica, CA 90406.
This paper argues that high Levels of insurance can permit medical care prices and expenditures to increase at above-average rates independent of a change in demand that a change in insurance induces. Present insurance heavily subsidizes the marginal unit, and insurance premiums do not reflect choice of provider. Therefore, it is likely that the rate of technological change is higher than would be observed in the absence of such insurance and that price competition among firms is diminished, thereby potentially giving the firm considerable discretion over its price. Both effects can serve to increase the rate of price and expenditure increase above what it would be without such insurance. To prove this hypothesis, above data were collected on the changes in price for four medical services (hospital services, physician services, dental services, and drugs), over the period 1949 to 1974. The empirical results, though weak, nevertheless supported the hypothesis. If the argument is accepted, implications for research strengthen assumed effects of the competitive supply curve, call for theories explaining medical firm behavior, and weaken the issue of demand-pull versus cost-push explanations of hospital cost inflation. Policy implications are that strategies should be sought to relate the premium for health insurance to the choice of provider through health maintenance organizations, as well as through schemes for rating hospitals physicians and on the basis of unit price and expenses engendered. It is essential to strengthen price competition in medical care. Footnotes, l figure, and 19 references are provded.
Descriptor(s): Medical technology impacts, Demand/utilization of health care programs, Competition/interaction among thirdparty payors, Impact of third-party coverage, Providers of health care services, Policy initiatives, Facilities providing health care.
Projections of dental insurance coverage based on the traditional wage-determination model, are made in this report. Historical data on the dependent variable (percentage of employees covered by dental insurance in industry) and independent variables for 1968, 1970, and 1973 are applied to estimate the model through multivariate regression analysis. The independent variables include factors affectinq the demand for labor and labor productivity, size of industry, labor-capital ratio, type of product, profitability, concentration ratio, skill requirements, and factors relating to the supply of labor in industry, such as education, sex, unionization, geographic scope of bargaining, age, and skill level of employees. The values of the independent variables are projetted to 1990. It is shown that the number of workers covered by dental insurance through their employment in the private sector will increase from 9 million in 1975 to 68.6 million in 1990. The average annual rate of increase is estimated to be 21.9 percent between 1975 and 1980, although it is anticipated that this growth rate will decline by 13.9 percent between 1980 and 1985 and by 8.2 percent between 1985 and 1990. Although employees' dental insurance coverage varies by industry, coverage is projected to increase overall, particularly retail trade and service industries. Supporting are provided. Information appended. (NTIS abstract
for and data wholesale and footnotes
on the classification modified)
of industries
is
Descriptor(s): Dental services, Private health care plans, Demand/utilization of health care programs, Participants in health care programs.
866. Study of Physician Reimbursement Medicaid. Volume I,
Under Medic_tre and
Charlotte F. Muller and Jonah Otelsberg. City Univ. of New York Research Foundation, New York, NY 10036 Health Care Financing Administration, Washington, DC. Sep 1979, 419 pp. Availability: Health Care Financing Administration, ORDS Publications, Baltimore, MD 21235.
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This volume, the first of a two-volume report, contains the resuits of a study conducted by the Research Foundation of the City University of New York (CUNY) concerning physician reimbursement under medicare and medicaid. Volume I is organized in two sections: Part A presents background material on the economics of aging and the medicare market, a review of literature, and a summary of medicare regulations; Part B reports on national findings about medicare practices and fees. In the CUNY national study described in Part B, two different techniques were used to measure the effects of carrier discretionaxy practices on medicare reasonable charges. The study used 50th percentile fees and adjusted prevailing fees for all medicare localities to analyze the joint influence of socioeconomic factors, carrier pricing practices, and certain indicators of regulatory effort in investigation and reduction of submitted claims on fees. Local economic features were found to exert the dominant influence on fees, but carrier discretionary practices did add some influence. Footnotes, 66 tables, and 7 figures axe included. Six appendices contain a chronology of medicare Part B laws and regulations concerning coverage, premiums, and fees; physician reimbursement studies; a memorandum on the evaluation of reasonable charge procedures; nonmedicare claims data for merger or comparison; a hypothetical illustration of fee results of alternative locality boundaries; and an outline of steps in reasonable charge process. (Author abstract modified)
Health
Care Financing
Grants and Contracts
Report
Aeries.
Descriptor(s): Demand/utilization of health care programs, Medicare, National economic conditions, Physicians, Reimbursement.
867. Study of Physician Reimbursement Medicaid. Volume II.
Under Medicare
and
ORDS
This volume, the second of a two-volume report, contains the results of a study conducted by the Research Foundation of the City University of New York (CUNY) concerning physician reimbursement under medicare and medicaid. Volume II is organized in two sections: Part C describes a two-county microstudy of carrier practices and experience of providers and
1-392
Health Care Financing
Grants and Contracts
Report
Series.
Descriptor(s): Medicare, Medicaid, Physicians, Policy tives, Reimbursement, Supply/availability of services.
868. Study of Physicians'
initia-
Fees.
Zachary Y. Dyckman. Council on Wage and Price Stability, Washington, Mar 1978, 169 pp. A vailability: National Technical Information field, VA 22161, HRP-0030055.
Charlotte F. Muller and Jonah Otelsberg. City Univ of New York Research Foundation, New York, NY 10036 Health Care Financing Administration, Washington, DC. Sep 1979, 352 pp. A vailabiliry: Health Care Financing Administration, Publications, Baltimore, MD 21235.
beneficiaries under medicare as well as a comparison with medicaid in one of the counties. Part D discusses methodological problems, summarizes findings, and presents a consideration of policy implications and recommendations for research. The study analyzed market behavior of both providers and beneficiaries in the counties of Queens and Nassau, as revealed by claims data, and developed standard formats that could be applied in creating physician and patient profiles in other years and in other places. The study showed certain similarities in distribution between the two counties, but the Nassau market had providers with more patients, services, and revenue. The comparison of medicaid with medicare, which studied physician response to comparative fee structures, found a gross lack in the supply of services to medicaid patients and a use of medicaid by the elderly to supplement medicare benefits. The study recommended greater standardization for specialty designation and medical procedures and more emphasis on quality of care, equity of access, and prevention. About 130 tables and footnotes are given. An appendix contains a glossary of terms used in the microstudy, coding materials, a comparison of fees for 50 selected procedures, and manual materials. (Author abstract modified)
DC 20506
Service, Spring-
This study analyzes increases in physicians' fees from 1950 to 1977 and their causes. During this period, physician fees increased 43 percent faster per year than did nonmedical care prices. Since 1965, the primary reason for the rise in physician fees has been the lack of market controls. The supply of physiclans seems to have no "bearing on the fees charged, and because most health care consumers do not pay the fees directly, but are covered by third-party insurers, there is no incentive for either the consumer or the physician to hold down fees. Before 1965, the primary reason for physician fee inflation was the anticompetitive practices of orgamzed medicine. The American Medical Association had reduced the number of medical students during the 1930's and restricted medical school growth during the 1940's and 1950's. Other topics examined in this study are the
Health Care Programs
geographic variations in physician fees (surgical fees are highest in the West and in very large cities), the relationship of physician income and expenses (malpractice insurance is the expense that has increased the most), and the national distribution of physicians. It is suggested that physician fees and other medical care
Descriptor(s): Cost/benefit analyses, Cost containment Claims administration, Private health care plans.
prices are understated in the consumer price index. Appendices contain discussions on reweighting the medical care component of the consumer price index, the impact of the time lag between
870. Study of Taft-Hartley Health and Welfare Trust Fund Operations Cost. Technical Report.
computing and implementing prevailing fees as well as a note on physicians' income data sources, and the median and 90th percentile surgical fees in selected metropolitan and nonmetropolitan areas, September 1975 to September 1976. Tabular data are supplied. (Author abstract modified)
Robert D. Cooper and Hetty K. Balanoff. International Foundation of Employee Benefit Plans, Brookfield, WI 53005 1979, 148 pp. Availnbih'ty: International Foundation of Employee Benefit Plans, Brookficld, WI 53005.
Descriptor(s): Physicians, Economic/commercial influences, Supply/availability of services, Health care costs, Impact of third-party coverage, Medical/surgical services,
869. Study of Taft-Hartley Health and Welfare Trust Fund Operations Cost. Summary Report.
Robert D. Cooper and Hetty K. Balanoff. International Foundation of Employee Benefit Plans, Brookfield, WI 53005 1979, 12 pp. A ¢ailability: International Foundation of Employee Benefit Plans, Brookfield, WI 53005. This study provides an extensive analysis of Taft-Hartley health and welfare plan costs of operations and is intended to serve as an information source for plan trustees regarding the costs of these operations. The health and welfare plans included in this study ranged in size from 17 to 41,500 participants and from $2,000 to $51 million in annual employer contributions. These plans represent a diverse cross section of Taft-Hartley multiemployer welfare plans providing at least some health benefits; over 97 percent provided hospital or surgical benefits. The study found that the number of plan participants was the single most important factor for estimating total operations cost. The location of the plan's administrative office and the type of industry were two additional statistically significant sources of cost variations. Based on these three characteristics, graphs and charts were developed representing a range of per-participant costs. In addition to the graphs, which compose the major portion of the study, a directory is included for selecting the appropriate graph or chart section for any given plan. Directions are also given for obtaining total operations cost and annual per-participant operations cost. An appendix lists the type of variables used in the study. (Author abstract modified)
efforts,
This study of Taft-Hartley trust fund operation costs and benefit payments expense is intended to be of practical and informative value to those involved -- in an administrative, fiduciary, or professional capacity -- in overseeing health and welfare fund operation and costs. The 355 plans surveyed covered 900,000 workers, mostly engaged in the construction, transportation, manufacturing, service, and retail trades; over 60 percent of the sampled plans were in the building and construction trades. Hospital and/or surgical benefits were provided in over 97 percent of the reporting plans. Almost two-thirds of the plans provide dental care, and over one-half provide vision carte. An analysis of operations expense isolated major determinants of operation cost variability and identified a set of formulas to estimate plan expenses. Substantial economies of scale axe evident in the operation of the health and welfare trust funds. The overall marginal cost for one additional participant is 79 percent of the current per-participant cost of operations. A model in which the processing and control of claims was measured by the number of checks (or claims) processed was used to measure benefit contributions expenses. The model involved four variables extracted in stepwise regression. The marginal cost for one additional check processed required 76 percent of the current per-check processed benefit payments expense. The results also indicate that there are no per-participant economies of ,'scale for total plan expenses. Tabular data, survey instruments, 28 references, and a subject index are provided. (Author abstract modifled) Descriptor(s): Claims administration, Private health care plans.
871. Study of the Administration ment Income Security Act. Office of Management Jan 1980, 81 pp.
Cost/benefit
analyses,
of the Employee Retire-
and Budget, Washington,
DC 20503
1-393
Availability: Office of Management DC 20503.
and Budget, Washington,
Responsibility for administration of ERISA is allocat,_l three agencies: the Department of Labor (DOL), the ment of the Treasury/Internal Revenue Service (IRS), Pension Benefit Guaranty Corporation (PBGC). This
among Departand the divided
responsibility was asserted to cause excessive paperwork and delays in resolving issues and in issuing regulations essential to the operation of private pension and welfare plans. As a result, Congress approved the President's Reorganization Plan No. 4 of 1978 which more clearly divided regulatory functions between the Labor and Treasury Departments. Section 107 of the Reorganization Plan provided that: "On or before January 3_, 1980 the President will submit to both Houses of Congress an evaluation of the extent to which this Reorganization Plan has alleviated the problems associated with the present administrative structure under ERISA, accompanied by specific legtslative recommendations for a long-term administrative structure under ERISA." This Report fulfills these requirements. The Report is in five pans: Development of Regulation of Private Employee Pension and Welfare Plans describes the context within which ERISA was developed. Regulation of Private Pension and Welfare Plans under ERISA describes the ERISA-related functions of Federal agencies principally involved in the Act's administration. Evaluation of ERISA Administration Under Reorganization Plan No. 4 of 1978 assesses the effectiveness of the Plan in operation. Evaluation of Alternative Organization sesses a number of reorganization options,
Structures
aa-
DesctTptor(s): Present legtslation/regulations, Outcome/evaluation of health administration, Private health care plans
ject=<< m_,.;,, ]earn how ph,, :,_cians responded to these changes an-t _vc.a_eii._ the__rr,_-sp_,n:,._shad on the delivery of services ":o t__.__'_,_lJi_ of Q,_eb_c. _'he study investigated the various fbrms wM.:h this ,espouse mtght take: changes in the decisions made by phy._.,cians about t{aelocation of their medical practices, caange_ in Y_ours workecl aJ,d the extent of use of staff and equiDmem, aud _terations in the mix of patients seen and types of services provided. Large data files from the claims files of the Quebec i-__ealth Insurance Board were obtained, covering the entire period from the start of the plan in 1970 through 1975. In addition, a survey ofingener;_l throughout province w,_ ¢.ooduc_ed 1977. Apractitioners total of 65 medical servicethemarket are_. _eq_:_h, base_ on the frequency with which patients ob_L:,.cd pn_,-a,_rymedical care within thetr market area. Findings are g_ve:_,regarding th,: distribution of physicians, the practices of gene_ a! practitioner, composition of physician output, and the _, _fmedical services per capita. The study concludes that the Qt_e._,3ec medicare system appears to be approaching one of the ma.,n objectives nornlally posed for a universal health msurauce p.rL_gram: reasonably uniform access to medical care acros_ income and iocatio_a _oups. In addition, the physicianpopu_a&.,r: ratio in Quebcx: has been rising rapidly, albeit at _ifl_: ent ,-atcs in different eaarket areas, without depressing average g_oss payraents per physician at constant fee levels. This phen _me_m _,._consistent with the theory that physicians can a.nd do create demand for their services in response to increases m the physician-population ratio. It also supports the hypothesis tha_ incre_ use of medical services is merely the result of p.hys_.ar_ fu!fi_lmg the demand for medical care. Other conclusions cono_ru the distribution of general practitioners, the plan's fee sche,-u_e. _nd physicians' surgical practices. Footnotes, tabu!a_ _t_, _:_ JubOut -4(-'references are supplied. 2reject Re;o:_7 No. 78-f_. Summarized in "'Responses of _ac/_/a_ Ph).;_./cinns to t_w Introduction of UniversM Medical Car_ _o:;ura.qc.e. _h_eFirs: l_'ve Years in Quebec. ""
872. Study ofoftheUniversal ResponsesMedical of Canadian Physicians The to the Introduction Care Insurance. First Five Years in Quebec.
_r/pa',art_):
Physicians, Supply/availability
of services, Corn-
par_,soas :egardmg foreign health policies, Evaluations/outcome of he;dth c:-re programs, Medical/surgical services.
Charles Berry, J. Alan Brewster, Philip J. Held, Barbara H. Kehrer and Larry M. Manheim. Mathematica Policy Research, Inc., Princeton, NJ 08540 National (:enter for Health Services Research, HyattsviUe, MD. Feb 1978, 489 pp. A vailabi/ity: Mathematica Policy Research, Princeton, NJ 08540. Because the introduction
of universal medical care insurance in
Quebec, Canada, brought about significant changes in the economic setting in which medicine was practiced, a research pro-
1-394
873. Study __oDetermine the Relationship of Commmai_ Health Centers, Commtmity Mental Health Centers, and Drug Treagmeut Centers tor the Provision of Mental Health Services to C_C Registrants. Final Report. Rachel Schwartz, Naomi Naierman and Anne Schwartz. Abt As_oc_:_es, Inc., Carabridge, MA 02138 AAI-75/151 Bureau of Community Health Services, Rockville, _ O:_va,.ional Development.
Health
MD. Div.
Care Programs
Nov 1975,199 pp. Availability: Abt Associates, Inc., Cambridge,MA
02138.
ableswhich givetheappearanceof cuttingcosts.As a result, governmentplansforsubstitution based upon unitpricesare generally ineffective and oftenmore expensive thanoriginal esti-
Findingsand recommendationsarepresented from a studythat mates.For example,many individuals believe medicaltechnoloexaminedthereiationshipsexistingbetweenthreefederallyfundgy should be severelyconstrainedto control costs,but differentiating betweenthecostofproducingtechnology and the ed healthservice programsatthelocal level; theprogramsexamcostofthetechnology totheconsumeroftenshows thatthecost ined are community health centers (CHC's), community mental of care is not out of proportion to the benefits. In benefit-cost health centers (CMHC's), and drug treatment centers (DTC's). ratios, benefits are generally more difficult to identify than costs The primary objective of the study was to determine how mental and are largely omitted, leading to underestimates. Planners and health services and drug treatment services are provided to CHC registrants when a CMHC and a DTC are located in the same analysts working with aggregated models tend to discount the area. The report, which is based on visits to 6 cities and 14 benefits of technology and hence question the costs. Substitution projects, summarizes how the visited projects interact with one of outpatient for inpatient care takes two forms: marginal and another and discusses some of the factors which influence ingross. Marginal substitutions such as preadmission testing, second opinion surgery, utilization review, professional standards teraction. Findings show that the projects interacted in the areas review organization, and insurance coverage of outpatient proceof administration, funding, planning and policy, clinical produres do not change the basic philosophy, organization,, or techgrams, indirect service programs and education, referrals, and research and evaluation. Where there was interaction in the nique of diagnosis or treatment. These substitutions attempt to planning and policy area, there tended to be more relationships of other types. Throughout the six site visits, it was obvious that there were environmental factors that could influence the establishment of relationships. Environmental factors having a posirive impact include the relationship of the catchment areas, the existence of leadership, the timing of funding, the community interaction, and existence of complementary services. The study also revealed several barriers which inhibit interaction among community agencies offering mental health services. The barriers are grouped into four major categories: lack of leadership, lack of community representation, the medical model as the mode of delivery, and the patients' view that using mental health services makes them inferior. Recommendations are offered for promoting relationships between the types of programs studied, Recommendations for further study are also provided. Site reports are appended; tabular data figures, and footnotes are included, Descriptor(s): Mental health services, Comparisons of health care programs.
874. Substitution
of Outpatient
Outpatient
facilities,
Care for Inpatient Care.
Problems and Experience.
contain expenditures by lowering need forhave inpatient care. Studies of the effectiveness of these the procedures been inconchisive. Gross substitutions, on the other hand, require significant changes in the delivery of care, such as neighborho_xt health centers, free-standing surgicenters, home health care, and health maintenance organizations. Gross substitutions can occur only gradually, even with government encouragement. Furthermore, policymakers have an inadequate understanding of how individuals make decisions about social systems. This leads to erroneous conclusions that consumers make incorrect decisions for lack of information or that producers are greedy and insensitive to consumer needs. The perceived failure to bring about substitution through incentives leads to increasing pressure for standardization, a pressure which is misguided by the camfusion between technological efficiency and economic efficiency. Illusory cost savings in planned substitution results. Although substitution is necessary to a viable economic system, due to these complex interrelated variables, policy implementation based upon broad aggregates is particularly hazardous. Sixteen footnotes are provided.
Earlier version of this paper presented at the Conference on Health Care Financing, sponsored by the Center for Public Law and Service and the College of Community Health Sciences of the University of Alabam_ April 197Z
Lewis Freiberg. 1979, 18 pp. A vailabilJty: Jnl. of Health Politics, Policy and Law v3 n4 p479-496 Winter 1979. The substitution of outpatient care for inpatient care is a cornplex process often involving nonquantifiable but important vari-
Descriptor(s): Demand/utilization of health care programs, Inpatient facilities, Outpatient facilities, Cost/benefit analyses, Medical technology impacts, Supply/availability of services.
1-395
875. Smamary of Impact of Alenhollsm Treatment on Medi. eal Care Utilization and Coat, 1979. K. Jones and Thomas R. Vischi. National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD 20857 1979, 27 pp. Availability: National Inst. on Alcohol Abuse and Alcoholism, Rockville, MD 20857. The report contains 12 studies, 9 of which were excerpted from a larger study on alcoholism, drugs, and mental health. These studies review a number of efforts concerning the impact of alcoholism on medical care utilization and costs. Of the 12 studies, 8 focused on employee-based alcoholism programs, while 3 studies were centered on alcoholism treatment within a health maintenance organization (HMO) setting. Eight of the studies found that alcoholism treatment was followed by reductions ranging from 26 percent to 69 percent in medical care use; the median reduction for medical care in these studies was 46 percent. Three of these studies found savings in general health care of 41 cents, 45 cents, and $1.10 for each dollar spent on alcoholism programs. Of the three HMO studies, the Group Health Association of America (GHAA) effort was the most significant because for the first time an attempt was made to examine systematically the feasibility of comprehensive alcoholism services in a prepaid practice/HMO setting. This study found a 31percent reduction in use of total health services as compared to 2 years before entering treatment and a 57-percent reduction in family member use following the initiation of treatment of alcoholic family members. The studies strongly suggest that treatment for alcohol abuse and alcoholism is frequently followed by a reduction in medical use and cost. However, all of the studies have at least some methodological limitations, such as small study groups, inadequate comparison groups, short-term spans, or only surrogate measures of medical utilization. Tables and footnotes are supplied. (Author abstract modified) National
Inst. on Alcohol
ance Resource
Abuse and Alcohoh'sm Hadth
Kit, Industry
The hospital rate review activities of the Maryland Health Services Cost Review Commission are described. The seven-member commission, established in 1973, supervises the public disclosure of the financial positions of all hospitals and related institutions, reviews hospital rates, and collects reports on certain dealings between hospitals and firms with which their trustees have a financial interest. Thus far, the commission has only exercised rate review for hospitals. This involves ensuring that a hospital's total costs are reasonably related to the total services rendered, that a hospital's agsresate rates are reasonably related to its aggregate coats, and that rates are set equitably among all purchasers and classes ofpurclutsers. The commission is empowered to review and investigate the established rates of hospitals, and no hospital may change its rates without commission approval. In order to determine the reasonable costs of providing individual hospital services, the commission has defined the cost elements to be considered and developed a uniform system for reporting these coats and measuring the amount of service petformed. Hospital cmts are segmented into patient care, research and education, and bnsin_ activities. Further, nonpatient revenues are not to be allowed to support ineffectiveness and inefliciency. Therefore, the commimion has taken into account, as a rate offi_t, varying amounts of nonpatient revenue, including income on endowments. The commi_on has interpreted its mandate to eliminate undue disorhnination among purchasers or classes of purchagert. This means that purchasers classified in any reasonable and relevant way cannot be subsidized by other classes of purchaser& Future directions of the commission's work are discmsed. The equation used to calculate rate differenrials and the hospital daily m charge from 1969 through 1978 for nine U.S. citim are appended.
Dtscn'pto_s): Cost containment efforts, Inpatient facilities, Methods of payment determination, Present legislation/regulations, Hospital services
Insur.
and Labor.
Descriptor(s): Demand/utilization of health care programs, Pre* paid plans, Mental health services, Health care cost trends/ projections.
877. Supldementary ne_ Strategy.
Health Inmwam_ and Cmt-Comudons-
Laurence S. Seldman. Pennsylvania Univ., Philadelphia, PA. Leonard Davis Inst. of Health Economics. 1978, 20 pp.
876. Summary of Rate Review ta Maryland. Theodore
Jni. of Risk and Insurance v45 n2 p291-310 Jim
N. Giovanis.
Sep 1979, 14 pp. Avai/ability: Maryland Health Services, Cost Review Cornmission, Baltimore, MD 21201.
1-396
Availability: 78.
Several health economists and health policy analysts advocate income-related major-risk (catastrophic) national health insurance (MR-NHI) that would fully protect all households against
Health Care Programs
medical expenses that are large relative to their income but provide little or no coverage for expenses that are moderate relative to income. Under MR-NHI, consumer cost-sharing and therefore, consumer cost-consciousness would increase sharply, compared to the present situation in which virtually all hospital care is "free" to the typical patient. This strategy, however, would be undermined if most households obtained "complete" supplementary private health insurance (SI). Whether SI becomes widespread depends on the treatment of expense on an SI premimum under MR-NHI. This paper develops a criterion for optimal treatment of SI. The aim should not be to minimize SI per se, but to maintain neutrality; that is, households should not be biased for or against SI. Under optimal treatment, the
dictory and inconclusive, but taken as a whole, seem to suggest that the supply elasticity of physician services is positive. Theoretical models of physician behavior and how they relate to empirical studies on physician supply are briefly mentioned. A summary and discussion of each of the publications are included. A total of 31 references are supplied. (Author abstract modified)
increase in a household's expected financial burden, if it buys SI, should equal the increase in the expected medical cost induced by SI. This principle is applied to an income-related MR-NHI
879. Surgical Innovation and Its Evaluation.
that is implemented by Federal income tax credits. Given the specific magnitudes of the MR-NHI cost-sharing scheme and the medical cost probability distribution across households, it is suggested tentatively that optimality would require full inclusion of expenses on SI for low-income households, partial inclusion
John P. Bunker, D. Hinkley and W. V. McDermott. 1978, 5 pp. Availability: Science v200 n4344 p937-941 26 May 78.
for middle-income househoMs, and complete exclusion for highincome households. Tables, figures, footnotes, and 20 references are included. (Author abstract modified)
The introduction and evaluation of four new surgical operations are reviewed in this article which recommends improved testing, review, and evaluation of new U.S. surgical innovations. Noting that new surgical operations may or may not be subjected to the
Descriptor(s): Cost containment efforts, health care programs, Policy initiatives,
same rigorous testing and controls as new drugs, the article examines four operations that entail substantial risk of mortality and morbidity: shunt surgery for portal hypertension, coronary artery bypass graft for occlusive coronary artery disease, small bowel bypass for morbid obesity, and total hip replacement. Three of the four operations were subjected to randomized clinical trials (RCT's), but only after the passage of much time and many procedures. In addition, it was apparent that earlier trials
878. Supply Elasticities
Funding/financing
of
for Physician Services.
Louis F. Rossiter. Dec 1978, 25 pp. Availability: National Center for Health Hyattsville, MD 20782.
Descriptor(s):
Supply/availability
of services, Physicians.
would have speeded the process of evaluation in each case. Early Services Research,
Literature on empirical studies dealing with the labor supply decisions of physicians are briefly reviewed. The review covers both aggregate and microeconomic studies, with emphasis on the microeconomic studies and their theoretical underpinnings. Two macroeconomic studies (Feldstein, 1970, Fuchs and Kramer, 1972) are discussed and evaluated. The macro studies find negative supply elasticities, but their methods are suspect and based on only a few aggregate observations. Four microeconomic studies are examined, with a model posited of a physician jointly choosing income and leisure. In general, positive supply elasticites are found, with a backward bending curve portion occuring well above the mean average income of physicians in the sampies. Further, the impact of the backward bend is small. The results from the microeconomic studies are sometimes contra-
clinical surveillance could have facilitated the design and early implementation of RCT's when necessary. Of equal oz' greater importance, long-term surveillance of clinical experience would have allowed continuing evaluation of new procedures alter their widespread dissemination into general practice. The article recommends that an Institute of Health Care Assessment be charged and adequately funded to provide independent evaluation of surgical procedures, including old procedures where professional uncertainty persists. This agency would take charge of standards, coordination, review, and funding; however, implementation and regulation of the evaluation should remain at the local or regional level and should use existing agencies, such as human research committees and local health systems agencies. The institute should approve and fund clinical trials but should prohibit funding from existing third-party insuring agencies during this phase of the evaluation. After the new procedurc is released for more general use, the institute should continue surveillance and compilation of data in registry form. Thirty-one references are given.
1-397
Deseaiptor(s): Medical/surgical services, Outcome/evaluation of qualityassurance, Policyinitiatives.
vices)were $33.85for individuals and $95.15 tbr families. HMO's reportedlowerphysical and mentalhealthhospital use and higherambulatoryusewhen compared withmore traditionalformsofhealthinsurance coverage. The present coverageand useofmentalhealthservices withinHMO's reflect greater varia-
880. Survey of HospitalSemi-Private Room Chargesas of January 1981.
bility ofbenefits and use.Furtherstudies ofmental healthuse inrelation toorganizationa_ structure and delivery patternrelationships withinHMO's areneeded.Footnotes, tables, and 14 references are given;3 tablesare appended.(Author abstract modified)
Health InsuranceAssociation of America,New York, NY 10022 1981,23 pp. Availability: Health Insurance Association York, NY 10022.
of America, New
Descriptor(s):
Prepaid plans, Mental health services.
Statistical data obtained from a mail survey on semiprivate room rates in January 1981 are reported. The survey was conducted by the Health Insurance Association of America. Questionnaires in postcard format were mailed to 3,776 nongovernmental shortterm general hospitals throughout the United States and in Puerto Rico. The listing of hospitals was obtained from the American Hospital Association Guide to the Health Care Field, 1975 edition. Replies were received from 3,195 hospitals (or 84.6 percent), 3,024 of which provided usable data for the survey. The data for these hospitals were matched by fast three-digit rap code area with State totals. Matching data are also reported with respect to those hospitals which replied to both the current
882. Survey of Recent Research in Health Economics.
survey and an earlier July 1980 survey. (Author fled)
A literature survey reviews recent research on the demand for health and medical care for adults and children, the effects of health on the labor supply and wage rates, and selected topics pertaining to the supply side of the medical care market. Most recent studies on adult health care demand have adopted a model which proposes that consumers demand good health, not medical services per se, when they purchase such services. The
Descriptor(s):
Health care costs, Hospital
abstract modi-
services,
881. Survey of Mental Health Service Coverage Within Health Maintenance Organizations.
Bruce L. Levin and Jay H. Glasser. 1979, 6 pp. Availability: American Jnl. of Public Health v69 nil 1125 Nov 79.
p1120-
This 1978 national survey of all operating Health Maintenance Organizations (HMO's) provides information on the current status of mental health services use and service coverage within HMO's. A total of 346 HMO's were contained within the final survey frame, and 123 HMO's completed and returned the questionnaires, making a 68 percent response rate. Approximately 90 percent (108) of the HMO's offered mental health services through basic or supplemental coverage plans. HMO characteristics reflected relative heterogeneity. The mean monthly costs for basic health plan coverage (physical and mental health set-
1-398
Michael Grossman. National Bureau of Economic Research, Inc., Cambridge, MA 02138 Robert Wood Johnson Foundation, Princeton, NJ. 1977, 7 pp. Availability: Survey of Recent Research in Health Economics v21 nl p14-20 Spring 1977.
demand curve for medical care must be derived from the interaction between the production function of health and the demand curve for health. The model facilitates predictions about the effects of shifts in variables other than income and the price of medical care on the quantities of health and medical care demand. This model has been applied to investigate the properties of the demand function for medical care, the role of spouses' characteristics in the production of individuals' health, the relationship between years of formal schooling and adults' health, and quantity-quality considerations in the market for physicians' services. In addition, several researchers have tested and contermed the hypotheses that exogenous improvements in health raise market productivity and should also increase the amount of time allocated to work in the market. These studies also suggest that the effect of health on productivity is strengthened when health is treated as an endogenous variable. Another group of studies seeks to estimate demand curves for pediatric care from the interaction between the demand and production functions of children's health. These studies reveal that mothers'
Health Care Programs
schooling has a significant effect on pediatric visits and that an increase in the relative productivity of certain health inputs (e.g., parents' time and pediatric visits) increases the quantity of the input demanded. Recognition of the unique role of physicians in the medical service market has led to empirical estimates of the role of physician availability. Such studies indicate that physicians can to some extent influence the demand for their services and that this availabifity effect falls as consumers' education level rises. The relatively high cost of physician input has stimulated analyses of the market for paramedical personnel, such as nurses. Such studies demonstrate a rise in the wage rates of registered nurses due to mandatory licensure. Twenty-seven references are supplied. Descriptor(s): Demand/utilization of health care programs, Supply/availability of services, Physicians, Nurses, Demographic features of population.
past surveys, group models tended to use hospitals less frequently. The weighted average for IPA admissions was 41 percent higher than for groups, while the rate of IPA hospital days per 1,000 was 23 percent higher than for group model enrollees. The survey data revealed that the populations served by HMO's were not comparable in terms of age. Some plans served the employed, under 65 population, while others served a substantial number of elderly members; in some plans, the elderly represented as much as 20 percent of members. After adjustment of the rate of hospital days per 1,000 for those plans with high elderly enrollment to make them comparable to rates of plans with no elderly enrollees, the study found that the average hospital days per 1,000 decreased, sometimes as much as 20 percent. Tables, footnotes, a list of HMO's operating at the time of the survey, and a map showing HMO locations are provided.
Descriptor(s): Demand/utilization of health care programs, Prepaid plans, Participants in health care programs, Comparisons of health care programs, Hospital services.
883. Survey Results, July 1980. HMO Enrollment and Utilization in the U.S. 884. System of Hospital Uniform Reporting (SHUR). Lenore Kligman Hoops. InterStudy, Excelsior, MN 55331 Henry J. Kaiser Family Foundation, Palo Alto, CA. Nov 1980, 17 pp. Avadabi]ity: InterStudy, Excelsior, MN 55331.
This report discusses the results of a July 1980 survey of health maintenance organizations (HMO's) in the United States. The survey identified 236 plans operating as of July 15, 1980. These plans served approximately 9,183,397 members. Total HMO enrollment increased 12 percent from June 1979 to June 1980, the same rate of increase observed the previous year. For this report, all plans have been classified as two basic types: (l) group practices, including physician partnerships, staff models, and networks of group practices; or (2) individual practice associations (IPA's) in which physicians contract individually or through a separate legal entity to serve I-IMO enrollees. Group practice models continue to be the dominant organizational form, both in number and in size; they comprise 66 percent of all plans and 86 percent of all members. In the survey, the HMO's were asked to report the proportion of their membership which is 65 years or older. Of the 203 plans that responded to that question, 54 (27 percent) reported having no elderly membets while 149 plans (73 percent) reported having some older members. The average admission rate for IPA's was 109 per 1,000 enrollees, while the average admission rate for group model plans was 111 admissions per 1,000 enrollees. A comparison of group and IPA model ut'flization rates indicated that, as in
Committee on Ways and Means (U.S. House) Subcommittee on Health, Washington, DC 20515 Iul 1979, 248 pp. Availability: Printed for the use of the Committee on Ways and Means.
Testimony on the Department of Health, Education, and Welfare's proposed System of Hospital Uniform Reporting (SHUR) is presented before the House Subcommittee on Health of the Committee on Ways and Means. SHUR is described by a General Accounting Office witness as not only a uniform reporting system but also an instrument for gathering cost reimbursement data, statistics needed for health planning, and health manpower data. As such, it would expand by lO the data forms currently required in the hospital medicare cost report. The General Accounting Office representative estimates the cost of implementing the system and offers suggestions for simplifying the proposed reporting system. A witness from the Department of Health, Education, and Welfare argues for the implementation of SHUR as a means of eliminating excessive and abusive claims for medicare reimbursement by hospitals. Many of the witnesses representing hospital organizations maintain that SHUR would not only be an expensive undertaking, but would require informarion not related to medicare cost containment issues. The Executive Director of the California Health Facilities Commission gives the commission's support to the latest version of SHUR, based on California's experience with a uniform report-
1-399
ing system deemed to be even more complex than SHUR. The commission believes the possible benefits of implementing SHUR fat outweigh the costs of implementation. In addition to the oral testimony, material submitted for the record is included.
Descriptor(s): Health information/data systems, Competition/ interaction among third-parTy payors, Third-party payors, Policy/changes re health care.
90th Congress first session, Serial No. 90-39. 886. Systems Development. Desct4ptor(s): Medicare, Inpatient facilities, Claims administration, Health information/data systems.
885. Systems Approach to Health Insurance Policy Information..at Preliminary Taxonomy of Health Insurance Issues, Program Options, Problems and Solutions.
J. L. DeVries and B. H. Perry. 1979, 14 pp. Availability: Socio-Economic Planning 140 1979.
Sciences v13 n3 p127-
By supplying a link between the quantitative and qualitative information available to health insurance policymakers this study presents a methodology for developing a systems approach to health insurance information and literature. Traditional cataloging and indexing techniques do not adequately meet the health policy researcher's and analyst's information needs. The most imlx_rtant of these needs is knowledge of the interrelationships between program options in terms of expected results in a wide range of settings. The key element of this methodology is the concept of an information frame, based on an understanding of health insurance as a system of issues, program options, problems, and solutions with interrelationships explicitly defined, The methodology provides initially qualitative identification of the interrelationship and makes them available via a machinereadable taxonom_ _of the components. Preliminary work on the building of the taxonomy substantiated by literature references, and based on 7 major health insurance issues, over 70 program options, 325 problems, and 350 solutions which have been identifled for 170 of the problems. The implementation of the methodology would provide analytically structured information for policy analysts in a format not presently available. For example, the multicountry information included allows consideration of alternatives which might otherwise be neglected. Once it is fully developed the system will improve an important element of the analytic process, and reduce the lead time required for inquiries by hcahh insurance policy analysts, legislators, health planners a,d administrators. Flow charts, tables, and 22 references are provided. (Author abstract modified)
I -_:_
Trends, Issues and Implications.
Montague Brown. 1979, 10 pp. Availability.. Health Care Management Winter 1979.
Review v4 n I p23-32
This article discusses the trend toward integrated systems in the U.S. health care industry and its implications for health care institutions, communities, and health care consumers. Increases in the cost of hospital and other health services have provided the impetus to explore me*hods of increasing the productivity of health care institutions. Numerous studies have identified regionalization as a principal means of improving continuity of care, reducing costs, and improving the quality of care. In addition, the recently enacted Health Planning and Resources Development Act stresses the sharing of administrative and clinical resources. Cost constraint, overbedding and tighter utilization controls, capital needs, and new medical technologies make it increasingly difficult to maintain a free-standing hospital. As a result, a variety of organizational arrangements are being developed to facilitate systems integration. Among these arrangements are shared services, condominiums, consortia, mergers, regional multiunit hospitals, and national chains. Policymakers should be interested in these industry changes for three major reasons. First, the changes have developed with little knowledge on the part of trade associations. Second, the regional interlocking of health care institutions and programs appears to approach the goal of public policy tbr national regional networks. Third, the development of the national investor-owned voluntary chains usually means one hospital per market or region. Reports of multiunit systems effectiveness indicate slower growth in case cost, lower price levels, and higher outputs. A persistent issue as systems of hospitals emerge is the struggle between unitbrmity and diversity and between centralization and decentralization. While the future of multihospital systems seems optimistic, actual development remains more a promise than a reality. Two tables and 28 references are included.
Adapted from a presentation at the Vienna Symposium for Hospital Management, LudwtgBoltzman Institute for HospitalEconomics, Vienna, Austria, September 21-22, 1978. Descriptor(s):Health care costs, Facilities providing health care, Hospital services, Voluntary initiatives.
Health Care Programs
887. Taking Action To Contm
Health Care Costs. Part I.
K. Per Larson. 1980, 6 pp. A vMlability: Personnel
Jnl. v59 n8 p640-645 Aug 80.
Methods for corporate control of health care costs are examined, Reduction of health care costs can be achieved most successfully by the organizations and individuals whose profits and paychecks are paying the bill (i.e., the corporate employer). For example, one company sponsored voluntary health screening for all employees over age 35. Of 72,821 employees examined over a 7-year period, abnormalities were detected in 4,075 cases. Hypertension was eliminated in 80 percent of the cases 4 years after it was identified as a company problem. Corporate concern for costs must focus on previously neglected areas. Four action areas can be identified, including top management, finance, personnel, and operations. Top management can directly negotiate rates with hospitals, encourage executives to become hospital board members, and establish task forces to investigate specific problems. Although the priority for action oRen originates with top management, leverage is best when expressed through finance, Finance has the power to generate data on which management can act. Additional possibilities for action by finance include claims processing risk assumption, and establishment of claims audit programs. Personnel can effect the copayment system, develop employee education programs with regard to health issues, and ensure that expenses such as outpatient surgery, obtaining a second opinion for surgery, and participating in smoking control clinics are covered in full by insurance. Operating management should direct its efforts toward allocating of costs, screening high risk conditions, instituting rehabilitation programs, and establishing programs to encourage use of safety measures outside the workplace. No references are included. Personnel
Jnl. Reprint.
Descriptor(s): Cost containment ment, Voluntary initiatives.
efforts, Source of premium pay-
policies that encourage disease and cost prevention, create a health program manager, and invest management time and training in cost prevention. However, business will get no help from the health industry in reducing costs, because both insurers and the industry are dependent on physicians to control supply, demand, and prices. Nevertheless, if companies do not act, the Nation faces a rise in health care costs of up to 12 percent of the gross national product in this decade. Actions companies can take to reverse the trend include having management from various companies band together to study and advocate cost prevention, lending management talent to providers, and providing employees with economy-minded company doctors or even total health care. Activities for financial departments of companies include jointly deciding on health benefits with personnel departments, sharing cost data with other companies, and ensuring that claims are processed efficiently. Actions for personnel departments include motivating employees to save costs by designing benefits that provide cost-effective health choices, coordinating benefits with employee safety and health education, and providing health promotion programs. Other management suggestions include keeping track of employee health and training supervisors to spot employee health problems before they demand too costly services.
Desedptor(s):
Cost containment
efforts, Voluntary
initiatives.
889. Tax Subsidies for Medical Care. Current Policies Possible Alternatives.
and
Joshua E. Greene. Congressional Budget Office, Washington, DC 20515 Apr 1980, 81 pp. A vailabils'ty: Superintendent of Documents, Government Printing Office, Washington, DC 20402, order number 052-070-05200-7. This paper, prepared at the request of the Subcommittee on Health and Oversight of the House Ways and Means Committee, analyzes threeFederaltaxsubsidies formedicalcareand sug-
888. Taking Action to Contain Health Care Costs. Part II.
K. Per Larson. 1980, 5 pp. Availability: Personnel
Jnl. v59 n9 p735-739 Sep 80.
Corporation management is instructed on how to reorganize its employee health care to prevent some health care costs. Companies will first need to redefine their role in health care, make new
gests possible alternatives. The fhst subsidy, the employer exclusion, exempts employer contributions to employee health and accident insurance plans, including plans established by employces themselves from all taxable income. While this exclusion stimulates health insurance coverage, it also encourages more frequent use and more elaborate forms of medical care. Possible alternatives include limiting the exclusion to a fixed-dollar amount, converting the exclusion to a limited tax credit, and requiring specific features in health insurance plans. The medical expense deduction subsidy, which allows taxpayers who itemize
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their deductions to subtract one-half the cost of their pa}ments for health insurance from taxable income, does not benefit most low-income and moderate-income persons, does not make payments available when expenses are incurred, and does not concentrate on expenses relating to catastrophic illness. Possible alternatives include changing the deduction to a tax credit, raising the deduction minimum, and providing catastrophic health insurance. Finally, the use of tax-exempt bonds to finance capital projects at private hospitals does not target aid on the most needy projects. As alternatives, Congress could maintain the current law regarding tax-exempt hospital financing. Tax-exempt funds for hospital projects could be eliminated, and taxexempt hospital bonds could be required to be general obligation issues. Notes are provided for each chapter, and seven tables are given. (Author abstract modified) Reprint
of earlier Background
Paper dated January
action would serve to make the purchase of private health m_urance more expensive, would make the sellers market more cornpetitive, and would cause le:_scomprehensive benefit packages to be sold. Tabular data and footnotes are supplied. Desct4ptor(sg: Facilities providing health care, Providers of health care services, Cost containment efforts, Competition/interaction among third-party payors, Demand/utilization of health care programs, Publicly sponsored/mandated health plans, Present legislation/regulations.
891. Technology and the Governance dustry. The Dilemma of Reform.
1980. Martin
Descriptor(s): Present legislation/regulations, Source of premium payment.
Policy initiatives,
890. Taxation and Its Effect Upon Public and Private Health Insurance
and Medical Demand.
Nancy T. Greenspan and Ronald J. Vogel. 1980, 6 pp. Availability: Health Care Financing Review vl n4 p39-45 Spring 1980. This study addresses the interrelationship between the private and Federal insurance market components, and it contends that this is an important area of consideration in the search for ways to control costs in the medicare and medicaid programs. Basically a literature review, this paper first cites studies indicating that increases in Federal program fees result in private insurer and provider responses that preclude increased access to care and merely aggravate inflation. Then this review focuses on studies that examine a special aspect of the private market, namely tax incentives in both the buyers' and sellers' markets of health insurance. The multiple tax subsidies available to buyers and sellers are shown to have the potential for creating excess demand for health insurance, which in turn creates excess demand for health services. Thus, the present tax structure of the private health insurance industry contributes to the rising costs in the medical care sector. This paper argues that as long as this is the case, Government health programs will have difficulty competing with the private health sector. A suggested option is to eliminate the present tax subsidies in the private market for both the buyers and the sellers of health insurance. At the margin, this
1 4()2
of the Health Care In-
A. Strosberg,
Charles Levine and Alfred
Mauet.
1977, 15 pp. Availability: Jnl. of Health Politics, Policy and Law v2 n2 p212-226 Summer 1977. This paper analyzes the effects of professionalism on the doctorpatient relationship and discusses how control over technology has enabled the medical profession to control its organizational environment. With increasing public expenditures for health care services, the accountability of the health care industry has become a major political issue. Concomitant issues concern the structures and processes through which the public as patients, customers, and citizens can directly influence the delivery of health care services. These issues, which are currently part of the national health policy debate, are indicative of the larger question concerning the relationship of the individual to an increasingly complex society. The medical profession, through its control of technology and its monopolistic hold on legitimate claims of expertise, is the primary determiner of the way health services are structured and resources are allocated. Domination of doctor-patient relationships, medical care delivery organizations, and the national health care policy process thus enables physicians to remain unaccountable to democratic institutions and insulated from public participation in decisionmaking. Moreover, lack of accountability, disproportionate professional power, and the failure of governmental regulation all raise questions about the role and irapact of the medical profession as a quasi-institutional political actor in terms of(l) the return on the investment of $135 billion spent annually for medical care, (2) claims of expertise and self-regulation, and (3) overarching democratic values. This al_icle has 52 notes. (Author abstract modified)
Descn'ptor(s): health care.
Policy initiatives,
Physicians,
Policy/changes
re
Health Care Programs
892. Technology and the Quality of Health Care.
This study focuses on the growth of new technologies that have been introduced in hospitals over the last 25 years. The study
Richard H. Egdahl and Paul M. Gertman. Robert Wood Johnson Foundation, Princeton, NJ. 1978, 311 pp. Availability: Aspen Systems Corp., Rockville, MD 20850.
concludes that medical care costs will only be restrained if spending -- whether for medical care or medical technology -- is restrained. The study's approach combines case study and statistical methods. The case study of each technology looks at its purpose and use, its history, the kinds and amounts of resources it employs and their cost, and its benefits for patients. The studies demonstrate that in the presence of third party payment, investment in a technology will continue until the benefit from any further investment is zero. The statistical analysis investigates the distribution of the technology among hospitals and tries to explain what factors account for that distribution. Major forms of intensive care, such as the IX_toperative recovery room, the mixed intensive care unit, and the
Contributions and proceedings at the Conference Care Technology and Quality of Care (November
on Health 19 and 20,
1976) are presented. The initial section on technology development application and impact includes background papers on the benefits to be gained from currently available technology; the role of the private and public sectors in the development, use and evaluation of technology; and on the evaluation of biomedical research arid health technology. The second section, focusing on the control of technology development and use, presents contributions on such issues as the 1976 Medical Device Amendments to the Food, Drug, and Cosmetic Act; Government powers to check the spread of technoloqy; and Government action to ensure appropriate and efficient introduction and use of new technology. The concluding chapter of this section looks speculatively at the types of future consequences that current efforts to control technology could produce. The third section presents a summary and recommendations of the health policy conference. Two issues forcefully emerged at the conference: the lack of adequate information and evaluation methodologies to assess health care policy problems; and the overwhelming cornplexities involved in formulating policies about future development and control of health care technology. Underlying these two factors, a third problem emerged: the need foi" effective mechanisms or structures to grapple with the lack of information or to integrate decisionmaking. The conference recommended a multilevel, integrate system of responsibilities for information gathering and analysis starting at NIH, moving to the level of assistant secretary at DHEW, and finally to the Office of Science and Technology Policy at the White House. The collection includes a selected bibliography of over 80 entries on health care technology. Descriptor(s): health care.
Medical technology
impacts,
Policy/changes
re
coronary care unit are examined. In addition, the speed with which three quite different technologies -- respiratory therapy, diagnostic radioisotopes, and the electroencephalograph -- were adopted in the late 1960's and early 1970's is considered. Another chapter looks at the current distribution of throe more unusual technologies -- open-heart surgery, cobalt therapy, and renal dialysis - which axe still found primarily in large hospitals. The book also discusses the policies of four countries -- the United States, Sweden, Great Britain, and France -- for dealing, directly or indirectly, with decisions about medical technologies. Tables, figures, and footnotes are included. Appendices give the distribution of hospitals used in the study and a method for estimating regressions when the dependent variable is binary. An index is provided. (Author abstract modified) Brookings
Studies in SociM Economics.
Descriptor(s): Medical technology impacts, Third-party payors, Inpatient facilities, Comparisons regarding foreign health policies.
894. Ten Years of Medicare. Impact on the Covered Population. Marian Gornick.
893. Technology Diffusion.
in Hospitals. Medical Advances and Their
Louise B. Russell. Brookings Inst., Washington, DC 20036 National Science Foundation, Washington, DC. 1979, 180 pp. A vailability: Brookings Inst., Washington, DC 20036.
Social Security Administration, Washington, DC 20203 1976, 19 pp. Availabih'ty: Social Security Bulletin v39 n7 p3-21 Jul 76. A 10-year review of medicare data is provided, focusing on the effect of medicare as insurance. Study of the use of medical benefits reveals that the proportion of enrollees using covered physicians' and related services has been at a relatively constant level throughout the past decade. Implementation of medicare
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apparently did not result in a period of unbounded use of covered services. The rapid increase in the price of medical care during this decade has been a major concern. Medicare has succeeded in accomplishing its primary goal of paying the major portion of large hospital and medical bills, but enrollees' out-of-pocket expenses are still likely to be a considerable burden to many beneficiaries. Topics addressed are eligibility under medicare (aged persons covered and disabled enrollees), utilization of medicare benefits (use by persons continuously enrolled from 1966 to 1974 and use of benefits in last year of life medicare reimbursements and enrollee liability (program payments and beneficiary liability), and medicare's role in personal health care spending for the aged, i.e., total per capita expenditures by type of service and sources of funds. Twenty-two references, a technical note, and 12 footnotes are provided. (Author abstract modified )
Descriptor(s): Demand/utilization of health care programs, Medicare, Participants in health care programs, Demand/utilization of health care programs, Eligibility requirements, Source of premium payment.
895. Ten Years of Short-Stay
persons using hospital services under medicare increased from $91 per person annually to $181. In addition, the proportion of the gross national product devoted to personal hospital care services increased from 2.1 percent in 1967 to 3.4 percent in 1976. A total of 9 figures, 215tables, and 22 references are given. Three appendices contain the medicare statistical system, information on the reliability of estimates, and a glossary. (Author abstract modified) Health Care Financing Research
Report
Series.
Descriptor(s): Demand/utilization of health care programs, Health care cost trends/projections, Medicare, Hospital services, Inpatient facilities, Participants in health care programs.
896. Terminal Care. Issues and Alternatives. Claire F. Ryder and Diane M. Ross. 1976, 10 pp. Availability: Public Health Reports v92 n 1 p20-29 Jan/Feb 77.
Hospital Utilization
and Costs
Under Medicare (1967-1976).
An increasing interest in the needs of the terminally ill and their families has led to the creation of home care programs and
Charles Helbing. Health Care Financing Administration Office of Research, Demonstrations, and Statistics, Baltimore, MD 21235 Aug 1980, 43 pp. Availability: Health Care Financing Administration, ORDS Publications, Baltimore, MD 21235.
inpatient facilities geared to their emotional and physical needs. However, changes are needed in Federal policy to overcome current inadequacies in financing, in gathering cost-effective in-
This report presents a statistical review of the first 10 years (1967-1976) of short-stay hospital services furnished to aged beneficiaries under the Medicare Hospital Insurance Program (HI). National and regional estimates of short-stay hospital use, charges, and amounts reimbursed are examined. The report data show that the HI program reduced financial barriers to the use of short-stay hospital services by the aged population. After the HI program began, nearly all persons aged 65 and over -- about 19.1 million -- were eligible for HI benefits; nearly half of these aged persons had no previous hospital insurance protection. By July 1976, the aged HI enrolled population reached 22.9 million, Program data show a greater use of short-stay hospitals as a result of the HI program; the use of inpatient services was about 25 percent higher during the first year of the program (1967) than in the preceding year. However, the rapid inflation in the cost of hospital services has progressively diluted the intended relief for the aged. Between 1967 and 1976, the liabilities of aged
i 404
formation, and in services 'already provided. Attitudes of denial toward the needs of the dying must be overcome. The medical profession's orientation toward cure rather than care of patients was imtil recently reflected in training and education programs in medical schools. Thus, current medical questions center on the exact moment of death rather than on the quality of care for the living. Hospital patients are often removed from contact with their families, from issues that affect their lives, and even from health care staff, resulting in the phenomenon of social death preceding physical death. Patient needs center on coping with death (consisting of four stages: denial, anger, bargaining, and acceptance), retaining a unique identity, maintaining close interpersonal communication with loved ones, meeting financial costs, and finding spiritual solace. Some alternatives which have arisen to deal with these needs are the hospice movement, home care programs, separate facilities for the terminally ill within the hospital setting, and fulfillment of special needs within a regular hospital. Short-term goals for care of the terminally ill must focus on education programs in medical and nursing schools, changes in medicare legislation, and placement of the terminally ill in environments best suited to their needs. Twenty-one references are included.
Health Care Proglazn_
Descriptor(s): Hospital services, Home health services, Policy initiatives, Facilities providing health care.
897. Textbook for Employee trators and Advisors.
Elizabeth
Benefit Plan Trustees, Adminis-
Annual Conference Pr_eedJngs SelieS, Volume No. 21. Procee_tings of the 1979 AnnualEducational Conference, held October 12-17, 1979, in New York, NE.
Descriptoffs): Cost containment efforts, Private health care plans, Prepaid plans, Inpatient facilities, Plan design/program provisions (under health plans), Claims administration, Present legislation/regulations, National health insurance (NHI), Funding/financing of health care programs.
A. Hieb.
International
Foundation
of Employee Benefit Plans, Brook-
field, WI 53005 1979, 494 pp. A vailab/lity: International Foundation Plans, Brooktield, WI 53005.
898. Theoretical Analysis of the Impact of National Health Insurance on Consumer Behavior in the Health Care Market. of Employee Benefit
Addresses from a conference on employee benefit plans discuss the general topics of Government programs and proposals, the legal-legislative environment, fiduciary standards, plan administration, welfare and pension issues, recordkeeping and data management, investments, and health care programs and cost containment techniques. Papers on Government programs and proposals consider employer liability issues and collective bargaining; the outlook for Social Security; changes in the concerns, concepts, and content of national health insurance; the possible impact of national health insurance on present plans and systerns; and whether national health insurance can meet the nation's health care needs. In the area of the legal-legislative environment, issues discussed include an explanation of litigation for the laypcrson, recent decisions affecting negotiated eraployee benefit plans and joint trusts, implications of the Pregnancy Disability Amendment for plan design, and trends in 1979 prohibited transaction exemptions. Addresses on fiduciary standards include a basic review of fiduciary responsibility and current guidelines for fiduciary liability. Topics treated in plan administration are vacation and apprenticeship fund reserves, payroll auditing and the employer, the annual audit, the vested separated participant, and health fired operations cost. A nnmber of the papers deal with the use of computers in recordkeeping and data management. The papers dealing with investments explore basic principles for operating in the stock market, innovations in investment management, selling call options to improve equity performance, and investment monitoring. Discussions of health care programs and cost containment techniques examine hospital cost control and reduction, cost containment techniques in the hospital claim, auditing of hospital bills, coordination of benefits, physician fee negotiation, second opinion programs, health maintenance organizations, and health education. A topical index is provided, and where appropriate, tabular and graphic data are provided to document the discussion,
Dudley W. Blair. Pharmacentical Manufacturers Association, Washington, DC. Dec 1975, 91 pp. Availabib'ty: University Microfilms International, Ann Arbor, MI 48106.
This study analyzes the effects of alternative forms of national health insurance (NHI) on an individual's demand for health care, referring to both medical care and nonmedical goods and services which may have an effect on the individual's health status. The actual proposals for NHI that have been introduced in Congress are briefly examined. From these proposals, four prototypieal plans axe specified for analysis. These plans differ according to their benefit structure and the method used to finance them, ranging from a catastrophic protection plan to a full coverage plan that is comprehensive in coverage. The theory that is developed to analyze each NHI plan is an intertemporal utility maximization model which is specifically formulated to include health insurance as a mechanism of financing medical expenditures. The theory includes time in the consumer's budget constraint as part of the full price of medical care. Individuals are viewed as being able to effectively choose the amount of sick time they will experience during any given period through their consumption decisions with respect to health care. It is hypothesized that the full price of medical care may be negative at times when its consumption may decrease sick time enough to offset the positive money price and opportunity cost of the time required to consume it. This suggests the possibility of a significantly increased demand for medical care until the marginal reduction in sick time from consuming each type of medical care diminishes to the point where a positive full price for medical care again occurs. It is concluded that NHI plans which lower the money price of medical care through lower coinsurance rates may actually redistribute medical resources toward the higher income levels, rather than towards the poor as is usually assnmed. It is also concluded that NHI may cause a change in
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lifestyle, by increasing the demand for goods which are detrimental to the individual's health. This would result from lowering the cost of health care used to compensate for such consumption activities. A glossary, a few footnotes, two tables, and 35 references are included in the study. (Author abstract modified)
providers competition is now a substantial factor in their continuing strength in the area. It remains to be seen whether continued reductions in physician supply and hospital beds will occur as a result of sustained competition, whether competing HMO's will serve the poor and elderly adequately, and whether Government will eliminate regulations which conflict with market forces. Thus far, however, it appears that physicians practic-
Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy to Texas A and M Univ., 1975.
ing under positive incentives created by a structurally sound, private, competitive marker, can contain costs while providing quality care. Five references and three tables are provided.
Descriptor(s): Demand/utilization tional health insurance (NHI).
of health care programs, Na-
899. Theory and Practice in Minneapolis-St.
Descriptor(s): Demand/utilization of health care programs, Cost/benefit analyses, Supply/availability of services, Competition/interaction among third-party payors, Prepaid plans, Private health care plans. Paul.
Walter McClure, Linda Krane Ellwein and David Aquilina. 1980, 4 pp. Availabilit): Internist v21 n12 p8-11 Dec 80-Jan 81.
900. Third Party Payment for Nonphysician lionel's. Realities and Recommendations.
Health Practi-
John G. Fox and Steven R. Zatkin. While the competitive health care system has developed only recently in Minneapolis-St. Paul Minn., the evidence suggests that competition has begun to have an impact upon communitywide use and costs. In 1971, the area had only one health maintenance organization (HMO), but now seven HMO's compete vigorously with each other and with fee-for-service physicians. Over 360,000 people are enrolled in the area's HMO's, or about 19 percent of the metropolitan population. While several cornmunities have higher HMO enrollments than Minneapolis-St. Paul, none has greater provider involvement. Approximately 80 percent of the area's physicians and most of the hospitals participate. The striking organizational diversity of the Twin Cities' HMO's demonstrates that a variety of prepaid plans can develop successfully in a community. Many large firms now have more than half of their employees enrolled in HMO's, and most major employers offer three or more prepaid plans in addition to a conventional insurance plan. The HMO's compete directly with each other as well as with traditional insurers. While the evidence can only be considered preliminary, it appears that competition has created cost-effective incentives on HMO physicians, forcing physicians to control use and costs tightly, particularly hospital services. In 1977, area HMO's hospitalized members at an average rate of 544 days per 1,000 and in 1979, 452 days per 1,000. For 1977, Blue Cross-Blue Shield averaged 860 days for comparably insured groups. Furthermore, Minnesota law requires HMO's to provide more benefits than does Federal law, but the HMO's have contained costs sufficiently to provide many employee groups with more comprehensive benefits at lower premiums than regular insurance. While it seems unlikely that competition is the sole cause of these trends, according to local
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1978, 12 pp. Availability: Family and Community Health vl nl p69-80 Apr 78.
Issues associated with third party payment for n0nphysician health practitioners are discussed, and recommendations are offered. The desire for increased access to reasonably priced health care has resulted in a growing interest in the use of physicians' assistants and nurse practitioners -- new health professionals (NHP's). Available data indicate that NHP's can produce cost savings, since reimbursement rates below the community rates for physicians can still bring a profit to a practice using an NHP. Further, studies show that NHP care quality is equal to that of a physician when the NHP works in collaboration with a physician and refers difficult eases to the physician. The available data, although incomplete, indicate that NHP's can improve the accessibility of care; this will be required if governmental reimbursement is provided for NHP care. While an independent practice for NHP's is undesirable, semiindependent practice with direct reimbursement to NHP's is desirable in underserved areas. Currently, State standards should be used to determine NHP eligibility for reimbursement; however, in the long run, some national consensus on defining NHP's will be necessary. In California, the following positions have been taken regarding reimbursement for NHP services under medicaid: (1) the State should reimburse for services provided at some percentage less than that provided physicians performing the same service; (2) the same level of reimbursement should be paid no matter who is performing the service, so long as they are competent; (3)
Health Care Programs
NHP's should be reimbursed under a different schedule than physicians; and (4) reimbursement for NHP services should be on the basis of billings for the actual cost for providing the services. The recommended approach is to reimburse at a single rate for NHP and physician services at a level between NHP real costs and usual physician rates. California's politics of NHP reimbursement are examined. A total of 46 references are provided.
Descriptor(s): Supply/availability of services, Methods of payment determination, Nurses, Allied health professionals, Policy initiatives, Cost/benefit analyses, Cost containment efforts, Impact of third-party coverage.
£k_criptor(s): Medicare, Methods of payment determination, Impact of third-party coverage, Medical/surgical services.
901. Third Party Reimbursement Aspects of Physician Compensation. Michael S. McKibben. 1978, 23 pp. A vai/ab//ity: Topics in Health Care Financing Spring 1978.
article discusses these restrictions, as well as the significance of components of services furnished by provider-based physicians. Basic types of compensation arrangements recognized by medicare are described, and physicians' reasonable and customary charges are detailed. Also considered are billing for services, particularly arrangements by provider-based physicians; provider billing to medicare for physicians' professional services; the impact of professional component revenue on providers' reimbursable cost; and responsibilities of providers. In addition, special situations for reimbursement are explored. Tables, 11 references, and 5 suggested readings are supplied.
902. Third-Party Payments for New Health Professionals. An Alternative to Fractional Reimbursement in Outpatient Care.
v4 n3 p35-57
The concepts which apply to third party reimbursement for physician services are as vitally significant to a provider's nonfinancial executive, physician, or governing member as they are to financial administrators. A clear understanding of the concepts controlling medicare reimbursement for physician services as they relate to existing and planned arrangements for physician services is essential in evaluating the overall impact of physician compensation on the provider institution. The rising cost of services of provider-based physicians is inevitable. There is some concern in public and private sectors over the amount of cornpensation of some provider-based physicians. There will be changes to the present aspects of third party reimbursement for the compensation of physicians. These changes may take the form of a capitation system, which pays a retainer to physicians providing services to program patients, or some other form. Whatever the changes, they will be better received if the provider and physician organizations have an active role in their development. It is necessary to separate physician compensation into the components of the different types of services the physician performs in order to ascertain accountability. The basic elassifications of all the different types of compensation arrangements are either variable, fixed, or a combination of the two. The medicare program uses the combined billing method so that medicare inpatients are relieved of their responsibility for the Part B deductible and coinsurance. The program picks up the full cost of the inpatient professional services. However, there are many restrictions on the use of the combined billing method. The
Stuart O. Schweitzer and Jane Cassels Record. 1977, 9 pp. Availabih'ty: Public Health Reports v92 n6 p518-526 Nov/ Dec 77.
The disadvantages of fractional reimbursement for new health professionals (NHP's) are discussed, and an alternative proposal for reimbursement based upon the service provided rather than the provider is presented. The main purpose of NHP training programs in the 1960's was to meet the accelerating demand for services. Cost containment was not a primary concern. National policymakers have chosen fractional reimbursement, the wrong instrument, for serving the needs of both accelerating demand for services and cost containment. The allowable fee should not be based upon the provider but upon the service provided. A major objection to fractional reimbursement is its suggestion of a eutrate price for an inferior service. The alternative reimbursement proposal, however, would permit third-party payers to differentiate between NHP-appropriate and physician requisite office visits with disparate allowable fees. In this manner, the Government or private insurer might capture some or all of the cost containment potential in using NHP's. At the same time, the two-price approach with prices differentiated for services rather than for providers is a substantial incentive for employing NHP's to perform simple services. No physician would be forced to delegate such procedures, but the inability of physicians to claim more than the set fee for handling a simple prcw.edure would offer a strong inducement to replace themselves at that level so they could concentrate on more highly skilled, and hence, highly priced services. Part of this proposal includes di-
1-407
rect reimbursement for properly certified NHP's practicing independently because virtually all third-party payers now refuse to reimburse them directly for their services. Where such NHP practices are already established, they tend to be characterized by two developments: fees well below the prevailing physician prices as well as practices largely abandoned or never really embraced by physicians (i.e., house calls, nutrition counseling), Service-based reimbursement does not mean that a patient should be denied the right to have a sore throat swabbed by a physician rather than a physician's assistant, but that neither taxpayers nor fellow subscribers to private insurance should pay the differential if a patient chooses a more expensive provider, This proposed reimbursement policy would necessitate a major revision of present reimbursement practices. A few tables, a chart, and 11 references are provided.
Modified version of a paper presented at the Symposium on Nurse Pt_ctz_'oners and Physicians Assistants. A Research Agend_ held at Airlie House, VA, June 21-22, 197Z Descriptor(s):
Demand/utilization
that, in total, the programs of the Administration on Aging, Department of Agriculture, Community Services Administration, Social Services Amendment, and the Department of Transportation together spent about $1 billion for health and social services in support of the elderly. Thus, the ratio of medically oriented services expenditures to health and social services expenditures for the long-term support of the health of the elderly may be placed at 30 to 1. The article recommends incorporating a system of long-term care into the overall health care policy framework in order to meet the changing health care needs of the elderly. A list of various kinds of funding for home health care, administration for home health care benefits, eligibility for benefits, and kinds of benefits is included to illustrate some of the administrative problems. Descriptor(s): Demographic features of population, Demand/ utilization of health care programs, Policy initiatives, Trends in health status, Long term care facilities, Home health services.
of health care programs,
Cost containment efforts, Supply/availability of services, Impact of third-party coverage, Allied health professionals, Methods of payment determination, Policy initiatives, Reimbursement.
904. Three World Systems of Medical Care. Trends and Prospects. Milton Terris.
903. Thirty-To-One Medical Solutions.
Paradox. Health Needs of the Aged and
Stanley J. Brody. National Journal, Washington, DC 20036 Xerox Corp., Washington, DC. 1979, 5 pp. Availability: National Jnl. vll n44 p1869-1873
3 Nov 79.
This paper, which served as the basis for a discussion during a 1979 conference on aging, describes the health needs of the elderly, their use of health care services, available resources, and the need for a long-term care support policy. The article states that chronic and degenerative diseases now predominate and are the primary cause of death and illness for the elderly population, The National Center for Health Statistics estimates that 81 percent of all persons over 65 have chronic conditions, 45.5 percent of those over 65 experience activity limitations due to these conditions and 39.4 percent are limited in major activities. In addition, although the aging compose only 10.8 percent of the current population, they used 28.9 percent of all health care resources in 1977. Health services for the aged are described as multiple, parallel, overlapping, noncontinuous, and, at the very least, confusing to the elderly consumer. The article estimates
1-408
1978, 7 pp. AvMlabiHty: American Jnl. of Public Health v68 nil 1131 Nov 78.
p1125-
This article considers current trends in the three basic systems of medical care in the world - public assistance, health insurance, and national health service -- and discusses the prospects of transition from one system to another. The public assistance system, dominant in 108 developing, agricultural countries (exeluding those with populations under 100,000), is provided through government hospitals and health centers and is financed by general taxation. The health insurance system, dominant in 23 industrialized nations with a capitalist economy, usually consists of both governmental and nongovernmental insurance and is financed by both taxes and general government funds. The national health insurance (NHI), dominant in 14 countries that are either industrialized or undergoing industrialization, covers the entire population and is financed by taxation. All of the national health services emphasize preventive measures, ambulatory care, and division of the country into units staffed by various health care personnel. The article describes the intermediate positions of the United Kingdom and Sweden whose health care systems lie somewhere between health insurance and a national health service. It analyzes prospects for transition from countries with a health insurance system, such as Denmark and Finland, and from countries with pubfic assistance, such as Cuba and
Health Care Programs
Mongolia, to national health insurance. Despite some resistance, in the industrial capitalist countries with well-entrenched health insurance systems, the trend is unmistakably toward the NHI service. Twenty-nine references are given,
apparent discrimination against minority groups needing longterm care who are not being admitted to nursing homes are discussed. The causes of these problems are identified as the lack of a national policy and enforcement standards compounded by a shortage of professional nurses and physicians' abdication of
Longer version of this paper presented at the Annual Meeting of the American Public Health Association, W&_ffngton, DC, November 2, 1977.
responsibility for nursing home institutions. America's finest nursing homes are described in terms of the kinds of rehabilitative and activity programs they provide and the way they train their employees and establish ties with the community. The development of a national policy for nursing home care is the primary recommendation for reform. Appendices contain a history of old age, advice to nursing home administrators, and a list of resources for finding help. Tabular data, chapter notes, and an index are provided.
Descriptor(s): Comparisons regarding foreign health policies, Third-party payors, National health insurance (NHI), Comparisons of health care programs,
905. Too Old, Too Sick, Too Bad. Nursing Homes in Ameri. CAl.
Descriptor(s): Medicare, Medicaid, Long term care facilities, Outcome/evaluation of health administration, Policy initiatives.
Frank E. Moss and Val J. Halamandaris. 1977, 326 pp. A vailabih'ty: Aspen Systems Corp., Rockville,
MD 20850.
Thisbook isbasedon a 14-year investigation intonursinghomes in theUnited States. Itincorporates information gleanedfrom hearingsof the SenateCommittee on Aging since1963,and subsequentresearch and associated work by theSubcommittee on Long Term Care.Inaddition torevealing thenegative aspects of many nursinghomes,thebook alsocoversthe positive and innovative efforts beingpursuedinothers. The history ofnursing homes in America is presented, as well as descriptions of what happens in such institutions, why, and what can be done to ameliorate the situation. The book also aids families who axe faced with the difficult decision of how to choose a nursing home. At the same time, this work is also a textbook for administrators who want to learn to improve the operation of their homes and to help erase the negative image associated with nursing homes. The overriding concern is the welfare of the millions ofolderAmericanswho suffer thecompound burdens of illness and advancedage.The materialisarrangedin four sections, with the first sectiondelineating the kaleidoscope of nursinghome problems,thesecondidentifying therootcauses of nursinghome abuse,thethirddescribing positive aspectsin long-termcare,and thefinal section presenting reforms. Among theproblemsrevealed herearethefearwithwhich elderly persons regardnursinghome institutions and the typesofabuses residents encounterthere, rangingfrom neglect tovarious forms of deliberate physical injury to theft and callous assaults on human dignity. Other problems concern drug use in nursing homes, including human experimentation and addictions; the threat of fires, and profiteering. Special problems with institutionalization of the mentally impaired in nursing homes and the
906. Toward a Community-Based
National Health Service.
Leonard S. Rodberg. 1979,8 pp. Availability: Jnl.of PublicHealthDentistryv39 n3 p187-194 Summer 1979.
Arguments against a national healthinsurance (NHI) program and fora national healthservice (NHS) arepresented. Proposals for an NHI system would provide Government support for the present private entrepreneur-dominated, piecework system of fee-for-service health care. The forces escalating costs would not only continue, but would be fueled under a NHI program. A better approach to health care is that proposed in the Health Service Act introduced by Congressman Ronald Dellums. The Dellums Bill would establish a community-based NHS, controlled democratically by locally-elected community boards. NHS workers would be Federalemployees under the U.S. HealthService; theywould be paidsalaries accordingto their qualifications and theperiodof timetheywork. Althoughdetractors ofsucha programarguethatsalaried healthprofessionalswould haveno incentive toprovidequality care,theservices providedby millions of salaried healthworkersin thearmed forces and thepublichealthsystemcontradict thisposition. The community-basedhealthservice would operatemuch likeexistinghealthmaintenanceorganizations, inthatservice would be prepaid and the orientation would be toward a comprehensive battery of health services oriented toward prevention of serious illness as well as its treatment. Each community-based service would operate on a fixed budget, providing an incentive for cost containment. Within cost constraints, quality of care would be
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monitored and encouraged by a locally elected board. Local health services would also be responsible for mounting cornmunity health education programs. Community environmental factors affecting the health of citizens would also be targeted, Five references are provided,
Descriptor(s): Providers of health care services, Supply/availability of services, Publicly sponsored/mandated health plans, Policy initiatives, National health insurance (NHI).
does exist, is disjointed and inequitable, with no clear conception of the public good or public interest. The health care market is constrained by artificial restrictions on entry, by consumers' lack of price control, by bureaucratization of payment, by disorganization of physician supply, and by increased Federal inw)lvement in the market. It :is suggested that such a market is unamenable to present regulation and control approaches. Adjustment and amelioration of the present situation must come through the political process. A few footnotes, extensive references, and 26 tables are included.
Descriptor(s): Characteristics care costs, Policy initiatives.
of U.S. health care system, Health
907. Toward a National Health Policy. Public Policy and the Control of Health-Care Costs.
Kenneth M. Friedman and Stuart H. Rakoff. 1977, 257 pp. Availability: D.C. Heath and Co., Lexington, MA 02137.
This book contains papers focusing on health care policy in the United States delivered at the 1975 Annual Meeting of the American Political Science Association. Three characteristics of the health care system provide explanations for both the demands for public action and the targets of proposed action. These characteristics include the difficult to define nature of health, the size and rate of growth of private and public health care expenditures, and the disjointed nature of the suppliers of health care. These factors detrme a system in which traditional methods of public regulation and action may be insufficient to control problems and excesses in the system and provide a framework for viewing these papers. One of the most difficult tasks in dealing with health care policy is defining the outputs of the health industry. Although per capita health care expenditures are higher in the United States than in any other industralized country, there is no clear relationship between these expenditures and health outcomes. Measured by life expectancy and disability, our level of health is less than other nations, Clearly, the outputs of the medical care system can be measured -- e.g., hospital beds, patients treated, and new technology -- but the way these outputs relate to health is not decipherable. The politics of health is especially prone to overstatement, oversimplification, and underestimation of costs. What passes for health policy are in reality methods designed to deal with the cost, distribution, and access to health care, which at the same time are stimulating the further growth of the medical care industry in a way that does not guarantee improvements in public health, Regulation of medical care may not only be marginal in its affect on health, but may also lead to deterioration in the quality of public health. The problems of regulation and cost control are directly related to increased expenditures of third-party payers and the noncompetitive nature of the market. Policy, where it
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908. Toward a Physician Payment Policy. Evidence From the Economic Stabilization Program.
Jack Hadley and Robert Lee. Urban Inst., Washington, DC 20037 Social Security Administration, Washington, DC. 1978, 16 pp. AvMlability: Policy Sciences vl0 n2/3 p105-120 Dec 78.
Concern over the rising cost of medical care has focused policy attention on methods of paying physicians. Unfortunately, limits placed on fees paid by public medical care financing programs -- medicare and medicaid -- adversely affect those programs' primary objective: making office-based physicians' services available to the poor and the elderly at affordable prices. This suggests that a second policy instrument, controls on physicians' private charges, may be needed. The Economic Stabilization Program (ESP) provides the only recent U.S. experience with a system that constrained both physicians' private charges and public payments. The study used a two-part methodology. First, it statistically estimated equations for physicians' billed charges, medicare assignment supply, and medicaid supply for both ESP and non-ESP years. Sectmd, it changed the values of the two variables directly affected by ESP, the medicare reasonable fee and the physician's billed charge, in order to simulate what billed charges, medicare assignment, and medicaid outputs would have been in the absence of ESP. The simulations suggest that without ESP, private charges would have been higher and the quantities of services provided to poor and elderly patients lower than were actually observed. It is concluded that the ESP experience supports the argument for controls over both public and private fees so that medicare and medicaid beneficiaries can benefit from contained costs and from access to physicians' services. Footnotes, tabular data, and 23 references are given. (Author abstract modified)
Health Care Programs
Descziptor(s): Health care cost trends/projections, Cost containment efforts, Medical/surgical services, Policy initiatives, Methods of payment determination, Publicly sponsored/mandated health plans.
910. Trends in Medical Care Costs. Do HMOs Rate of Growth.
Lower the
Harold S. Luft. Social Security Administration, Washington, DC. 1979, 16 pp. Availability: Medical Care v18 nl pl-16 Jan 80. ' 909. Trends in Facility Use. An Evaluation of the Impact of Adverse Economic Conditions on the Status of the Poor.
Judith D. Bentkover and Claudia R. Sanders. Policy Analysis, Inc., Brookline, MA 02147 National Center for Health Services Research, Hyattsville, MD. Aug 1977, 197 pp. Availability: National Technical Information field, VA 22151, PB-273 313.
Service, Spring-
This report presents the results of an economic analysis of the impact of the 1974 through 1975 recession and the rapid increases in prices for the use of public community hospitals which accompanied it. The report describes characteristics of and trends affecting public hospitals, specifies an economic model which relates the output of public hosoitals to the unemployment and inflation experienced during the recession, and compares this experience with that of hospitals in the private sector. The purpose of the analysis is to increase the ability to deal effectively with the problem of minimizing the adverse effects of inflation and unemployment on the health status of the disadvantaged. The public community hospital sector is examined, and a statistical profile of the public community hospital is presented. After an overview of the entire U.S. public hospital system and a description of the significance of the public hospital, the findings of a field survey of public and private hospitals are related, Survey findings are then delineated in greater depth, and a formal model of public vis-a vis private hospital use is presented, The report then relates the results to the estimates of the effects of unemployment and inflation on hospital use. Study findings indicate that unemployment and inflation had a negative impact on public hospital use both in absolute terms and relative to the use of private hospitals. The reports mention implications of these findings, given policy alternatives which potentially could ameliorate the observed deleterious effects of adverse economic conditions on the health status of the disadvantaged. Iilustrations, over 100 references, appendices presenting methods of data analysis, and 30 tables are included. (Author abstract modifled)
Descriptor(s): Demand/utilization of health care programs, Nationai economic conditions, Inpatient facilities,
This paper compares trends in utilization and costs for health maintenance organizations (HMO) enrollees and comparison groups to discern the cost benefits of HMO's. Although total medical care expenses are generally lower for HMO enrollees than for comparable persons with other health care coverage, studies seldom examine whether HMO enrollees experience a slower growth of health care costs. Since changes in insured populations cause problems in examining costs and utilization, this study draws on data from groups of California State and Federal Government employees having multiple options in health insurance. Data from California State employees show that, while HMO enroUees had the lowest total costs (out-ofpocket and premium) in both study years, 1962to 1963and 1970 to 1971), their cost increases were only slightly lower than those of commercial indemnity or Blue Cross-Blue Shield plans. AIthough Blue Cross-Blue Shield and commercial plan enrollees experienced the greatest increase in premium costs, these costs reflected an increase in benefits. For Federal employees, cost data were gathered from 1961 to 1974 for HMO's in New York, Washington, D.C., California, Minnesota, and Hawaii, as well as from nationwide Blue Cross-Blue Shield plans and other plans. Although cost changes due to benefit changes are ignored, in general, HMO Federal enrollees experienced a 10 percent to 35 percent slower growth in costs. Moreover, a simultaneous rapid growth in benefits suggested an HMO decrease in administrative costs. HMO and Blue Cross-Blue Shield hospital utilization were also compared. While Kaiser-Oregon effected a hospital use decrease from 800 to 900 hospital days per 1,000 members to 450 by 1960, Blue Cross-Blue Shield utilization increased from 950 to 1,200 days per 1,000 members from 1955 to 1965, but showed a rate of decline similar to Kaiser-Oregon after 1970. Trends in ambulatory visits and ancillary care in Kaiser-Oregon are also discussed. The study concludes tentatively that HMO's have achieved a somewhat slower rate of growth in costs over time. In addition, the data show that long-term changes in HMO costs come not from improved productivity in providing a unit of service or micro-efficiency but from relative reductions in the number of services rendered. Thirty-three references, graphs, and tables are included.
Earlier version of this paper presented at the 105th Annual Meeting of the American Public Health Association, Washington, DC, Octo_r 30-November 3, 1977.
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Descriptor(s): Cost containment efforts, Prepaid plans, Health care cost trends/projections, Demand/utilization of health care programs, Private health care plans, Comparisons of health care programs.
911. Trends in Muitihospital
Systems. A Multiyear Compari-
912. Trends in State Administration
of Medicaid
Programs.
David F. Chavkin. Health Care Financing Administration, Washington, rice of Research, Demc,nstrations, and Statistics. 1979, 231 pp. Availability: Health Care Financing Administration, Publications,
Baltimore,
DC. Of-
ORDS
MD 21235.
SOn.
Montague Brown, Michael Warner, Paul R. Luehrs, Theodore E. Krueger and John N. Hatfield. 1980, 14 pp. Availability: Health Care Management Review v5 n4 p9-22 Fall 1980.
A survey conducted by the American Hospital Association in 1975, 1978, and 1979, and focused on the ownership, growth, and control of multihospital systems. Of the total 245 systems surveyed, 202 were covered in both the 1975 and 1979 survey, Results indicate that Government and medical center systems are much larger in average hospital size than the other systems, Only the investor-owned systems, on the average, have fewer beds per hospital than avergae U.S. community hospitals, Thirty-one percent of all community hospitals are multihospital systems. Of this number, 50 percent have Catholic ownership, 11 percent are investor-owned, and 12 percent are classified as other religious in ownership. The degree of management of a system of hospitals was considered to be an important distinction to make between the system orientation and the traditional concept of the independent community hospital. Analyzed data conform to most expectations in this regard. Overall, multihospital systerns were classified as managed and affiliated, and within those two classifications, centralized versus decentralized and coordinated versus autonomous management. In general, multihospital systems are growing in bed size and with regard to the number of hospitals per system. Those systems that actively manage their hospitals are clearly outpacing the more loosely affiliated multihospital systems. More thorough investigation is necessary to truly monitor the success of the systems approach, Cost effectiveness, quality of services, and access are major factors in determining if the trend toward systems configurations should be encouraged or discouraged. Eleven references and 14 tables are included in the article.
This paper presents an overview of current and proposed State medicaid policies as of late 1978. Specific aims of the study were to (1) identify potential changes and trends in eligibility criteria for medicaid; (2) compare the use and operation of the spenddown provision for the medically needy among States: (3) review current and potential benefit restrictions under medicaid; (4) report State activity to restrict payment of hospital, physician, or other services; and (5) ascertain the extent of coverage of the poor who are not eligible t'or medicaid. A total of 28 States are included in the report. Findings revealed that most States have been increasing income criteria for their medicaid programs, but this is generally not done on an ordered basis. Also, resource criteria have been increased since the advent of the supplemental security income (SSI) program, with most States increasing their resource criteria to SSI levels. However, Aid to Families with Dependent Children resource levels continue to lag far behind the adult aid categories. States have generally increased income lines on a limited basis, btlt operation of spend-down programs is not changing signiiieandy. In addition, only a few States are presently considering new limits on scope of services, but many States continue to apply limits on services that are unrelated to medical necessity. Physician fees are being limited in most of the States through several methods, including maximum fee schedules, noncurrent physician profiles, and negotiated statewide fee schedules. In several States, non-medicaid eligibles are eligible for a similar program. Also, several States have extensive State-administered or locally administered public hospital systerns to serve indigents and catastrophic health insurance financed by State funds. Substantial patient expenditures are required before eligibility for those programs is established. Reports on each of the Stat_: studied are included. Tables delineate coverage on specific categories of patients for each State. (Author abstract modified)
Health Care Financing
Descriptor(s): Descriptor(s): Health care costs, Inpatient facilities, Policy/ changes re health care, Evaluations/outcome of health care programs,
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Grants and Contracts
Report
Participan_Is in health care programs,
requirements, Medicaid, Non-participants in health grams, Limitations on coverage, Outcome/evaluation administration.
Health
Scrtcs.
Eligtbility care proof health
Care Pro,grams
913. Two Decades of Health Services. in Use and Expenditure.
Social Survey Trends
Ronald Andersen, Joanna Lion and Odin W. Anderson. National Center for Health Services Research, Hyattsville, MD. 1976, 387 pp. Availability: BaUinger Publishing Company, 02138.
Cambridge, MA
Patterns and trends in health care use in the United States are presented, based on household surveys conducted in 1953, 1958, 1963, and 1970. In the latest survey, 3,880 families were inter-
914. Type, Length, and Cost of Care for Home Health Patients. A Report of the Discharge Summary Feasibility Study.
Goldie Levenson. National League for Nursing Council of Home Health Agencies and Community Health Services, New York, NY 10019 1975, 15 pp. A vailabih'ty: National League for Nursing, New York, NY 10019.
viewed in their homes. One or more members of each family provided information on the use of health services, the cost of these services, and how this cost was met for the calendar year l970. In addition to data provided by the sample families, information was collected from physicians, clinics, hospitals, insuring organizations, and employers about the families' medical care and health insurance for the survey year. The design of the sample for the latest study over-represents the inner city poor, the aged, and rural residents. All tabular data are based on weighted distributions to correct for the oversampling of the above groups and to allow estimates to be made for the total noninstitutionalized U.S. population. Reported findings deal with health care use, expenditures, and health insurance experience. Differences in that experience are provided for various subgroups according to age, sex, income, race, education, and residence. The magnitude and rate of increase of health service expenditures are examined at the individual and family level. Overall, results show that more people are using more services as measured by visits to physicians and dentists and admissions to hospitals. There is now concern with overuse of health setvices. Health insurance is gradually paying for increasingly larger portions of total health service expenditures, particularly hospital expenses. The trend is toward extensive coverage of physician services, and a start is being made in covering other
Home health care agencies have traditionally kept ongoing statistics on their patients but, with a few exceptions, have been unable to relate this information to total care provided per patient. For the purposes of this study, a form was designed for use by clerks in recording discharge information. Eleven agencies provided 1,321 usable discharge forms for a l-month period in 1974. Although the initial decision was to include 1-day cases, these weere later separated and studied separately, so that the total number of discharges studied was 1,154, with 167 l-day cases excluded. Findings were summarized according to patient characteristics (age, sex, and living arrangements); source of referral and medical care; length of service, diagnosis, and discharge; and types of services provided. Data showed that the total service was primarily to patients above age 58. Of the total discharges, 63 percent were 65 years or over; 37 percent of the patients discharged were male and 63 percent were female. Family physicians provided medical care to 49 percent of the patient, 68 percent of the cases were referred by hospitals and 14 percent by private physicians, and 62 percent of the cases had been discharged from the hospital within 2 weeks prior to admission to home health. This feasibility study has shown conclusively that the discharge summary can produce valuable information to present a clearer picture of services provided and needed, information essential for work with actuaries and insurance un-
health goods and services. The use of services by lower income groups is increasing in relation to those of higher incomes. A serious undesirable trend is the decrease in physicians in inner city low-income areas and rural areas. Gaps between need and use of services remain, particularly for the poor, although these are narrowing. Implications of the findings for structuring the health services system are considered. The study methodology and instruments are appended; tabular data, about 36 references, and an index are also provided.
derwriters. The Council of Home Health Agencies and Commtmity Health Services of the National League for Nursing therefore recommends the inclusion of the discharge summary as part of the statistical reporting system of the home and community health agency. A new form is being designed which will include the addition of an indication of source of payment and outcomes. Five tables summarizing the data and an appendix containing the patient discharge information form are included.
Descriptor(s): Demographic features of population, Demand/ utilization of health care programs, Health care cost trends/ projections, Private health care plans, Participation in health care programs, Supply/availability of services, Facilities providing health care.
Publication No. 21-1589.
Descriptor(s): Health information/data systems, Home health services, Providers of health care services.
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915. Unemployment, Insurance Benefits.
Eligibility
Rules and the Loss of Health
916. Urban Fiscal Crisis in the United States, National Health Insurance, and Municipal Hospitals. John Craig and Michael S. Koleda. Robert Wood Johnson Foundation, Princeton, NJ.
Kenneth M. McCaffree and Suresh Malhotra. Battelle Human Affairs Research Centers Health and Population Study Center, Seattle, WA 98105 International Foundation of Employee Benefit Plans, Brook-
1978, 21 pp. Availability: International Jnl. of Health Services v8 n2 p329349 1978.
field, WI 53005 National Center for Health Services Research, Hyattsville, MD. 1977, 42 pp. A vailabih'ty: International Foundation of Employee Benefit Plans, Brookfield, WI 53005.
This study addresses questions of the financial vulnerability of municipal hospitals and the related issue of the continuing need for such institutions upon enactment of national health insurance (NHI). The financial status is closely linked to the financial situation of the cities in which the hospitals are located. Although the Nation's 40 largest cities are presently suffering from economic stress, few appear to be moving inexorably toward draconic cutbacks in city services. Furthermore, despite talk about the disadvantaged position of the public hospital in cornpeting for limited public funds, statistics indicate that the public hospital has actually done very well in maintaining its share of local government expenditures over the past 15 years. Data also
This booklet studies the effect of rising unemployment upon the loss of job-related health care benefits in Taft-Hartley health and weffare trust funds and discusses the implications of the findings for those involved in the design and operation of employee benefit trust funds. It describes the size of the International Foundation of Employee Benefit Plans member health and weffare funds by industry and region, and it discusses the comparability of the International Foundation members to all Taft-Hartley health and weffare funds in the United States. In addition, the differences in eligibility provisions and health benefits across funds by industry and region are detailed. These differences include trends in eligibility rules and serf-pay provisions over the last 10 years. The impact of the 1974-1975 recession on the health insurante coverage of workers covered by Taft-Hartley jointly trusteed health and weffare funds is analyzed, using (1) eligibility provision analysis, based on the eligibility provisions of unionmanagement jointly trusteed health and welfare funds, and (2) eligibility experience analysis, based on the actual eligibility experience during 1974-1975 of fund beneficiaries from a selected group of such funds across the United States. The report found that the impact of rising unemployment varied substantially across industries and regions. In addition, the percentage of unemployed who lost their insurance benefits depended, to a large extent, on the difference between RTED (Retention of Eligibility Duration) and MED (Maintenance of Eligibility Duration). The report also discusses several trustee alternatives in providing for the unemployed worker: change in the eligibility rules, self-pay and reciprocity, and supplemental insurance. A total of 21 tables and 31 footnotes are provided. (Author abstract modified)
suggest that hospital closings in New York City are indicative of a unique situation in that city rather than a national trend. As municipal hospitals provide services which no one else supplies, even ff only at a critical level, widespread abandonment of such facilities seems unlikely. As for the effects of national health service, the medicaid experience suggests that the impact of such insurance on utilization of municipal hospitals will depend on the type of insurance enacted. The more restrictive the eligibility requirements and the less innovative the reimbursement mechanisms, the less likely municipal hospitals are to be affected. But even under extensive universal plans, demand among the poor, especially for ambulatory services, is expected to increase so rapidly that municipal hospitals will remain important sources of health care to inner city populations. Despite this optimistic prognosis, municipal hospitals face difficult decisions relating to cost containment, (e.g., whether to reduce particular services or new technologies,) as well as to their role in the local health care network (e.g., whether to concentrate on upgrading ambulatory and emergency service rather than inpatient care). Over 40 references and tabular data are supplied. Descriptor(s): Reimbursement, Demand/utilization of health care programs, National economic conditions, Inpatient facilities, National health insurance (NHI), Eligibility requirements.
917. U.S. Health Insurance Industry. An Alternative Descriptor(s): National economic conditions, Private health care plans, Participants in health care programs, Eligibility requirements, Non-participants in health care programs.
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View.
Albert Woodward. 1978, 17 pp. Availabih'ty: International Jnl. of Health Services v8 n3 p491-
Health Care Programs
507 1978.
tion are needed to provide a stable basis for hospice fimding, staffing, and regulation. Particular attention needs to be given to
This article examines the history and structure of the U.S. health insurance industry and its effects on consumers. The health insurance industry can be characterized as a concentrated industry. It has evolved into its current structure as a result of certain historical conditions, particularly those following the Great Depression. The structure of the industry can be characterized as one in which a small number of insurers dominate on a
using existing resources, to standards and licensure, to reimbursement policies, and to regional planning, especially by Health Systems Agencies (HSA's). To date, hospice services have not particularly benefited from third-party payors. Atthough a few projects have been able to obtain third-party reimbursement from Federal and private payors, it is often on the basis of existing coverage for services included in hospice care.
national or State level. The product either is incommensurable for individual policies or is differentiable but sold noncompeti-
Two local Blue Cross organizations are conducting experiments in hospice reimbursement. One involves a home care program in Genesee Valley, N.Y., and the other an inpatient program in Washington, D.C. Continuing dialogue among providers, con-
tively for group policies. Size advantages and control of the market constitute barriers to entry, and the premium cost structure has been historically determined but is difficult to compare among types of insurers. This structure has had an effect on the way the industry sells insurance as well as on ever-increasing hospital costs which the consumer ultimately pays. Therefore, the health insurance pricing mechanism is that of a price leader setting a limit price. Health premium prices are higher than they would otherwise be without the current structure, and regulation has been ineffectual due to the historical domination by providers and insurers. In addition, the costs of hospital and other health care have increased beyond what would be expected as a result of a cost-pass-through. Tabular data and 37 references are given. (Author abstract modified)
sumers, and policymakers of various backgrounds is necessary to bring about appropriate hospice development in the United States. Twenty references are provided. (Author abstract modifled) Descdptor(s): Impact of third-party coverage, Facilities providing health care, Hospital services, Home health services, Long term care facilities.
919. Use and Expenditures Analyses From the National Medical Care Expenditure Survey. Descriptor(s): Health insurance industry, Economics of thirdparty payors, Competition/interaction among third-party payors, Impact of third-party coverage.
918. U.S. Hospice Movement.
Issues in Development.
Marian Osterweis and Daphne S. Champagne. National Inst. of Health, Bethesda, MD. Biomedical Research Support Branch. 1979, 5 pp. A vailability: American Jnl. of Public Health May 79.
v69 n5 p492-496
Hospices as alternative forms of care for terminally ill patients must be valued in terms of relieving unnecessary human suffering, not just in terms of dollars. Most hospice organizers base their plans on the British model, but differing cultural characteristics, health care delivery mechanisms, legal requirements, and financial constraints will require some adjustments for successful U.S. application. The appropriateness of this care for many patients, the best locations for hospices, or the effects of hospice development on the entire health care delivery system are not yet known. Experimentation with diverse forms and careful evalua-
Gail R. Wilensky. National Center for Health Services Research, Hyattsville, MD 20782 Aug 1978, 20 pp. A vMlabib'ty: National Center for Health Services Research, Hyattsville, MD 20782.
The objective and methodology of the National Medical Care Expenditure Survey (NMCES) are described. The NMCES is a major survey research project that will give a detailed description of the personal health care expenses and the level of health insurance coverage of the American people in 1977. The primary source of information will be interviews with 13,500 families which have been selected to represent the civilian noninstitutionafiz_ population of the United States. The most important analytical issues to be addressed with the NMCES data base are the cost, use, and financing implications associated with alternafive national health insurance proposals. Other issues which will be examined are the use and distributional implications resulting from medicare and medicaid programs, the distributional implications of the current tax treatment of medical expenditures, the social and private costs of various episodes of illness, and the implications of different measures of _ to care as they affect the patterns of and expenditures for medical care. In addition to
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these major analytical topics, a set of descriptive reports on the use mad costs ofhealth care for various soeiodemographic groups will be published. There will also be descriptive reports on the type and depth of insurance coverage cross-classified by the socioeconomic characteristics of the individual and the family, differential measures of access to care by socioeconomic charactea'isties, analyses of the use of care by severity and type of illness, and a descriptive summary of charges and sources of payment by type of visit, type of care, and type of setting. Some of the major issues which need to be resolved in establishing the empiricad framework which will be used to estimate the demand for medical care equations axe discussed. A system of equations is outlined for ambulatory care, hospital care, prescription drug use, dental care, and other medical care.
sions, the surgical rates under the 2 plans become very close (35.7 admissions and procedures per 1,000 personyears under the Kaiser plan and 37.6 under the Clinic plan). This lends some support to the hypothesis that the lower hospital surgery rates found under prepaid group practice plans may be due as much to the group practice form of their organization as to their prepaid feature. The study offers some possible reasons for this, including the hypothesis that surgeons in a fee-for-service group practice are less likely to be tempted to generate demand for their services than their solo practice colleagues and that peer presence tends to make for relatively conservative use of hospitals and especially of hospital surgery. In addition, it is suggested that the difference in the surgical ease mix under the two plans may be attributable not so much to differences in plan characteristics but rather to serf-selection. Footnotes, 6 tables, 16 refer-
Prepared for presentation at the Society of Government Economists, American Economic Association, Chicago, IL, August 29-31, 1978.
ences, and an appendix listing surgical procedures are included. (Author abstract modified) Descriptor(s):
Descriptor(s): Health care costs, Participation in health care programs, Demand/utilization of health care programs, Health information/data systems.
Cost containment
efforts, Medical/surgical
ser-
vices, Prepaid plans, Hospital services, Comparisons of health care programs, Demand/utilization of health care programs.
921. Use of Medicare Benefits Under HIP's 3-Yenr Incentive 920. Use of Hospital Services Under Two Prepaid Plans.
Reimbursement
Anne A. Seitovsky and Nelda McCall. Social Security Administration, Washington, DC. Health Care Financing Administration, Washington, DC. National Center for Health Services Research, Hyattsville, MD. 1979, 14 pp. Availability: Medical Care v18 n l p30-43 Jan 80.
Paul M. Densen, Ellen W. Jones, Isidore Altman and Joseph A. Miller. Harvard Center for Community Health and Medical Care, Boston, MA 02115 Social Security Administration, Washington, DC. Aug 1978, 94 pp. Availability: National Technical Information Service, Springfield, VA 22161, HRP-0029405.
This study compares the use of hospital services under two prepaid plans in California offered to Stanford University eraployees and their families. One is a Kaiser plan while under the other (Clinic plan), physician services are provided by the Palo Alto Medical Clinic, a multispecialty, largely fee-for-service group practice, and hospital services are covered by a Blue Cross policy. Using age-and sex-adjusted data, the hospital admission rate, excludiug deliveries, is higher under the Clinic plan (44.2 admissions per 1,000 personyears compared with 38.2 under the Kaiser plan), but hospital days per 1,000 personyears are almost identical (249.8 days under the Kaiser plan, 250.7 under the Clinic plan). The difference in the admission rates is due to the higher surgical admission rate under the Clinic plan (32.4 admissions per 1,000 personyears compared with 25.0 under the Kaiser plan). However, when surgical procedures performed in the hospital on a nonadmission basis are added to surgical admis-
I-41 ¢)
Experiment.
Based on use data and reimbursed charges, evaluation findings and implications are presented for the Health Insurance Plan of Greater New York (HIP), a medicare incentive reimbursement experiment. HIP beneficiaries were compared with non-HIP medicare beneficiaries for the baseline year 1969 and for the 3 years of the experiment (1970 to 1972). The financial incentive for HIP was a share in demonstrated '_vings," defined as differences between total reimbursed charges for HIP members with medicare coverage and a sample of the area's medicare population not enrolled in HIP. HIP's share in turn was distributed by formula among the HIP medical groups which succeeded in attaining project goals for their enrolled medicare members. HIP's evaluation was based primarily on data regarding the amounts of money reimbursed for services to HIP members and a comparison population and the use of particular types of bene-
Health
Care Programs
fits giving rise to the reimbursed charges. Study of Ihese data involved a comparison of the experience of all HIP members enrolled in medicare with that of medicare enrollees living in the same geographic area and a comparison of certain subgroups within the HIP enrollment. Findings show that in HIP's first year both total reimbursed charges and the rate of increase over reimbursed charges for the preexperiment year were less for medicare HIP enrollees than for non-HIP beneficiaries; however, differentials were not maintained in subsequent years of the experiment. The following conclusions are drawn: (1) it does not appear reasonable to expect to control total costs of care for members of a prepaid group practice in a system in which there are few disincentives to out-of-plan use of reimbursable services; (2) no single measure, programmatic or otherwise, is likely to have a major impact on total use and costs; and (3) for improvement in the delivery of health services to the elderly, there must be a mechanism for examining use and costs throughout the system, regardless of payment method. Twenty-eight references and 24 tables are provided. Ten additional tables are appended. (NTIS abstract modified)
composition, socioeconomic status, health status, attitudes toward seeking care, length of plan membership, thmily size, and satisfaction with the plan. However, when adjustment is also made for differences in physician affiliation, the Ka2ser rate becomes half a visit higher than the Clinic rate. This is because under both plans, members who have a specific plan physician as regular source of care use more services than those without one and because only 42 percent of Kaiser members compared with 87 percent of Clinic members stated that they had a specific plan physician. Six tables and seven references are included. (Author abstract modified)
Descriptor(s): Reimbursement, Medicare, Methods of payment determination, Outcome/evaluation of quality assurance, Participants in health care programs.
923. Use of Tax Subsidies for the Cost of Compliance Safety and Health Regulations.
Descdptor(s): Demand/utilization of health care programs, Prepaid plans, Physicians, Comparisons of health care programs, Service benefit plans, Plan design/program provisions (under health plans), Participants in health care programs, Medical/ surgical services.
With
Department of the Treasury Office of Tax Analysis, Washington, DC 20220 Jan 1981, 59 pp. 922. Use of Physician Services Under Two Prepaid Plans.
Anne A. Scitovsky, Lee Benham and Nelda McCall. Social Security Administration, Washington, DC. National Center for Health Services Research, Hyattsville, MD. 1979, 20 pp. Availability: Medical Care v17 n5 p441-460
May 79.
Use of physician services under two prepaid plans offered to Standford University staff is analyzed and compared in this study. The study population consists of 4,200 persons covered by the plans during the period from July 1973 through June 1974. One is a Kaiser plan; under the other (Clinic plan), physician and outpatient ancillary services are provided by a predominantly fee-for-service group practice, and hospital services are covered by a Blue Cross policy. The two plans provide much the same benefits, but in addition to the difference in their organization, they differ in their financial provisions. While the Kaiser plan has only a token copayment for office and home visits, the Clinic plan has a 25-percent eoinsurance provision applying to all physician and outpatient ancillary services. Despite these differences, the mean number of physician visits per year is the same for the two groups after account is taken of differences in age
A railability: Department of the Treasury, Office of Tax Analysis, Washington, DC 20220.
An analysis of the appropriateness of providing preferential tax treatment for expenditures made in order to comply with regulations of the Occupational Safety and Health Administration and the Mine Safety and Health Administration is presented. First considered is whether a subsidy for compliance costs could be administered fairly and effectively. The experience of tlhe Internal Revenue Service with tax subsidies provides valuable insights; the tax law currently provides preferential tax treatment for capital expenditures made in response to the Environmental Protection Agency requirements, and implementation has been difficult. Similar problems could be expected concerning proposed measures. An additional problem in the case of the regulations under consideration is the need to distinguish gross and net costs of compliance. Also considered herein are the economic effects of specific subsidy proposals. The most: efficient subsidy would be one that subsidizes net compliance costs of all kinds at the same rate. When the tax system is used to make subsidy payments the normal budget and appropriations processes are bypassed. It is suggested that special investment tax credits, rapid writeoffs for certain capital equipment, or the une of tax-exempt bonds to finance the equipment required to cornply with regulations are particularly inequitable and inefficient.
1-4_7
A statistical analysis of regulatory compliance costs illustrates the degree to which variability of costs would present problems
925. Utilization of Services of an HMO by New Enrollees.
of designing and implementing a compliance subsidy. For the 48 companies studied, the cost of environmental regulations amounts to about 60 cents per $100 sales dollars. By comparison, the gross cost of occupational safety regulation is about 4 cents
Ron N. Forthofer and Jay H. Glasser. National Center for Health Services Research, MD
per $100 sales dollars. Several footnotes, 23 tables and figures, and appendices of related data are included. (Author abstract modified) Descriptor(s):
Workers compensation,
Present legislation/regu-
lations, Policy initiatives,
924. Utilization and Cost of Mental Illness Coverage in the Federal Employees Health Benefits Program, 1973. Edwin C. Hustead and Steven S. Sharfstein. 1977, 5 pp. Availability: American Jnl. of Psychiatry v135 n3 p315-319 19 Mar 78. The use of mental illness benefits under the Blue Cross/Blue Shield (the Blues) and Aetna plan for Federal employees is examined. The Aetna plan sharply cut back its mental illness benefits in 1975. In 1973, mental illness benefits represented 7.4 percent of all payments under the Blues plan and 12 percent under the Aetna plan. The benefit for mental illness treatment under the Blues averaged $12.52 per person covered and was 7.3 percent of the total benefits for all conditions. Younger enrollees and their spouses tended to receive mental illness benefits primarily for outpatient treatment, while children and older adults received benefits primarily for hospitalization. These data raise key questions for claims review and peer review activities, which are critical in increasing the accountability of the insurance plan and therefore the maintenance of the mental illness benefit. The "medical necessity and appropriateness" of mental illness treatments must be demonstrated. In addition, cost-effectiveness studies are necessary; these can document savings resuiting from lower use of general medical services when mental illness services are provided. Coverage for mental disorders under national health insurance is dependent on accurate information regarding use and costs, on convincing demonstrations of the feasibility of quality and cost review for mental treatments, and on information indicating the effectiveness of these treatments. Tabular data and five references are provided, Descriptor(s): Cost/benefit analyses, Cost containment efforts, Government employee plans, Mental health services, Participattts in health care programs, Demand/utilization of health care programs, Policy initiatives,
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Hyattsville,
1979, 5 pp. A vadlability: American Jn]. of Public Health v69 n I 1 p l 1271131 Nov 79.
This study investigates whether there is a built-up demand for health services that surfaces when people enroll through a group plan in a health maintenance organization (HMO). The study population consists of newly enrolled subscriber units of the Kaiser Foundation Health Plan (Oregon Region). The utilization variables examined include the number of inpatient and outpatient contacts with the plan, the number and type of specific services performed, and the type of outpatient contact. The enrollees were followed over 12 quarters (3 years). The analysis showed that the first quarter stood out in three respects: (1) its average number of inpatient and outpatient contacts were the lowest of any quarter; (2) the mean numbers of radiology services and laboratory tests per outpatient contact were the highest during this quarter; and (3) the highest proportion of regularly scheduled contacts and the lowest rate of patient cancellation of visits also occurred during the first quarter. Hence, these data are not supportive of the idea of a built-up demand. Rather, they suggest that the enrollee requires some time to learn how to deal with the system; once a new member contacts the system, the system may perform a number of tests to obtain baseline data about the enrollee. Additional analysis did not suggest the prosence of any time trends in the utilization references are included. (Author abstract Descriptor(s): paid plans.
926. Variations
Demand/utilization
data. Tables and five modified)
of health care programs,
Pre-
in State Medicaid Programs.
Stephen M. Davidson. American Philosophical Society, Philadelphia, PA. Administration on Aging, Washington, DC. 1978, 17 pp. Availability: Jnl. of Health Politics, Policy and Law v3 nl p54-70 Spring 1978. This paper presents a construct which captures much of the variation in important characteristics of State medicaid programs and which can serve as a guide to the development of similar measures for other Federal or State programs. The meas-
Health
Care Pr_,_rams
ure, called the Medicaid Program Index (MPI), is applied to State medicaid programs in t970 and 1975. The MPI differentiates among State medicaid programs according to four importaut characteristics: inclusion of the medically indigent, the optional services covered, limitations on the provision of the basic services, and arrangements for paying providers. The intent is to describe with a single score a State's relative position with regard to the four components. The higher a State's score, the more closely it is thought to reflect the stated congressional intent of making necessary medical services available to people who otherwise would not be able to afford them. Summary results for 1970 show that the States vary considerably on these factors. As with any summary measure, variation can be masked by obscuring the sources of the differcmces, but the origin of interstate differences can be studied by examining each element of the MPI separately. Nonetheless, the MPI can be used to identify the extent of medicaid differences among the States, to account for those differences, to identify trends over time, and to suggest hypotheses to account for those trends. Six tables of data and 13 references are supplied. (Author abstract modified)
dollar value of services, number of dental visits, and types of treatment. All information was analyzed by computer using the Statistical Package for the Social Sciences and appropriate techniques to test the data's statistical significance. About 49.6 percent of eligible individuals used the dental plan in 1974, which closely approximated the 48.9 percent use rate shown in a 1973 National Health Survey of the U.S. population. Salaried employees and their famih'es were more likely than lower income famih'es to claim dental benefits. Sharp differences in use were noted among divisions of the corporation; these might be related to institutional factors. The average individual expenditure for dental care was $120.59. Contrary to expectations, higher income families did not spend greater proportions of their dental dollars on diagnosis, prevention, fixed bridges, or orthodontics. Tables and references are provided.
_'ptor(s): Dental services, Demand/utilization of health care programs, Private health care plans, Economic/commercial influences, Participants in health care programs, Plan design/ program provisions (under health plans).
Descriptor(s): Health information/data systems, Medicaid, Eligibility requirements, Claims administration, Present legislation/regulations. 928. Varintions ia Utilization
of Health Services by Children.
Barbara Starlield, Belt J. Van Den Berg, Donald M. Stein927. Variations in Utilization Dental Plan.
of a Multi-State
Company
Dennis H. I,everett, Stephen D. Hooper and Wanda N. Russell. 1977, 6 pp. Availabill"ty: American Jnl. of Public Health v67 n12 p11731178 Dec 77.
A study was conducted of family records and claim forms of a company-sponsored dental plan to determine the effects of age, income, and sex on utilization patterns. The rapid growth of dental insurance coverage can be attributed in part to the increasing availability of reliable data regarding use. The Sybron Corporation's plan is paid for and administered by the company with no contribution from employees. Any dentist may participate, and dentists are reimbursed according to their customary fees. Persons who have been employed by the company for at least 1 year and their dependents are eligible. The plan includes deductibles and limits on coverage. This study selected a sample of 1,896 individuals in over 600 families who were eligible for dental benefits throughout 1974 from the company's 48 divisions in the United States and Canada. Data were obtained from the dental program files on age, sex, employment status, income,
wachs, Harvey P. Katz and Susan D. Horn. Johns Hopkins Univ., Baltimore, MD 21218 California Univ. Child Health and Development Studies, Berkeley, CA 94720 National Center for Health Services Research, Hyattsville, MD. National Inst. of Health, Bethesdg MD. Biomedical gesearch Support Branch. National Inst. of Child Health and Human Development, thesda, MD. 1979, 9 pp. Availability: Pediatrics v63 n4 p633-641 Apr 79.
Be-
Data on children enrolled for several years in two separate prepaid group practices were analyzed to estimate variations in utilization patterns. Information on atypical use of medical care can be used to identify dissatisfaction, evaluate preventive care, and allocate resources. This research studied 1,204 children enrolled in the Columbia Medical Plan, a prepaid group practice affiliated with the Johns Hopkins Medical Institutions. The study covered the years from 1971 to 1976. Children were primarily from middle-class and upper-class families and averaged 5 visits pet year between ages 1 and 10 and 3 visits for ages 11 through 18. The second group studied consisted of over 2,800 children between 0 and 9 years old who were enrolled in the
1-419
Kaiser Foundation Health Plan in Oakland, Calif., between the years 1959 to 1967. For children aged 1 to 9, average use decreased progressively from 5.8 Visits during the second year of life to 2.2 during the 10th year. Families enrolled in the plan came from widely diverse ethnic, social, and economic backgrounds. Analysis of the data indicated that many more children tended to stay at the same level of use over time than would have been expected by chance alone. Overall, about 13 percent remained consistently in the highest third of the distribution of use and another 13 percent remained consistently in the middle or lowest third. Existing models to determine what factors infhience use of health services overemphasize patient characteristics and neglect the impact of the system. Consistently hiqh use could also be explained by chronic illness, dissatisfaction with services, and failure of the clinic situation to meet unrecognized psychosocial needs. Low use could be attributed to ignorance about preventive care. In insurance programs, large copayments discriminate against consistently high users, and deductibles deter low users. Thus, planners for a national insurance program should examine variations in use patterns so that all segments of the population can be served. Tabular data and 15 references
tional outpatient clinic and substituting a primary care group practice is described. The changes show that hospitals can provide cost-effective medicare to all patients, regardless of income. Some of the activities of the Robert Wood Johnson Foundation Program which provides funds to help institutions willing to establish primary care group practices are described. In addition, Black Friday November 2, 1975 is discussed; hospitals which had spent 11 months worth of expenditures were told by the State Health Department of New York that day that reimbursement rates would be made on the basis of 1974 rates, retroactive to January. The efforts of the city of Rochester and a 9-county area to develop a community prospective deal with this crisis are described. In another chapter, it is suggested that some of the problems with vertical integration are inherent in the cost, based reimbursement system. The final chapter explores the organizational challenges associated with vertical integration: defining a vertically integrated organization, dealing with administrative challenges, maintaining structure and control; coping with growth, eliminating deadwood, building teams, avoiding burnout, using organizational leverage, and more.
accompany
Report of the 1978 NationM Affairs.
Descriptor(s):
the article. Demand/utilization
Forum
on Hospital
and Health
of health care programs, Pre-
paid plans, Preventive services, Outpatient facilities, Participants in health care programs,
Descriptor(s): Supply/availability of services, Health care/services, Facilities providing health care, Outcome/evaluation of health administration, Voluntary initiatives.
929, Vertically Linked Health Organizations. 930. Veterans Administration Hospitals. An Economic Anal. B. Jon Jaeger. Duke Univ. Dept. of Health Administration, Durham, NC 27710 1978, 86 pp. Availability: Duke Univ., Dept. of Health Administration, Durham, NC 27710. Vertical integration, an organizational arrangement in which a firm controls all aspects of a product from transformation of raw materials to product provision, is described in its developing stages in several medical systems: Medical City Hospital in Dallas, Tex.; the Geisinger Medical Center in Danville, Pa.; Memorial Hospital of Almance County, N.C.; Forbes Health System in Pittsburgh, Pa.; and the Rush University System for Health, centered in Chicago, Ill. These systems range in size from the single hospital, to the Multihospital Rush System, which includes medical schools and a network of affiliated colleges covering a multistate area and providing students for vailous professional programs. In addition, the experience of Genesee Hospital in Rochester, N.Y., in closing down a tradi-
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ysis of Government Enterprise. Cotton M. Lindsay. American Enterprise Inst. for Public Policy Research Center for Health Policy Research, Washington, DC 20036 Nov 1975, 88 pp. A vailabib'ty: American Enterprise Inst. for Public Policy Research, Washington,
DC 20036.
This examination of the existing Veterans Administration (VA) medical system focuses on its ultimate objectives: (1) improving the welfare of veterans, and (2) insuring an adequate supply of health personnel. The existing system is seen as failing to satisfy the first objective due to inequitable benefits provision; inefficient distribution resulting from in-kind rather than monetary payments; and inefficient operation. An examination of the caseload and medical training in VA hospitals shows that doctors are unlikely to develop special expertise in the treatment of dutyrelated injury or illness. On the contrary, those cases occupying most of the space in VA hospitals are associated with advancing
Health Care Programs
age. The most equitable and efficient way to improve the lot of veterans is to pay military personnd more while they are on active duty. If the Congress is determined to provide benefits in the form of medical care, however, it may do this more equitably and efficiently by providing each veteran with paid-up hospitalization insurance rather than involving the VA in the operation of a separate hospital system. An appropriatdy designed hospital insurance program for veterans need not fall victim to the inflationary problems experienced by medicare and medicaid. Under a flat indemnity plan, subscribers opting for higher quality setvice would pay the full difference between the indemnity paid and the purchase price ofthe care. Such a variable cost insurance plan would permit differing qualities of care to be insured. It would retain the essential quality-control features provided by customers' monitoring in a market framework, while financial responsibility for most ofthe care would be borne by the VA. VA
more are very close to such action. The remaining 8 hospitals are in various stages offkscal impairment. One of the reasons for this fiscal decline in the voluntary hospitals is the general socioeconomic change occurring in New York City. A high rate of unemployment, the departure of the middle class to the suburbs, the increase in illegal aliens residing in the city, and the general deterioration of the city's tax base have contributed to a decline in consumer and public resources available for financing the city's voluntary hospitals. Another fiscal problem for the voluntary hospitals is the State's restrictive reimbursement policy, designed to limit revenues rec_ved by the hospitals so as to force hospitals to contain costs. From the State's perspective, the policy is working, since its health care costs have been curtailed; however, the State's policy, which narrows the gap between cost and charges, limits the ability of a hospital to achieve a gain on some cases to offset losses on cases whose reimbursement is
hospital facilities could then be transferred to community or proprietary control. Sales of these facilities would provide a not insignificant part of the trust fund required to administer a hospital insurance program for veterans as well as provide health care and hospitals for the community as a whole. Tabular data, chapter notes, and a table of contents axe provided. (Author abstract modified)
State-regulated. The unrelenting continuation of fiscal pressure on voluntary hospitals can only cause further deterioration and possible ending of the city's voluntary hospital system. Tabular cost data are provided.
AEI Series on EvMuative
Stua_'es, No. 23.
Descriptor(s): Economic/commercial influences, National economic conditions, Publicly sponsored/mandated health plans, Inpatient facilities, Reimbursement, Present legislation/regulations, Demand/utilization of health care programs, Funding/ financing of health care programs.
Descriptor(s): Health care cost trends/projections, Cost/benefit analyses, Cost containment efforts, Government employee plans, Publicly sponsored/mandated health plans, Participants in health care programs, Hospital services, Premium determination/underwriting, Source of premium payment, Policy initiatives, Inpatient facilities, Outcome/evaluation of quality assurance.
931. Voluntary Hospitals Suffer From Fiscal Erosion. Their Existence is Being Threatened. City Could Lose 5,200 Beds, 20,000 Jobs.
James C. Ingrain. 1979, 6 pp. Availability: Hospital Financial Management p32,33,36,38,40,41 Dec 79.
v33 n12
Results are reported from a study of the effects of fiscal erosion and restrictive reimbursement regulation on 11 representative voluntary hospitals in the Bronx, Brooklyn, Manhattan, and Queens (New York City). All of the 11 hospitals were functioning in the summer of 1979, even though 1 fded a petition for reorganization under the Federal Bankruptey Act and at least 2
932. Wasted Health Dollars.
Committee on Interstate and Foreign Commerce CLI.S. House), Washington, DC 20515 Mar 1980, 144 pp. A vailabih'ty: Printed for the use of the Committee on Interstate and Foreign Commerce.. This House of Representatives subcommittee met to determine whether wastage in expenditures for health care are due to insufficiencies in the current laws, whether the existing laws are being executed properly, and whether suppliers and providers of care are taking unfair advantage of American consumers and taxpayers. Among those testifying were representatives from the General Accounting Office (GAO) and the Department of Health, Education, and Welfare (DHEW), as well as the DHEW Sexretary and the Comptroller General of the United States. Additional material was submitted for the record by the GAO, including a breakdown of certain expenditures reported in the GAO analysis of hospital purchasing, and excerpts from the report "Medicaid Insuranc_ Contracts--Problems in Procuring, Administenng, and Monitoring." Among the DHEW submitted
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material were estimates of medicaid eligibility error rates for each State (determined by social security insurance for JulyDecember 1978). The Interstate and Foreign Commerce Cornmittee Subcommittee on Oversight and Investigation's memorandum on the Comptroller General's report on attainable benefits of the medicaid management information system was also submitted, 96th Congress second session, Serical No. 96-143. Descriptor(s): Cost containment efforts, Participation in health care programs, Funding/financing of health care programs, Medicaid, Health information/data systems,
933. Welfare Medicine in America. A Selected Research Guide (1964-77).
Bibliographic
same period. Data were derived from a systematic probability sample of household residents of the Harlem Hospital inpatient district population surveyed July 1967-June 1970. Welfare recipient respondents were more likely to perceive their health as fair or poor than were persons not on welfare. This difference persisted when the data were analyzed by sex, age, reported levels and type of illness, hospital days and number of stays, and current usual activity; usual activity was a major explanatory variable but only partially accounted for the relationship. It has been hypothesized that in achievement-oriented societies, illness may be used as justification for a culturally induced sense of personal failure to fulfill socially prescribed role obligations. The data are consistent with this hypothesis. Because the subsample respondents do not represent all welfare recipients but only those who were hospitalized during the prior year, the findings cannot be generalized to all those on welfare. Footnotes, tabular data and over 20 references are appended. (Author abstract modified) Presented at the 103rd Annum M_ting of the American Health Association, Clu'cago, IL, 1975.
Prakash C. Sharma.
Public
Sep 1978, 8 pp. Availability:
Vance Bibliographies,
Monticello,
IL 61856.
This bibiographic research guide lists selected literature on welfare medicine in America for the years 1964 to 1977. The 101 citations are arranged in two parts -- books and articles in journals and periodicals. Entries are listed alphabetically by author. Subjects covered include poverty in America and a national policy relating to health and poverty; medicaid and medicare, and abuse of these programs; social security; negative income tax; guaranteed income for the poor; free clinics; State medicaid programs; national health insurance; dental care; and more. No annotations are provided in addition to the standard bibliographic data. Public Admim'stration
Descriptor(s):
Series Bibh'ography
Publicly sponsored/mandated
health plans.
Jnl. of Pubhc Health v68 n9 p865-869
The self-defined health status of welfare recipients hospitalized for illness during the preceding year was compared to that of persons not on welfare but hospitalized for illness during the
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features of population,
935. What We Have (And Haven'0 tire Payment Programs.
Trends in
Learned From Prospec-
Jerry Cromwell. Abt Associates, Inc., Cambridge, MA 02138 Apr 1977, 40 pp. A vMlabill"ty: Abt Associates, Inc., Health Care Systems Area, Cambridge, MA 02138.
No. P-68.
934. Welfare Status, Illness and Subjective Health Definition. Edgar O. Prince. 1978, 5 pp. Availability: American Sep 78.
Descriptor(s): Demographic health status.
Evaluations of hospital prospective payment programs in Rhode Island, New York, New Jersey, Western Pennsylvania, Indiana, Michigan, and South Carolina are reviewed. Prospective reimbursement (PR) programs involve the setting of fLXedrates of payment to hospitals for periods of time without automatic adjnstment in an effort designed to motivate hospitals to contain costs. The discussion includes a critique of the methods and analyses used in previous research and consideration of the limitations under which the research was conducted. Hospital behavioral responses to PR are then summarized. The analysis examines changes in productivity, volume, factor prices, service adoption, intensity, quality, case mix, total and net revenues, and internal bureaucratic reorganization. The next section addresses the broader issues of market structure, conduct, and performance. The concluding section discusses key program issues of self-regnlation, negotiated versus formula rate setting, and some
Health Care PrL_._lt_,,
do's and don'ts of specific mechanics. One of the striking conclusions of the evaluations to date is that the conduct and performance of hospitals under PR are quite different, depending on the type of hospital and location. Further, results show that in only one of the evaluations was any statistically significant costcontrolling impact from PR documented. A total of 17 references and 21 footnotes are provided.
ed policy medicaid siderably provided.
formulation, and the peculiar characteristics of the program have caused medicaid HMO's to deviate confrom expectations. Seventy-three reference notes are (Author abstract modified)
Descriptor(s): Outcome/evaluation of health administration, Prepaid plans, Medicaid, Comparisons of health care programs.
Discussion Paper No. HCSA-IO. Presented at the Eastern Economic Association Meetings, Hartford, Connecticut, April 1416, 19ZZ 937. Who Are the Uninsured. Data Preview Descriptor(s): Cost containment efforts, Methods determination, Present legislation/regulations, evaluation of health administration.
of payment Outcome/
936. When a Solution Is Not a Solution. Medicaid and Health Maintenance Organizations.
Bruce Spitz. 1979, 21 pp. A vailabih'ty: Jnl. of Health Politics, Policy and Law v3 n4 IM97-517 Winter 1979. The development of HMO's (health maintenance organizations) which service medicaid clients exclusively is discussed in this article. Extraordinary increases in medicaid expenditures over the past few years have forced States to experiment with cost containment strategies that attempt to improve the efficiency of the existing system or create an alternative mode of delivery. The alternative has taken the form of the HMO in California, New York, Michigan, and several other States. HMO's are repeatedly described as a general solution to the health care crisis and a specific solution to the problems confronting medicare and medicaid. The potential incorporation of HMO's into medicaid has promised to improve the States' ability to accurately budget program expenditures, simplify management, eliminate abusive practices directly linked to fee-for-service practices (such as billhag for undelivered services or providing unnecessary care), and contain costs. At the same time, it has promised to increase access to mainstream medicine. However, experience has shown that HMO's created specifically for medicaid clients have displayed characteristics which differ widely from established prepaid group practices, contradict theoretical expectations, and vitiate the promise of HMO's. Such HMO's are severely compromised by unethical marketing practices, inadequacy of services, and excessive administrative costs. It is suggested that the political processes which created HMO's, the rhetorical claims which exaggerated the strengths of prepaid group practice and distort-
1.
Judith A. Kasper, Daniel C. Walden and Gail R. Wihmsky. National Center for Health Services Research, Hyatts_dlle, MD 20782 1980, 12 pp. A vailabih'ty: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782.
This analysis of the insured population as opposed to uninsured is based on the landmark study by the National Center for Health Services Research. Fourteen thousand randomly selected households in the civilian noninstitutionalized population over an 18 month period during 1977 to 1978 were surveyed, as were the physicians and health care facilites providing care to household members during 1977, and the employers and insurance companies responsible for their insurance coverage. National Medical Care Expenditure Survey (NMCES) data which were completed in September 1979, provide the most comprehensive statistical picture to date of how health services are used and paid for in the United States. Previously, data used to determine the extent of health insurance coverage in the United States were based on information usually gathered for other purposes, causing large variations in results. A major goal of the NMCES was to collect detailed information about health insurance for a large sample of the civilian noninsitutionalized population, and with such information, gain the ability to estimate the numbers of the insured population with greater accuracy. Results show that during the first months of 1977, 12.6 percent of the civilian noninstitutionalized population, or 26.6 million persons, had no health insurance coverage. Furthermore, coverage differed significantly according to various population characteristics. Among age groups, persons 18 to 24 were most likely to be without health insurance, and persons 65 years of age or older were least likely to be without it, attributable largely to medicare. No differences in coverage existed between sexes, although large differences were observed between whites and all other.;. Differenees among the four categories of perceived health were statistiearly significant, although relatively small. Persons with relatively few years of education were more likely to be, without
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coverage. When grouped by place of residence, the highest percentage of persons without health insurance coverage was found in predominantly rural areas, and was lowest in the South and West. Patterns of coverage varied within families. A detailed analysis of this variation is provided by breaking down coverage in families which contain uninsured members into five types. The sources and limitations of the data are discussed, and some technical notes are provided. The data are presented in three tables,
expenditures between joiners and nonjoiners. Their self-reported health ratings did not differ, and disability over the last 2 weeks was about the same. Physician utilization rates and inpatient rates were similar, except for the spouses of subscribers to one plan. However, the joiners were younger, had lived in Rochester for a shorter period, and had made less use of physicians in private practice. The three prepayment plans appealed to different population groups. The Network joiners were young, lowincome families, mostly from the city. The Group Health joiners were young families with few children who especially valued
NCHSR
availability, accessibility, and comprehensiveness. Health Watch joiners were older couples who preferred to use the traditional avenues to health care. Photographs, tables, footnotes, and 16 references are included. (Author abstract modified)
National
Health
Care Expenditures
Study.
Descriptor(s): Health information/data systems, Participation in health care programs, Participants in health care programs, Non-participants in health care programs, Demographic features of population, Private health care plans, Publicly sponsored/mandated health plans,
938. Who Chooses Prepaid Medical Care. Survey Results from Two Marketings of Three New Prepayment Plans.
Descriptor(s): Prepaid plans, Participants in health care programs, Comparisons of health care programs.
939. Who Initiates Visits to a Physician. Data Preview 3. Louis F. Rossiter.
Klaus J. Roghmann, J. William Gavett, Andrew A. Sorensen, Sandra Wells and Richard P. Wersinger. Public Health Service, Washington, DC. Regional Medical Program. 1975, 12 pp. Availability: Public Health Reports v90 n6 p516-527 Nov/ Dec 75.
National Center for Health Services Research, Hyattsville, MD 20782 DHHS/PUB/PHS-80/3278 Sep 1980, 12 pp. Availabih'ty: National Center for Health Services Research, Publications and Information Branch, Hyattsville, MD 20782.
This paper presents findings from two enrollment surveys of employees joining or not joining three newly marketed prepayment plans in Rochester, N.Y. The employees were surveyed during the first marketing period and during another open enrollment period 18 months later. The three plans were the Rochester Health Network Plan (Network), which offers services primarily in the inner city of Rochester; the Genesee Valley Group Health Association Plan (Group Health), sponsored by the Rochester Blue Cross and Blue Shield and providing care at a new health center in the northern part of Rochester; and Health Watch, sponsored by the Moaroc County Medical Society (New York), which renders medical services through the private offices of participating doctors. The new plans include outpatient hospital services, maternity care, and office visits to physicians. In the 1973 survey, the respondents were 149 subscribers (family contracts covering 568 persons) to the new plans and 224 nonjoiners (a total of 802 persons in their families). In the 1975 survey, the respondents included 326 joiner families (1,101 persons) and 145 nonjoiner families (483 persons). There were no significant differences in previous out-of-pocket health
This report shows the rc_lative frequency of visits to doctors initiated by patients as opposed to those initiated by physicians. Since physician income is generally based upon a fee-for-service arrangement, the distinction concerning who initiates the visit is an important one. From January 1 to March 31, 1977, about 60 percent of the physician visits in the National Medical Care Expenditure Survey (NMCES) were initiated by patients, while about 36 percent were initiated by physicians having made an appointment with the patient during a previous visit. The data for NMCES were obtained by surveying 14,000 randomly selected households. Results show that the percentage of physicianinitiated visits was higher for hospital outpatient departments than for visits in physician offices. Visits for older people were more likely to be initiated by the physician than visits for younger persons. Visits for a prenatal or postnatal examination were more likely to be initiated by the physician; those for an eye examination for glasses were primarily initiated by the patient. It should be noted that these findings show differences in who initiated physician visits by the type of visit, but arc not concerned with whether the visits were medically appropriate. Re-
1-424
Health
Care Programs
gional variations were small, and the percentage of physicianinitiated visits were less for persons who perceived their health as good or excellent. Furthermore, there is a major statistical difference among the percentage of physician-initiated visits by uninsured persons, those covered by private insurance, and those covered by medicare and medicaid. In summary, the percentage of visits initiated by the physician differs markedly according to the purpose of the visit, with selective preventive care visits largely initiated by the physician, except for eye examinations for glasses. Five tables are provided.
NCHSR
National
Health
Care Expenditures
Study.
Descriptor(s): Demand/utilization of health care programs, Irapact of third-party coverage, Participation in health care programs, Outpatient facilities, Physicians.
940. Who Pays for Pediatric Care. Out of Pocket and ThirdParty Party Payments for Physician Visits. Louis F. Rossiter and Daniel C. Walden. Nov 1979, 20 pp. A vMlabib'ty: National Center for Health Services Research, Hyattsville, MD 20782. Data from the National Medical Care Expenditure Survey are used to provide crude estimates of who is presently paying for pediatric health services. Average total charges are presented, as are the average proportions paid by the family, by private health insurance, by medicaid, and by other third-party payers for pediatric visits in the doctor's office. Estimates are differentiated by several individual and demographic characteristics, including age, color, region, residence, and education of parents. The estimates of charges for pediatric care and sources of payment presented are for office visits to see a medical doctor or doctor of osteopathy. Five types of visits are examined, each calculated as a percentage of all other visits: visits in which x-rays were taken; visits in which laboratory tests such as a blood test, urinalysis, or culture were done; visits for which care for a specific condition was sought; visits for which prophylactic shots and immunizations were administered; and visits for a general physical examination or checkup in the absence of a specific condition. The data show that during the first quarter of 1977, the average charge for visits of children to a physician in the doctor's office was $17.33. Variations occurred in the average share paid by the family, private health insurance, medicaid, and other sources. The family paid for most of the charges for the care of children in the first 3 months of 1977. Medicaid usually paid 10 percent of the charges, generally paying more of the total charge for nonwhite
children. Nonetheless, even among these visits, the family paid about 50 percent more than any other source, including medicaid. Private health insurance paid more in the West than in the South. In the first quarter of 1977, 15 percent of the children had at least one ambulatory visit to any type of medical provider for reasons other than a particular health condition, though less than 7 percent of the children received general physical examinations in this period. An appendix of technical notes and seven tables are included. Prepared for presentation at 107th APHA Annual l_Ieeting, MedicM Care Section, New York, NE, November 6, 1979.
Descriptor(s): Demographic features of population, Private health care plans, Publicly sponsored/mandated health plans, Preventive services, Medical/surgical services, Source of premium payment, Diagnostic services.
941. Why Do HMOs Seem to Provide More Health IVIaintenanee Services.
Harold S. Luft. Social Security Administration, Washington, DC. 1978, 29 pp. A vailabih'ty: Mllbank Memorial Fund Quarterly/Health
and
Society v56 n2 p140-168 Spring 1978. A great deal of discussion has focused on the supposed incentives leading Health Maintenance Organizations (HMO's) to provide more preventive health services than fee-for-service (FFS)recallcal practices. The usual argument is that because HMO's are responsible for all the medical care required by their enrollees, they will use preventive services to reduce the need tbr more expensive treatment at a later date. Counterargnments claim that HMO's also have the incentive to undertreat patients and thus might skimp on preventive care or do no more than FFS practitioners. From a comprehensive review of the literature, a comparison is made between the use of preventive services in HMO's and under conventional insurance coverage. The results at first glance seem contradictory. One group of data :supports the hypothesis that HMO enrollees receive more preventive services whereas a second group indicates no differences or points out that some HMO enrollees receive fewer preventive services. With a few exceptions, the contradictory results can be reconoiled by determining which individuals had insurance coverage for preventive visits and which persons were not covered. Such coverage is almost universal with HMO's, but rare with traditional insurance. Thus, those studies that involve a comparison between HMO enrollees and people with traditional insurance
1-425
are actually testing two variables, an HMO health maintenance effect and different t'mancial coverage for preventive care. These findings suggest that contrary to the rhetoric of health maintenance advocates, the greater use of preventive services by HMO enrollees appears to be attributable to better financial coverage for ambulatory visits, not HMO preventive care ideology. If more preventive service is the goal of policy, then complete ambulatory coverage under insurance is likely to be easier than enrolling the whole population in a system of HMO's. Although some preventive services are probably better than none, these services may be unnecessary and are almost always costly, Whether individuals prefer the extra risk in exchange for the potential savings will depend upon many factors, one of which is some evidence of the cost effectiveness of such procedures, Tables comparing costs and use of services and preferences for health care benefits are provided, along with 40 references. Presented
at the 105th Annual Meeting of the American
Health Association, 1977.
Washington,
tions were the geographical locations of the group health clinics, which are located near freeways throughout the St. Paul/Minneapolis metropolitan area and offer good access to 88 percent of the respondents. The new members' demographic characteristics are deemed to have played an unspoken role in their preference for the group health program; women outnumber men, the single outnumber the married, and most enrollees are professionally higher on the occupational scale than the general area population. These new members are young and upwardly mobile, have modest incomes, and are relatively settled. Because of their youth, they have changes jobs as they advance, so that 51 percent of those who joined the group health plan have only recently been employed in an organization where this program is offered as a fringe benefit option. Tabular data are given. From 'Sla'lls Development for the HMO Managers 1980's,' p 71-77, 1980, edited by Eugenia Warhol.
of the
Descriptor(s): Participants in health care programs, graphic features of population, Prepaid plans.
Demo-
Public
DC, October 30-November3,
Descriptor(s): Demand/utilization of health care programs, Third-party payors, Private health care plans, Comparisons of health care programs, Prepaid plans, Preventive services, Participants in health care programs.
943. Women, Work, and Health. Challenges to Corporate Policy.
942. Why New Enrollees Choose to Join Group Health Plan, Inc.
Diana Chapman Walsh and Richard H. Egdahl. Boston Univ. Health Policy Inst., Boston, MA 02215 1980, 259 pp. Availability: Springer-Verlag, New York, NY I0010.
John C. Kidneigh. 1980, 7 pp. Availability: Group Health Association Washington, DC 20036.
of America, Inc.,
This article reports the results of the study by Group Health Plan, Inc., of Minnesota to determine why newly enrolled members had chosen their plan for medical care. Questionnaires were sent to 2,764 new members enrolled between May 15 and August 15, 1979; the 902 returns were received (33 percent). The survey asked questions about advantageous features of the health maintenance organization, adequacy of the information supplied about the organization, access to clinics, and the demographics of newly enrolled members. Survey results indicated that the most influential factors in the choice of the group health plan were low total health care costs, the quality of health care provided, full service centers, comprehensive benefits, and accessiblity to service. Also important in the decisionmaking were the method and process of giving information about the group health plan combined with a spouse's influence. Further attrac-
1-426
As women enter the work force in unprecedented and increasing numbers, health issues concerning women become more important for employers. Congress recently passed the Pregnancy Disability Act of 1978, P.L. 95-555. Questions and concerns surrounding this law were the immediate stimuli for this volume which presents papers from a conference held on women, work, and health: challenges to corporate policy. Following an overview of the health of working women, discussion focuses on physical conditioning, strength, and stamina with two papers that examine the state-of-- the-art of strength testing and moving women into outside craft jobs. Next, social conditioning and the culture of the corporation are highlighted in papers that consider changing roles and mental health in women, employee health services for women workers, special needs of women in health examinations, and sex discrimination in group pensions. The question of reproductive potential and possible occupational hazards is examined in papers that focus on a legal perspective on workplace reproductive hazards, the biology of toxic effects on reproductive outcomes, and evaluation and control of embryofetotoxic substances. In addition, articles deal with fetotox-
Health Care Programs
icity as it affects the fight to work of fertile female employees and the control of hazardous exposures in the workplace. Other papers highlight a legal perspective on pregnancy leave and benefits and nonmedical issues presented by the pregnant worker, The final paper discusses future challenges to corporate policy, Chapter notes and a list of conference participants are included.
health issues, names en's health-related abroad, and sample er providers. About ed.
of feminist periodicals, a directory of wolnorganizations in the United States and evaluation schedules for physicians and oth600 references as well as indices are includ-
Praeger Special Scientific Studie.s. Springer
Series on Industry
and Health
Care, No. 8.
Descriptor(s): Participants in health care programs, Eligibility requirements, Health care/services, Exclusions from coverage, Present legislation/regulations.
944. Women's Health Movement. Feminist Alternatives to Medical Control.
Sheryl Burt Ruzek. National Inst. of Mental Health, Rockville, MD. 1978, 351 pp. Availability: Praeger Publishers, New York, NY 10017.
This study examines conflicts between professional health services and consumers from the feminist perspective. A discussion of the unique problems that the health care system poses for women emphasizes that the speciality of obstetrics and gyneeology forces women to enter the medical system through their reproductive organs and organizes their care accordingly. Abortion is named as the key issue for women attempting to assert control over their bodies and a catalyst for reform. An historical discussion of the women's health movement considers efforts to improve routine care, investigate effects of drugs and birth control devices, revise childbirth practices, and reduce unnecessary hysterectomies and mastectomies. Beginning with an analysis of social control functions of physicians, a description of sexism in the medical profession is presented. Typologies of health care settings are presented, ranging from the traditional-authoritarian to the radical-feminist. Beliefs regarding the appropriate social distribution of medical knowledge, the division of labor, access to curatives, and management of services are discussed as they relate to these settings. Strategies commonly used to iraprove health care are reviewed, including health movement organizations, educationalprograms, legislation, alternative health care institutions, and self-help techniques. The women's health movement is viewed in the context of other reform groups, and conflicts stemming from class and status differences among feminists are identified. The final chapter discusses how the women's health movement broadened its scope and planned effective strategies to affect changes in medical care. The appendices conrain a list of programs and conferences conducted on women's
Descriptor(s): Voluntary initiatives, Demand/utilizat:ion of health care programs, Supply/availability of services, Physiclans, Participants in health care programs.
945. Workers' Compensation Diseases.
and Work-Related
Illnesses and
Peter S. Barth and H. Allan Hunt. 1980, 391 pp. Availability: Massachusetts Institute of Technology, bridge, MA 02139.
Cam-
This book deals with occupational diseases and the compcnsation of workers who are disabled by them. The book bridges two bodies of knowledge -- the fields of occupational health and workers' compensation. Occupational diseases are becoming recognized as a serious health problem as science uncovers the existence of previously unsuspected hazards in the workplace and reveals that many illnesses once thought to be ordinary diseases of life are in fact traceable to conditions of employment. This book establishes that the existing system of workers' cornpensation in the United States is inadequate to meet the needs and claims of workers who suffer severe disabilities caused by contact with pesticides, vinyl chloride, asbestos, and a host of other industrial substances. While the system presently encorepasses injuries or death incurred directly on the job or in the workplace, it presents considerable obstacles for workers seeking compensation for diseases of complicated origin involving long latency periods. Examples of court cases, includinq data from nationwide surveys of closed court cases, illustrate that major reforms of the existing workers' compensation laws are called for. Separate chapters are devoted to the incidence of occupational disease, the critical issue of etiology and diagnosis of disease, and occupational disease and the law. One chapter compares the handling of cases on a State-by-State basis The approaches to workers' compensation practiced in Eng!and, France, Belgium, Denmark, Switzerland, Germany, the Nctherlands, and Ontario, Canada, are also compared to provide insights into policy alternatives that eliminate the need fox"costly adversary proceedings and litigations. The book concludc_ widl an overall assessment and recommendations for reform. ('tJ,lJler
notes contain references. Appendices match worker classifications with the kinds of diseases associated with each group. An index is also provided. (Author abstract modified)
Descriptor(s): Workers compensation, Source of premium payment, Present legislation/regulations, Health care cost trends/ projections.
Descriptor(s): Trends in health status, Workers compensation, Present legislation/regulations, Comparisons regarding foreign health policies.
946. Workers' Compensation Insurance. Recent Trends in Employer Costs. Martin W. Elson and John F. Burton. 1980, 6 pp. A vMiabih'ty: Monthly Labor Review v 104 n3 p45-50 Mar 81. This article presents estimates of employers' costs of workers' compensation insurance purchased from private carriers or State funds. It covers 47 States, and the data are valid as of July 1, 1978. The purpose of this investigation is to determine whether variations in workers' compensation insurance premiums influence employers' decisions to locate establishments in certain areas and whether recent trends in premium levels indicate any reluctance by States to boost program benefits and costs for fear of losing employers to lower cost jurisdictions. Employers' costs for workers' compensation insurance may be measured in several ways. For purposes of this study, three combinations of employers that account for substantial percentages of the national payroll were selected, and the costs of insurance for employers were determined for each State. This procedure makes it possible to estimate insurance costs which employers would encounter by moving among the States. Insurance rates for each type of eraployer may be obtained from a State manual. Information on employers' costs of workers' compensation insurance is available for 45 types of employers for selected years since 1950. Data analysis reveals that on the average, employers' premimums for workers' compensation insurance have increased sharply since 1972, and cost differences among jurisdictions have widened considerably. Many factors outside the scope of this study influenee the level and trend of premiums, including the extent of litigation, differing legal interpretations of statutory provisions, the local cost of medical and rehabilitation services, and the approach used by the State to compensate permanent partial disabilities. However, recent increases in the multistate premium averages may also be explained in part by the States' modification of their programs in response to recommendations contained in the 1972 Report of the National Commission on State Workmen's Compensation laws. If the growth in interstate cost differentials since 1972 is related to unequal rates of improvement in State statutes, the ease for Federal minimum standards for workers" compensation is considerably strengthened. Five tables, one chart, and 16 footnotes are provided.
1-428
947. Working Papers on Major Budget and Program in Selected Health Programs.
Issues
Congressional Budget Office, Washington, DC 20515 Dec 1976, 143 pp. A vaJlabih'ty: Superintendent of Documents, Government Printing Office, Washington, De 20402, order number 052-070-03810-1. This collection of nine working papers deals with major budget and programmatic issues in a number of federally supported health programs. The fv:st section consists of seven papers analyzing proposals made t_ythe President in the fiscal year 1977 budget to modify the str_cture of existing health programs or significantly alter the level of Federal support. The analyses focus on the following issues: (!) medicare catastrophic proposals, (2) short-term options for the medicaid program, (3) shortterm options for Categorical Health Grant Programs, and (4) hospital cost increases. The issues of Public Health Service hospitals, Federal support for biomedical research, and Federal support for health manpower development are also discussed. For each issue, a sumnmry of the proposal, an analysis, and a consideration of alternative options is given. The evidence is supported by detailed statistical and cost information. The second section contains two papers which analyze the operation and effectiveness of two major Federal health programs designed to improve the delivery of health ca:re services: the Health Maintenance Organization (HMO) and medicaid's early and periodic screening, diagnosis, and treatment program (EPSDT). All analyses are considered working papers only, designedto focus discussion on major budget issues in Federal health programs. They contain program options, but no recommendations. Prepared for the Task Force on _Human Resources mittee on the Budget (U.S. House).
of the Com-
Descriptor(s): Policy initiatives, Medicare, Health care costs, Medicaid, Cost containment efforts, Prepaid plans, Inpatient facilities.
948. Working With the Insurer. Jeffrey A. Prussin and Jack C. Wood. 1975, 15 pp. Availabill"ty: Topics in Health Care Financing
v2 nl p65-79
Health Care Programs
Fall 1975. This article on working with the insurer reviews hospitals' and physicians' responsibilities to patients, provides an explanation of insurance language, discusses the right of the hospital and the physician to payment and the problem with slow-pay and no-pay insurer, and outlines data requirements. The article notes that patients generally rely on their physician to determine the needed services and arrangements and discusses a Pennsylvania case in which a physician was held liable for unnecessary services. It is contended that the physician and hospital are not liable for erroneous interpretation of the patient's insurance coverage unless they promise that the provided care will not cost more than a fixed amount above the amount paid by the patient's health insurance plan. Some of the principal problems encountered by hospitals and physicians in analyzing and understanding insurance contracts are identifying the beneficiary, defining the loss, and determining the scope of covered services and exclusions. Problems that may arise under the scope of covered services are reviewed, including contract ambiguity, restriction of coverage to certain specific diseases, charges for multiple surgical procedures, hospital coverage limitations, exclusions based on preexisting conditions, interpretations of 'incurred' expenses and 'performed' services, and the coordination of benefits. The article also examines the right of the hospital and the physician to payment, citing a Nebraska case in which the Supreme Court ruled hospitals need not repay overpayments made in error by insurers; suggests some solutions to the problems of slow-pay and no-pay insurers; and discusses information that should be included on standard data sets maintained on each patient and legislation to standardize claim forms. Twenty-eight references are given. Descriptor(s): Third-party payors, Private health care plans, Plan design/program provisions (under health plans), Exclusions from coverage, Reimbursement, Mandated benefits.
1-429
H. Research 8001. Alternatives Initiatives.
to Institutional
Care. An Analysis of State
Gail E. Toff. George Washington Univ. Intergovernmental Health Policy Project Washington, DC 20006 Health Care Financing Administration, Washington, DC. Estimated completion date Jtm 1981 In this study of Institutional Care Alternatives, IHPP will present an overview of key state demonstration projects, with special emphasis on innovative nursing home programs, promoting the continuity of care/case management approach. The work will center on the organization, coordination, and financing arrangements of these programs and contrast program outcomes with current health/welfare cost issues. An effort will also be made to compare these experiences with other institutional programs, as well as with the current literature. Emphasis will be placed on total system effects relative cost benefits, impacts on state budgets and implications for Federal legislation. Descriptor(s):Outpatientfacilities, Cost/benefitanalyses, initiatives, Health care cost trends/projections.
Policy
8002. Aspects of Medicare in Colorado.
Stanford Research Inst. Menlo Park, CA 94025 Health Care Financing Administration, Baltimore, MD. Estimated completion date 1981 In 1978, a 3 year grant was awarded to analyze a variety of issues, using medicare paid claims from Colorado Blue Shield for 1974 to 1978 as data. These issues include the impact on physician pricing, service behavior, and use of medicare services resuiting from changeovers from a 10-locality system for prevailing charge determination to a single Statewide area; significant factors in determining assignment of medicare claims; effects of private complementary insurance on use of medicare services; utilization patterns and characteristics of selected groups such as joint medicare-medicaid beneficiaries, beneficiaries in the first year of eligibility or last year of life, and continuously enrolled eligibles; the extent of out-of-plan utilization of
in Progress
services by medicare beneficiaries who are enrolled in Health Maintenance Organizations (HMO's); medicare beneficiaries' reasons for joining HMO's, their satisfaction with the HMO's, and their utilization of services. (Author abstract modified)
Descriptor(s): Supply/availability of services, Prepaid plans, Medicare, Medicaid, Impact of third-party coverage, Demand/ utilization of health care programs, Methods of payment deterruination, Participants in health care programs.
8003. Cancer Insurance, A Review of Publicly Available Documents.
Federal Trade Commission Washington, Estimated completion date 1981
DC 20850
This investigative report includes material taken from the November 1978 House Select Committee on Aging hearings on cancer insurance. Information was presented by numerous state insurance departments as well as the Department of Health and Human Resources third cancer survey (1979). The report coneluded that: 1) consumers are better served by general health insurance policy since other chronic diseases(i.e. heart disease, diabetes, etc.) occur more frequently, posing greater health risks and heavier health expenses; and 2) insurance agents often use sophisticated promotional techniques that misrepresent the statistical occurence of cancer, exploiting an individuars fear of cancer. The FTC initiated the report upon receiving numerous complaints about cancer insurance; the fastest growing, and reportedly, the most profitable line of insurance. The report was completed in February, 1980 but has not yet been rele_ed publicly.
Also see "Cancer Insuranee. Exploiting Fear for Profit. An Examination of Dread Disease Insurance. ""
Descriptor(s): related plans.
Health
insurance
industry,
Non=employment
II-1
8004. Capitation for Pharmacy Services.
Descriptor(s): Diagnostic tary initiatives.
services, Preventive
services,
Volun-
Joseph Norwood. Iowa Univ. Health Services Research Center Iowa City, IA 52242 Estimated
completion
date 1981
8007. Consumer Preferences
for Health Insurance.
This is a 3-year study dealing with taking medicaid payments for pharmacy services and changing to a pro-payment system from a system of paying for each prescription. - Descriptor(s): determination.
Pharmaceutical
8005. Characteristics Health Insurance 10022 Estimated
of payment
Higher deductibles and coinsurance rates are being proposed for national health insurance programs to control overutilization of services. To determine if these proposals are acceptable policy
of Group Health Plmss.
Association
completion
services, Methods
of America
New York, NY
date Apr 1981
HIAA is preparing an in-depth profde of six Medical Exponditures Policies in force as of the end of 1980. The report will highlight the extent of benefits which feature cost-containment provisions in insurance opinion and ambulatory
plans such as pre_admission, care services,
second
Descriptor(s): Cost containment efforts, Plan design/program provisions (under health plans), Health care/services.
8006. Clinical Efficacy Assessment Program. American Coll. of Physicians Philadelphia, PA 19104 John A. Hartford Foundation, New York, NY. Estimated completion date Jan 1984 This 3-year project will evaluate the usefulness of nonsurgical diagnostic tests and procedures, such as pulmonary function testing, cardiac stress testing and intermittent positive pressure breathing. The project will help to control the rising cost of medical care through improved education regarding nonsurgical procedures. The granters will also monitor the work of other organizations engaged in studying medical reform and will establish contact with experts in medicine and science, convene review panels, submit reports and evaluate recommendations regarding medical care. The Clinical Efficacy Assessment Program (CEAP) is a followup to the ACP's 1976 Medical Necessity Project which made numerous recommendations regarding medical care endorsed by the medical community and contributed to significant savings in the cost of medical diagnostic tests.
11-2
S.U. Williams, J. C. Hersey, H. Kunreuther and J. S. Schwartz. Pennsylvania Univ. National Health Care Management Center Philadelphia, PA 19104 Estimated completion date Jun 1981
alternatives, a measure of consumer's utilities for selected components of health insurance policies was developed. Personal interviews were conducted with over 400 employees of the University of Pennsylvania who were randomly selected after stratification by job level and by the number of people covered. Participants were asked to make pairwise comparisons of hypothetical policies, each of which had different coverage, and prices, Each participant compared one policy that was similar to his/her existing policy with 5 of 50 alternative policies according to a fractional factorial design. Conjoint analysis of the main effects and of selected first-order interactions was performed to measure the relative utilities for each component. Change in utility relative to change in actuarial value varied widely across age and lower coinsuranee limits more than lower deductibles and coinsurance rates. This contrasts with studies of other forms of insurance, which show that consumers discount coverage for rare events and overvalue coverage for common events. To conclude, before adoption of a national health insurance program, a national study is necessary to determine the acceptability of alternative insurance policies designed to discourage unnecessary utilization of service..
Descriptor(s): Natioual health insurance CNHI), Comparisons health care programs, Deductible/coinsurance.
of
8008. Cost Effect and Benefits Associated with Domiciliary Care and Intermediate Nursing Care.
Douglas Holmes. Community Research Applications, Inc. Weston, CN 06883 Administration on Aging, Washington, DC. Estimated completion date 1981
Health Care Programs
The study is designed to provide data on the cost effects and benefits associated with domiciliary care and intermediate nursing care for older people. Little is known about the impact of these modalities on persons with different needs and characteristlcs. Data are to be collected on approximately 1000 clients/ residents from 42 programs/facilities _14 DCFs, 28 ICFs (14 proprietary and 14 voluntary)t_ in six counties. Five counties will be selected at random from among a lx)ol of counties which have all of the above program facilities, and one county will be selected at random from a CRA listing of the 10 percent of counties in the United States with the highest proportion of minorities, At each program/facility, data will be coUected on approximately 30 clients, 15 of whom will be new admissions during the course of the study. All measures will be taken on two occasions in a design which allows for time series analysis. Data collection will use OARS, the Philadelphia Geriatric Center Morale Scale, facility questionnaires, and service receipt questionnaires. Descriptor(s):
Intermediate
Despite a continued increase in per capita expenditures on medicad services, the age-adjusted death rate has failed to decline significantly. Specification of the factors important to health and the determination of the degree to which these factors affect health are issues open to debate. This project seeks to determine the interactions between economic, social and behavioral variables in the determination of health status. It examines the effect of each input individually as well as in conjunction with the others. Not only will this knowledge be valuable in formulating policy, but also it may be beneficial in causing individuals to alter their behavior by providing information on the subsequent effects of their actions on their health and the trade-offs they may be unknowingly engaged in through their present choices of behavior.
Descriptor(s):
Preventive services, Trends in health statns.
care facilities. 8011. Effectiveness of Alternative Approaches to Utilization Review of Physicians Office Practices.
8009. Diagnosis Related Group (DRG) Management tion System Studies.
InformaS. Schwartz, S. Williams and J. Eisenberg.
Health Research and Educational Trust of New Jersey Princeton, NJ 08540 Kellogg (W.K.) Foundation, Battle Creek, MI. Estimated completion date Dec 1983
Pennsylvania Univ. National Health Care Management ter Philadelphia, PA 19104 Estimated completion date Jan 1982
Two study sites are being tested in the development and iraplementation of the DRG (Diagnosis Related Group's)payment system, as part of the DRG Management Information System Studies. Attention is being paid to the development of staff and staff experience in processing medical record abstract data. The first study site will focus on investigating abstract and billing data available in a large hospital to determine appropriate diagnostic groupings and the second study site will assess the costs of data collection and preparation required by the DRG system, Descriptor(s): Methods of payment determination, Reimbursement, Hospital services, Health information/data systems,
8010. Economic, Social and Environmental Determinants of Adult Health. Some Implications for Future Research and Policy. C. J. Carlton. Pennsylvania Univ. National Health Care Management ter Philadelphia, PA 19104 Estimated completion date Jul 1981
ten-
Cen-
One of the major methods undertaken in an attempt to control health care costs has been the implementation of various utilizatioo review (UR) programs. While utilization review is expensive, its effectiveness is unclear. Therefore, it has been suggested that combining UR with incentives acting directly upon the physician would result in a more effective system. While most UR programs have concentrated on reducing hospitalizations (primarily through reductions in length of stays), little attention has been paid to the general problem of overutilization of services, despite the fact that such areas are thought to ao_ount for a substantial portion of unnecessary medical expenditures. UR programs have also been plagued by high costs of operations, stemming primarily from the expense of detecting overutilization. Thus, the need for efficient case finding techniques has been raised. This study aims to measure the effect of the UP, program developed by Pennsylvania Blue Shield (PBS) on the provision of physician services. The PBS UR system incorporates a computer based data system to facilitate screening of likely overutilizing physicians, covers all physician services regardless of their site of provision, and imposes financial penalties upon doctors found to be overut'dizing services. The project will measure the impact of the two major LIP, programs PBS employs; one which depends only upon notification of physicians with the highest utilization rates and is primarily educational in nature, the se-
II-3
cond which applies financial disincentives to overutilizers through a traditional peer review process. It is predicted that the stronger the intervention and the resulting incentives acting upon the physician, the greater the impact. The results of this study should have significant impact upon government regulators, planners, and legislators, insurers, hospitals, and providers, The project will serve as a model for the immediate implementation of some components of the system by other insurers, Descriptor(s): Cost containment surgical services,
8012. Effectiveness American 20009 Estimated
ltealth
of Certificate Planning
completion
efforts,
Physicians,
Medical/
of Need Programs.
Association
Washington,
DC
date 1981
cians, closely resembling MPR's concurrent 1979 Resurvey of Private- Practice Physicians. Data collected in the NHSC survey and in the 1979 Resurvey will be used to determine the changes in care delivery attributable to the placement of NHSC physicians and to investigate the existence and possible causes of differences in productivity both among NHSC physicians and between NHSC and private-sector physicians. The second part entails another survey of NHSC physicians, modeled on the National Ambulatory Medical Care Survey (NAMCS). Data obtained in this survey will be used to examine the morbidity profiles of patients seen by NHSC physicians and the treatment provided to those patients. The NHSC patient-private-sector physicians. That analysis will determine whether there are differences in the two groups that help explain any productivity differences found in Part I. Part III will analyze microdata from the Health Interview Survey (National Center for Health Statistics) from 1974 to 1978, conduct surveys of two communities, and conduct site visits to these, communities and their respective NHSC sites. The purpose is to determine whether NHSC physician placements have resulted in identifiable changes in care access and health status for shortage- area populations and their
An ongoing special analyses survey dealing with the health planning agencies and certificate of need process is being conducted
component
by the American Health Planning Association. Routine questions and special topical surveys will be directed toward the health systems agencies (HSA's) and the SHPDA's to determine the status, issues, and problems encountered during the certificate of need and review process.
Descriptor(s): Supply/availability of services, Physicians, come/evaluation of quality assurance.
Descriptor(s): Present legislation/regulations, come of health care programs,
8014. Evaluation of the National Long-Term Care Channeling Demonstration.
Evaluations/out-
8013. Evaluation of the Effects of National Health Service Corps Physician Placements on Medical Care Delivery in Rural Areas.
Barbara H. Kehrer. Mathematica Policy Research, Inc. Princeton, NJ 08540 Department of Health and Human Services, Washington, DC. Office of Planning, Evaluation, and Legislation. Estimated completion date Jun 1981 Mathematica is performing this study to design, conduct, and analyze the results of a three-part evaluation of the National Health Service Corps (NHSC) program in rural areas. The purposes of the evaluation are to examine the productivity of Corps physicians and to measure the impact of the care they provide on the overall patterns of care delivery and on the availability of care to populations in health manpower shortage areas. The first part of the study includes a survey of NHSC primary-care physi-
11-4
subpopulations. Out-
Peter Kemper, Ralph L. Andreano and George Carcagno. Mathematica Policy Research, Inc. Princeton, NJ 08540 Department of Health and Human Services, Washington, DC. Office of the Secretary. Estimated completion date Mar 1982
Mathematica Policy Research was recently awarded a contract by the U.S. Department of Health and Human Services to evaluate, over a 5-year period, the effectiveness of new methods for providing long-term care services to the functionally impaired. This nationally important project will evaluate different approaches to the delivery of long-term care services that will be implemented in 21 demonstration sites across the country. Potential clients will be allocated by strict random assignment either to the channeling agency or to a control group, according to an experimental design using randomly selected treatment and control groups. This will identify the effects in clients of channeling as distinct from the effects of other components of the health-care environment. Total projected sample size is in excess of 10,000 persons, constituting 6,800 experimentals and
Health
Care Programs
3,400 controls. Several types of data collection will take place over the first three years of the implementation. Current evaluation plans call for functional assessments of individuals by inperson interviews conducted every six months for experimentals and once a year for controls. Information on health-care provid-
Descriptor(s): Long term care facilities, Health care cost trends/ projections, Publicly sponsored/mandated health plans.
ers will be collected from an annual mall questionnaire plus provider records extracted every three months. Data on provider
8017. Foreign Hospitals Reimbursement Systems.
costs will come from cost ease studies conducted annually using provider records. Qualitative data on the actual implementation of channeling will come from project narratives undertaken every six months.
Columbia Univ. New York, NY 10027 Health Care Financing Administration, Baltimore, MD 21235 Estimated completion date 1981
Descriptor(s): Therapeutic services, Long term care facilities, Outcome/evaluation of quality assurance,
8015. Expanded Health Care Coverage Alternatives. Arnold A. Budin. Delaware Bureau of Health Planning and Resource Development New Castle, DE 19720 Estimated completion date Jun 1981 The Delaware Bureau of Health Planning and Resource Development is conducting a study of various financing options available to the State to more adequately provide health care services to the medically indigent population. A special task force has been assigned to review various components of optional versus mandatory coverage for the medically indigent. They have identiffed 21 public health options for medicaid reimbursement including: 1) medicaid options for new recipients, 2) fully State funded options such as pharmacy and dentistry services and 3) optional coverage for medically needy recipients. Descriptor(s): Policy initiatives, Medicaid, Funding/financing of health care programs.
8016. Forecasting
Reimbursement,
Federal Long-Term Care Expenditures.
Harold M. Ting. ICF, Inc. Washington, DC 20009 Health Care Financing Administration, Estimated completion date Jun 1981
The objective of this 3 year grant, which ends in 1981, is to study the methods of reimbursing hospitals under national health insurance in Great Britain, West Germany, Holland, France, and Switzerland. Descriptive analyses, which may be relevant to American efforts, will be developed on these systems and their experience in hospital financing. The foreign experiences will be compared to various cost containment approaches being tried in the United States. Primary data will be gathered via interviews with foreign program officials and their American counterparts on the State level, budget review and prospective rate-setting programs, for example. (Author abstract modified) Descriptor(s): Methods of payment determination, regarding foreign health policies.
Comparisons
8018. Health Care Cost Containment. John Billings. Utah Academy of Preventive Medicine Utah Health Cost Management Foundation Salt Lake City, UT 84112 Hartford Foundation, New York, NY. Estimated
completion date Feb 1983
This study will examine the methods available to the coalition of employee and employer groups regarding cost containment for health care. It will analyze the factors involved in promoting health care provider competition and health insurance reforms in Utah. A main purpose of the study is to develop watch-dog institutions to serve as alternatives to regulatory agencies.
Washington,
DC.
Contractor will develop a model to estimate Federal long-term care service utilization expenditures under medicaid, medicare, and Title XX. Estimates will include separate State comparisons. The intended use of the model will be to help evaluate the effects of various proposals for modifying Federal long-term care policies.
Descriptor(s):
Cost containment
efforts, Voluntary initiatives.
8019. Health
Care Data Initiatives.
Health Insurance Association of America Washington, 20006 Estimated completion date 1983
DC
II-5
In recent years there has been dramatic growth in the demand for statistics related to health. Health cost escalation has heightened the need to manage and monitor the lrmancing and delivery of health services. At the same time there has been a growing awareness that there are serious deficiencies in the type and quality of information available to support a sophisticated decisionmaking process. The complex web of reporting systems that have developed, often duplicative and inconsistent in nature, have made the aggregation of orderly, reliable and comparable data extremely difficult. The HIAA is working closely with HCFA, other third party payers and the provider community, to develop uniform nomenclature, coding formats and tape specifications for machine readable claims. The Association has played an active role in the development and implementation of the Integrated Data Demonstration projects. Eleven member companies are developing a nationwide clearinghouse which will serve as a conduit for the electronic transmission of claims information from providers to commercial insurance carriers. A private corporation has been created, developmental work has begun, and it is estimated that the clearinghouse will be opera-, tional by early 1983.
Descriptor(s): Health information/data systems, health insurance plans, Claims administration,
8020. Health
Commercial
Insurance Study.
Rand Corp. Santa Moniea, CA 90406 Department of Health, Education, and Welfare, Washington, DC. Office of the Assistant Secretary for Planning and Evaluation. Estimated completion date 1984
Descriptor(s): Funding/financing of health care programs, Plan design/program provisions (under health plans), Health care costs, Demand/utilization of health care programs, Impact of third-party coverage.
8021. Hospital Cost Inflation Study. Vanderbilt Univ. Nashville, TN 37203 Health Care Financing Adnainistration, Estimated completion date Oct 1981
Baltimore, MD 21235
In October 1978, a 3 year grant was awarded to study the behavior of hospitals in response to changes in the makeup of their physician staffs and the degree of unionization among their employees. Specific issues being examined include the effect on hospital cost inflation of the physician market, hospital medical staff characteristics and hospital-based physician arrangements, and the relationship between hospital-based physician arrangements and hospital performance. In addition, the project is assessing the impact of increased hospital utilization on hospital wage rates and costs. Data sources include the American Hospital Association annual and special surveys on hospital administrative services and the Professional Activities Survey, as well as hospital wage and benefit surveys conducted by the researchers. A descriptive paper on hospital organization and physician-hospital relationships and an analysis of hospital costs and input choices was completed in 1980. (Author abstract modified) Descriptor(s): ties.
Supply/availability
of services,
Inpatient
8022. Impact of Long-Term Care on Functionally Adults. This study addresses questions of health care financing by surveying 800) individuals in 2750 families. The study seeks to estimate how alternative cost sharing arrangements affect the demand for health care services; determine whether (and by how much) cost sharing arrangements affect poor families more than higher income families; assess the impact of varying the cost of health services on the health status of individuals; ascertain how the ambulatory care system can accomodate varying levels of demand or stress; gain familiarity with the difficulties of administering health insurance plans that place a ceiling on out of pocket expenses by the family; learn how the quality of medical care received differs (if at all) among individuals who have vailous insurance plans; and compare utilization, quality of care, health status outcomes and consumer satisfaction in an existing prepaid group practice with a fee for service system,
11-6
facili-
Disabled
Francis G. Caro and Christina Brinldey-Carter. Mathematica Policy Research, Inc. Princeton, NJ 08540 Community Service Society New York, NY 10010 Health Care Financing Administration, Baltimore, MD. Estimated completion date Jun 1981 The purpose of this study is: (1) to determine the circumstances under which at-risk person.s make use of home services and (2) to examine the consequences of service utilization for both the functionally disabled and the principal sources of informal support. Subjects will be recruited through the in-patient populations of several New York ihospitals, in order to study access to home services. Data will be obtained from a variety of sources,
Health Care Programs
including long-term care patients, principal sources of informal support, hospital personnel, home-service providers, and staffof long-term care facilities. After acute care has ended, patients will be followed for one year. Follow-up contact will be maintained primarily, but not exclusively, through quarterly telephone in-
or protocol of age-related, sex-related procedures and visits which, based on both medical and epidemiologic experience, prove to offer possibilities for cost-effective and health-effective approaches to preventive medicine.
terviews. Extensive in-person interviews will be conducted with study participants and principal sources of informal support in the third and twelfth month after acute care ends. The study is expected to address several major issues: the conditions under which organized services are introduced; the implications of _rvice implementation for viability of independent living; the division of labor between providers of organized services and informal supports; the durability of independent living arrangemants; the quality of circumstances in various residential settings; and the cost implications for the public.
Descriptor(s): Cost/benefit cal/surgical services.
Descriptor(s): Therapeutic Home health services.
services,
8023. Life Cycle Preventive Services
Long term care facilities,
Study.
Rutgers Univ., Insurance Network for Social, Urban and Rural Efforts New Brunswick, NJ 08854 American Council of Life Insurance, Washington, DC. Health Insurance Association of America, Washington, DC. Estimated completion date 1983 The American Council of Life Insurance and the Health Insur-
8024. Maintaining
analyses, Preventive services, Medi-
the Elderly in the Community.
David L. Rabin. Georgetown Univ. School of Medicine Washington, 20001 Administration on Aging, Washington, Estimated completion date Apr 1981
DC
DC.
This project attempts to demonstrate that the health needs of an inner city elderly, chronically ill, but currently ambulatory, population can be met through the intervention of a nurse interventionist operating out of a family practice. This is expected to result in better health status, more appropriate use of services (medical and community-based social services), less institutionalization, and lower overall costs than would be the case without the intervention. A cost-effective analysis employing interrupted time series techniques with individuals as their own controls is utilized. The sample for the experimental intervention consists of 300 black, largely female, ambulatory elderly (aged 65 and over) in active treatment for chronic illness at the model family practice center run by Georgetown University and Providence
ance Association of America are sponsoring a 3-year study to determine the most cost-efficient system of health care for consumers. This program will use the life cycle or age grouping approach to develop and test preventive health procedures which can be performed efficiently and economically by physicians or other personnel. Goals of the project include: identifying appropriate health care goals for various age groups; determining what
Hospital in Washington,
D.C.
services are cost and health effective for various age groups; promotion of such services to doctors, patients and those who pay for health care; and demonstrating how these services can be effectively provided in the settings where most Americans receive their health care. The program will cover an estimated 20,000 volunteers of all ages at three different locations. The lifeeycle monitoring program will divide the study population into 10 groups ranging from the pregnant mother to older individuals to determine the specific health goals suitable for each age group. The lifecycle study represents an effort to arrive at a more efficient approach to preventive medicine for the well population. Instead of an annual physical and a rather ritualistc approach to determining what procedures will be part of that physical, the study will try instead to develop a definite schedule
8025. Metropolitan Comprehensive Proposal.
Descriptor(s):Cost/benefit analyses, Outpatient facilities, Home health services, Allied health professionals.
Care Demonstration
State of New York Office of Health Systems Management Albany, NY 12237 New York State Dept. of Health, Albany, NY. Office of Health Systems Management. Estimated completion date 1984 The City, State, and Federal governments have undertaken a major demonstration project at Metropolitan Hospital, a New York City Municipal facility. Initially, the hospital will significantly reorganize its management and delivery system, including
II-7
the establishment of a new subsidiary corporation, which should significantly improve the quality of services and increase efficiency. A new organizational structure will be established to improve the management of the facility and services will be reorganized around health care teams who will operate as the private physiclan for patients. Users of the program will have to enroll in the program which will cover comprehensive health services. The medically indigent ineligible for Medicaid who live in the area and meet certain income requirements will be eligible for 'Citycaid' if they enroll in the Metropolitan program. Citycaid is basically an insurance program for the medically indigent and will be funded by the City and Federal governments. Persons enrolled at Metropolitan through Citycaid will receive basically the same benefits as the Medicaid population. This demonstration addresses many issues of great concern to the State, including: increasing access to care; financially distressed hospitals; reorganizing hospital-based ambulatory care; expanding the availability of HMO's; testing approaches to financing ambulatory care; and understanding the medically indigent and filling the gaps in the Medicaid program, Descriptor(s):
Hospital
8026. Model Wellness
services, Inpatient
facilities.
Program.
Equitable
Life Assurance
Estimated
completion
Society New York, NY 10019
date 1984
Equitable Life Assurance Society is conducting a pilot Model 'Wellness Program for employees in Charlotte, N.C. in order to enhance productivity and possibly eventually to reduce mortaliity, morbidity and health care costs.
Descriptor(s):
Preventive
services,
Analyzing how Americans use health care services and determining the patterns of health expenditures and insurance are the goals of this study. The study will provide important information and analyses on a number of issues: the cost, utilization, and financing implications of various national health insurance proposals; the influence of Medicare and Medicaid programs on the use of medical services and the costs of providing care; the extent of and reasons for chamges in Medicaid participation over time; the extent to which different government programs at the Federal, State, and local levels affect access to care; the distribution of tax benefits to individuals and business under current tax laws concerning medical and health insurance expenses, and the potential changes in the distribution of benefits if these laws were to be changed; the costs of illness for various diagnoses in different treatment settings; the breadth and depth of coverage; and the proportion of medical costs paid by health insurance. The National Health Care Expenditures Study (NHCES) is generating a series of analytical relx_rts on critical national health policy issues for government agencies, legislative bodies, health professionals, and others concerned with health care policies. Basic data for these reports were supplied by the National Medical Care Expenditure Survey (NMCES), which is providing the most comprehensive statistical picture to date of how health services are used and paid for in the United States. The survey was completed in September, 1979. Data were obtained in three separate, complementary stages which surveyed (1) about 14,000 randomly selected households in the civilian noninstitutionaiized population; each household was interviewed six times over an 18-month period during 1977-78; (2) physicians and health care facilities providing care to household members during 1977; and (3) employers and insurance companies responsible for their insurance coverage. Five Data Preview Reports presenting preliminary estimates of several key measures of health insurante, health services use, and health care expenditures have been issued to date.
Descriptor(s): Health information/data systems, Health care/ services, Health care costs, Private health care plans, Publicly sponsored/mandated health plans.
8027. National Health Care Expenditure Survey. 8028. National Health Care Strategy Series Update. National Center for Health Services Research Div. of Intramural Research Hyattsville, MD 20782 Research Triangle Inst. Durham, NC 27706 National Opinion Research Center Chicago, IL 60637 Abt Associates, Inc. Cambridge, MA 02138 National Center for Health Services Research, Hyattsville, MD. National Center for Health Statistics, Hyattsville, MD. Estimated completion date 1981
[I-8
InterStudy Excelsior, MN 55331 National Chamber Foundation, Washington, Estimated completion date 1981
DC.
This will update the 1978 study on how to improve health and contain costs. Subjects to be studied will include: how business can promote good health for employees; how business interacts
Health Care Programs
with the health care system; how business can use specific techniques to control health care costs; how business can stimulate competition in the health care system; and how business can improve health planning and regulation, Descriptor(s):
Cost containment
8029. Nationwide
efforts, Voluntary
Study of Domiciliary
initiatives.
Care.
The DRG Evaluation study will study the development of the new system for reimbursing hospitals for patient care based on Diagnosis-Related Groups (DRG's). This model system is being implemented in 26 New Jersey hospitals and is expected to replace traditional per diem reimbursement systems in the state by 1982. The evaluation, which will be presented in the form of a final report and interim report series will serve to: l) promote understanding of the DRG reimbursement system; 2) determine the usefulness and advantages of the DRG model by examining the quality of data, adequacy of reimbursement procedures and viability of the concept; and 3) determine ifDRG reimbu:rsement will be equitably suitable to insurers and providers.
Sylvia Sherwood. Hebrew Rehabilitation Center for Aged Dept. of Social Gerontological Research Boston, MA 02131 Administration on Aging, Washington, DC. Estimated completion date 8 1981
Descriptor(s): Reimbursement, Hospital services, Evaluations/ outcome of health care programs.
This project seeks to describe the status of domiciliary care across the nation, including (1) a delineation of the supply, costs and level of services provided to the different types of domiciliary care settings; (2) the extent and types of linkages between homes and community providers; and (3) the dynamics underlying the entry of elderly persons into these homes. In addition an empirical analysis of the relationship between Federal and State policies and the supply, adequacy, quality and appropriateness of services provided to residents is used as a basis for making policy recommendations regarding reimbursement levels, licensing requirements and case management programs. A national survey of Domiciliary Care Programs across the fifty States will be conducted (1) to provide a description of the status of domiciliary care across the nation and (2) to identify a sample of six States having different programmatic orientation. An empirical study in these six States including client and provider interviews, as well as in-depth case histories of regulation and program implementation, will be carried out to provide a rational basis for making policy recommendations,
8031. New York Case Mix Study.
Descriptor(s): ties.
which represent a cross section of hospitals in the entire State. Researchers are also performing inter-State comparisons; of data with Maryland and New Jersey, focusing on questions of validity of case-mix measures, cost variations among patients of different financial classes, and fixed-variable costs in the context of DRGs. The State also plans to initiate case-mix reimbursement demonstrations with a group of New York hospitals. Each hospital would be paid its own DRG costs, inflated forward using the New York State trend factors but probably also deflated for
Long term care facilities, Intermediate care facili-
8030. New Jersey Diagnosis Related Group (DRG) Evaluation. Health Research and Educational Princeton, NJ 08540
Trust of New Jersey
Kellogg (W.K.) Foundation, Battle Creek, MI. American Medical Association, Chicago, IL. Estimated completion date Dec 1983
State of New York Office of Health Systems Management Albany, NY 12237 Health Care Financing Administration, Baltimore, ME) 21235 Estimated completion date 1981 In February 1979, a 2 year grant was awarded to develop a case-mix-based prospective reimbursement system. Methodologies will be produced for measuring inpatient case-load cornplexity and calculating the average cost per inpatient case based on Yale University's diagnosis related groups (DRGs). ,_malyses of providers for DRG cost differences will also be included. During the In'st phase of the demonstration, an acceptable cost allocation methodology for converting patient bills to a cost basis was completed, as were procedures for linking bills and discharge abstracts. Researchers are now attempting to merge their case-mix system with the Statewide reporting, billing, and abstracting system. There are currently 41 hospitals in the sample
expected length of stay. (Author abstract modified) Descriptor(s): Cost/benefit analyses, Reimbursement, Methods of payment determination, Hospital services, Companisons of health care programs.
II-9
8032. Paths to Alternative Service Modalities and Differential Impact of Three Modalities on Familiar Groups of Vulnerable Elderly.
Descriptor(s): sign/program
Sylvia Sherwood. Hebrew Rehabilitation Center for Aged Dept. of Social Gerontological Research Boston, MA 02131 Administration on Aging, Washington, DC. Estimated completion date Aug 1981
Cost/benefit analyses, Policy initiatives, Plan deprovisions (under health plans).
8034. Preventive Health Services For Children. What States are Learning.
Karen Kurzweil. Focusing on applications to alternative long-term care modalities and a follow up of matched samples of those who become clients of these alternative modalities, the major research objectives can be summarized as (1) to examine and gain knowledge useful for policy planning and action concerning the decision making process in selecting long-term care services; and (2) to determine costs in a variety of community-based programs and institutional facilities on the lives of the elderly recipients. Within the framework of a controlled impact study, applicant cohorts will be pretested and a multivariate clinical clustering technique used to construct an impact sample of recipients who will be post-tested. Differential program impact will be assessed using ANOVA and the relationship between program costs and the relative benefit (in terms of positive client outcome) will be compared. Factors related to and predicting the service modality choice will be determined using regression and discriminant function
techniques,
Descriptor(s): Long term care facilities, Evaluations/outcome health care programs.
George Washington Univ Intergovernmental Health Policy Project Washington, DC 20006 Health Care Financing Administration, Washington, DC. Estimated completion date Jul 1981
This report will outline the innovative approaches of two States, Minnesota and California in developing their Early Screening Prevention, Detection and Treatment programs (ESPDT) for children. Although an IHPP overview of state Child Health Prevention programs found that few states had taken aggressive efforts in these areas, the two states featured in this report highlight some rather innovative efforts. For example in California, efforts are made to reimburse services directly through the child's regular source of provider of care, not just through ESPDT or public clinics. Minnesota has devised a unique approach coordinating screening services through any of the following agencies -- the Department of Education, the Department of Health, oi' the Welfare program.
of Descriptor(s):
8033. Potential
Impact of Mandatory
services, Reimbursement.
Cafeteria Style Health
Benefit Programs for the Cost of Health Insurance. Carol M. Noyes. International Foundation of Employee Benefit Plans, Brookfield, WI. Estimated completion date Jun 1981
This study will examine the impact of mandated or enforced 'cafeteria style' benefit plans or mandated choice of benefit plans for employees. There may be national legislation in the next few years proposed to mandate this type of choice for employees of firms with more than 50 employees. The choices would most likely include: 1) HMO's; 2) high deductible-high coinsurance plans; or 3) low deductible-low coinsurance plans. The intent of this type of mandated choice is to increase competition. It is designed to be enforced through tax laws. All of these impacts are to be explored in this forthcoming study,
II-10
Preventive
8035. Prospective Reimbursement System Based on Patient Case Mix for New Jersey Hospitals.
Joanne E. Finley, Bruce C. Vladeck, James R. Hub, Joseph I. Morris and David M. Talbot. New Jersey State Dept. of Health Trenton, NJ 08625 Health Care Financing Administration, Washington, DC. Estimated completion date 1983
The New Jersey Department of Health has developed a system for reimbursing hospitals based on the various diagnosis of patients within the hospital_, or the 'case mix.' Under this experiment, many of the State's hospitals are paid a fixed amount based on the average cost incurred in treating patients with a particular diagnosis rather than for the number of days which a patient resides in the hospital.
Health Care Programs
8036. Reductions in Public Health Care Coverage.
Descriptor(s):
Health infoIvnation/data
systems, Physicians.
Arnold A. Budin. Delaware Bureau of Health Planning and Resource Development New Castle, DE 19720 Estimated completion date Dec 1981
8038. Role of Fee Schedules in Physician
The Delaware Bureau of Health Planning and Resource Development's Division of Planning, Research and Evaluation is conducting a study to determine reductions in pubhc health program coverage. This study will focus on determining various options for Medicaid restrictions and eligibility, review the State medicaid reimbursement system, determine the viability of reducing optional medicaid coverage and study the possibilities of obtaining additional coverage for the medically needy from other public health programs including Maternal and Child Health Services, Alcohol and Drug Abuse Services and Mental Health Services. A taskforce will attempt to make recommendations regarding various systems for reducing public health care coverage. Descriptor(s): Medicaid, Reimbursement, mandated health plans, Policy initiatives.
Pubhcly
sponsored/
Princeton Univ. Princeton, NJ 08540 Health Care Financing Administration, Estimated completion date 1983
Reimbursement.
Baltimore,
MD 21235
A 4 year grant was awarded in 1979 to examine various aspects of the role of fee schedules in physician reimbursement under third-party payment systems. Specifically, the study will examine the development of the conceptual basis for fee schedules and the analytic frameworks for assessment of changes in them. It will also study descriptive analyses of fee schedules and relative price structure in the United States, and review fee schedules and relative value studies set in Canada, France, and West Germany. Finally, it will resurvey a sample of general practitioners in Quebec and analyze their responses to fee schedules. (Author abstract modified) Descriptor(s): Medical/surgical services, Economics of thirdparty payors, Impact of third-party coverage, Reimbursement.
8037. Resurvey of Private Practice Physicians,
1979.
Barbara H. Kehrer and Judith Wooldridge. Mathematica Policy Research, Inc. Princeton, NJ 08540 Department of Health and Human Services Washington, Office of Planning, Evaluation, and Legislation. Estimated completion date 1981
8039. Role of HSA's in Development Services.
of Ambulatory
Care
DC. Harry Schwartz. American Health Planning Association Washington, 20009
In the fall 1979, Mathematica Policy Research, Inc. designed and conducted a third national survey of private-practice primary-care physicians, replicating data collected in the 1975 Physician Capacity Utilization Resurvey. MPR will prepare an edited, documented computer data file for analysis that includes a combination of individual records of data from the previous survey in 1975. The purpose of the resurvey and the data file is
Robert Wood Johnson Foundation, Princeton, Estimated completion date 1982
to permit the analysis of changes in market conditions, prices, and health-production inputs for physicians and for their MPR's concurrent evaluation of the National Health Service Corps (NHSC) program. Data from the 1979 Survey will be used to help determine the existence and possible causes of differences in productivity between NHSC and private-sector physicians, and to help establish any changes in private-sector care delivery attributable to the placement of NHSC physicians. Approximately one-half of the respondents to this survey were surveyed in 1975. Responses were obtained from approximately 6,600 physicians' offices.
Descriptor(s):
DC
NJ.
The American Health Planning Association is preparing a report on Ambulatory Care Services and the role of HSA's in their development. Medical/surgical
services.
8040. South Carolina Voluntary Effort Report 1980-81. South Carolina Hospital Research and Education West Columbia, SC 29169 Duke Endowment, Durham, NC. Estimated completion date Mar 1982
Foundation
II-11
The report will examine the ways in which hospitals can voluntarily contain the rise in health care costs. Through continuing education it will explore some methods so financial executives or governing board members can be more productive. The programs will include shared nurse recruitment and hospital-based community health education, and sets forth the considerations in the measurement and evaluation of the results. A monetary outline and progress of the two study groups will be included in the report. •Descriptor(s):
Voluntary initiatives, Cost containment efforts.
Descriptor(s):
Cost containment
efforts, Medicaid.
8043. Study of Health Maintenance
Organizations.
Lawrence Brown. Brookings Inst. Washington, DC 20036 Smith, Richardson Foundation, Inc., Greensboro,
NC.
Estimated completion date 1981 This study will present research on health maintenance organizations dealing with the Federal effort for growth of HMO's.
8041. State Comprehensive and Catastrophic anee Programs. An Overview.
Health Insur-
The manuscript will discuss organization and political issues, political history of federal programs, and issues of interaction with Federal efforts and with policy strategy.
T. Van Ellet. George Washington Univ. Intergovernmental Health Policy Project Washington, DC 20006 Health Care Financing Administration, Washington, DC. Estimated completion date May 1981 The research monograph will present an overview of state efforts including Comprehensive and Catastrophic Health Insurance programs. The report will summarize state intiatives, legislation and regulations, provide a comparative analyses of key program components and discuss the strengths and weaknesses in the state approaches. Descriptor(s):
Present legislation/regulations,
Descriptor(s):
Prepaid plans, Policy initiatives.
8044. Study of the Utilization
and Effect of Temporary
Nursing Services. Barbara H. Kehrer. Mathematica Policy Research, Inc. Princeton, NJ 08540 Health Resources Administration, Washington, DC. Estimated completion date Aug 1982
Mandated bene-
fits.
8042. State Guide to Medicaid Cost Containment.
A 'temporary nursing servace' (TNS) is a temporary employment agency that employs registered nurses and assigns them to work on a temporary or supplemental basis for its clients. These clients, who include hospitals, nursing homes, other health-care institutions, and individual patients, pay the TNS for the services of its employees. The rise of these temporary-help agencies as a
Bruce Spitz. National Governors' Association Dept. of Human Resources Washington, DC 20001 Health Care Financing Administration, Washington, DC. Estimated completion date Apr 1981
factor in markets for registered nursing services is such a recent development that neither its magnitude nor its significance has been well documented. MPR's TNS study has been designed to fill this information gap. Five major tasks comprise this project: (1) a review of the literature on TNS's and preparation of an annotated bibliography; (2) identification of the universe of
Under a grant from the Health Care Financing Administration, the National Governors' Association's Department of Human Resources will be collecting, analyzing, and disseminating in formation on State Medicaid cost containment efforts. Part of
TNS's in the United States; (3) the design and administration of three separate sample surveys -- TNS agencies, TNS registerednurse employees, and health-care agencies which are TNS clients (4) analysis of the data collected in the surveys; and (5) prepara-
this project will be to transfer replicable information and experiences among the states with respect to medicaid cost containment, policy initiatives, program changes and demonstration projects. One product of this 18-month project will be an update of the State Guide to Medicaid Cost Containment.
tion of a report describing the study design and findings, and containing conclusions, recommendations, and implications, for use by policymakers and researchers.
11-12
Descriptor(s):
Nurses, Supply/availability
of services.
Health
Care Programs
8045. Workers' Compensation Research Studies. Peter S. Barth. Connecticut Univ. Storrs, CT, 06268 Department of Labor, Washington, DC. Employment ards Administration.
Stand-
Estimated completion date Jul 1981 The study will include a total of eight research studies and a research conference. Proposed and ongoing research projects deal with significant issues in the field of workers' compensation. Descriptor(s):
Workers compensation.
II-13
III.
Information
Sources
Sources of Information on Health Care Programs The following list includes organizations that either conduct or sponsor health care program research. It also includes other organizations which served as intbrmation resources for the Bibliography. Addresses are included for each organization as are the titles of periodicals published by each. This list is divided into six parts: • • • •
Educational Institutions, Research Organizations Trade and Professional Associations Federal Government State Governments
and Foundations
• Indexes and Clearinghouses • Publishers
Educational
Institutions,
Abt Associates, Inc. 55 Wheeler Street Cambridge, MA 02138 Actuarial Research Corporation 900 South Washington Street Suite 110 Falls Church, VA 22046 American Enterprise Institute Center for Health Policy Research 1150 17th St., N.W. Washington. DC 20036 AEI t:coll,,,.,*tlst Regulat_m
Research Organizations Battelle Human Affairs Research Center 4000 N E 41 st Street Seattle, WA 98015
Ithaca, NY 10021 Duke University School of Law Durham, NC 27706 Duke Law Journal
Boston, MA 02215 The Brookings Institution 1775 Massachusetts Ave., N.W. Washington, DC 20036
Duke University Dept. of Health Administration RO. Box 3018 Durham, NC 27710
Brookings Bulletin Carnegie Mellon University Schenley Park Pittsburgh, PA 15213
Aspen Systems Corp. 1600 Re_earch Boulevard Rockville, MD 20850 l",_milv and Community Health
The Conference Board 845 Third Avenue New York, NY 10017 Conference Board Record
Manae, ement Tcg_ic_'in Health Care Financing
Cornell University Medical Center 1300 York Avenue
Boston University Center for Industry and Health Care Health Policy Institute 53 Bay State Road
American Health Foundation 320 Ea_ 43rd Street New '_brk, NY 10017
tlc,dth Care Management Review Journal oj dmbulatory Care
and Foundations
Commonwealth Fund One East 75th Street New York, NY 10021
Journal of Health Politics, Policy and Law Financial Executives Research Foundation 633 Third Avenue New York, NY 10017 Ford Foundation 320 East 43rd eet New York, NY 10017
111-1
George Washington University Intergovernmental Health Policy Project 1919 Pennsylvania Ave., N.W. Suite 505 Washington, DC 20006 State Health Notes
Employee Benefits Journal
George Washington University National Health Policy Forum 1901 Pennsylvania Ave., N.W. Washington,
International F'oundation of Employee Benefit Plans 18700 West Bluemound Road Box 69 Brookfield, W1 53005
DC 20006
Government Research Corp. 1730 M St., N.W. Washington, DC 20036
Stanford University
John A. Hartford Foundation
University of California Health Policy Department 1326 3rd Avenue San Francisco, CA 94143
Johns Hopkins University Health Services Research and
Harvard University Graduate School of Business
Development Center Baltimore, MD 21218
Administration Soldiers Field Boston, MA 02163 Harvard Business Review
Mathematica Policy Research RO. Box 2392 Princeton, NJ 08540 MPR Policy Newsletter
Health Insurance Institute 1850 K Street, N.W. Washington, DC 20006 Health Research and Educational 760 Alexander Road, CN-1
Trust
Princeton, NJ 08540 Health Research Institute 44 Montgomery Street
Milbank Memorial Fund One East 75th Street New York, NY 10017 Milbank Memorial Fund Quarterly Health and Society National Bureau of Economic Research 1050 Massachusetts Avenue Cambridge, MA 02138
San Francisco, CA 94104
Smith Richardson Foundation 114 East 32nd Street New York, NY 10016
InterStudy RO. Box S 5715 Christmas Lake Road Excelsior, MN 55331
405 Lexington Avenue New York, NY 10174
National Journal
S RI International 333 Ravenswood Avenue Menlo Park, CA 94025
NBER Reporter
Department of 94305 Economics Palo Alto, CA
University of California Aging Health Policy Center School of Nursing N 631 San Francisco, CA 94143 University of Iowa Health Services Research Center Iowa City, IA 52242 University of Michigan School of Public Health Cooperative Information Center Ann Arbor, M1 48109 Abstracts of Health Care Management Studies Medical Care Review University Pennsylvania Leonard ofDavis Institute of Health Economics
Henry J. Kaiser Family Foundation Two Palo Alto Square Palo Alto, CA 94304
National Chamber Foundation 1615 H Street, N.W. Washington, DC 20062
Heritage Foundation 513 C Street, N.E. Washing,ton, DC 20002
Rand Corporation 1700 Main Street Santa Monica, CA 90406
University of Pennsylvania National Health Care Management Center 3641 Locust Walk Philadelphia, PA 19104
1CE Inc. 1850 K Street, N.W. Washington, DC 20006 ICF Health Reports
Robert Wood Johnson Foundation EO. Box 2316 Princeton, NJ 08540 Roche Laboratories
Advanced Data Interchange University of Virginia Center for Comprehensive
Institute for Contemporary 260 California Street
Studies
San Francisco, CA 94111 Institute for Health Planning 702 North Blackhawk Ave. Madison,
111-2
WI 53705
340 Kingsland Street Nutley, NJ 07110 Russell Sage Foundation 633 Third Avenue New York, NY 10017
Philadelphia,
PA 19104
Planning Charlottesville,
Health
VA 22903
University of Wisconsin Institute for Research on Poverty 3412 Social Science Building Madison, WI 53706
Rutgers University Bureau of Economic Research Winants Hall New Brunswick, NJ 08903
Health
Care Programs
The Urban Institute Health Policy Program 2100 M Street, N.W. Washington, DC 20037 Search W.K. Kellogg Foundation 400 North Avenue Battle Creek, MI 49016 Yale University ' Center for Health Studies 77 Prospect Street P.O. Box 15A Yale Station New Haven, CT 06520 Yale Journal of Biology and Medicine
Trade and Professional Associations American Academy of Actuaries 1835 K Street, N.W. Washington, DC 20006
American Management Associations 135 West 50th Street New York, NY 10020 American Medical Association 535 N. Dearborn St. Chicago, IL 60610 American Medical News Journal of the American Medical Association American Public Health Association 1015 15th St., N.W. Washington, DC 20005 Nation's Health American Risk and Insurance Association Brooks Hall University of Georgia Athens, GA 30602 Journal of Risk and Insurance American Society of Chartered Life Underwriters Box 59 Bryn Mawr, PA 19010 CL U Journal
American Association of Retired Persons/National Retired Teachers Association 1909 K Street, N.W. Washington, DC 20049
Association of Private Pension and Welfare Benefit Plans 1725 K Street, N.W. Washington, DC 20006
AA RP/NRTA Journal American College of Physicians 4200 Pine Street
Association of University Programs in Health Administration One Dupont Circle
Philadelphia, PA 19104 Ammls of Internal Medicine American College of Preventive Medicine 1015 i5th Street, N.W. Washington, DC 20005
Suite 420 Washington,
DC 20036
Blue Cross and Blue Shield Associations 840 North Lake Shore Drive Chicago, IL 60611 Inquiry
American Dental Association 211 East Chicago Avenue Chicago. IL 60611 J(mrnal of the American Dental Assocmtio,t
Chamber of Commerce of the United States 1615 H Street, N.W. Washington, DC 20062
American Health Planning Association 1601 Connecticut Ave., N.W. Suite 700 Washington, DC 20009 7oday in Health Planning
Group Health Association of America 1717 Massachusetts Ave., N.W. Washington, DC 20036 Group Health Journal Health Insurance Association of America
American Hospital Association 840 North Lake Shore Drive Chicago, IL 60611 Health Services Research Itoslmal._
Midwest Business Group on Health 200 East Randolph Suite 6757 Chicago, IL 60601 National Association of Employers on Health Maintenance Organizations 1134 Chamber of Commerce Building 15 South 5th Street Minneapolis, MN 55402 National Association of Manufacturers 1776 F Street, N.W. Washington, DC 20006 National Conference of State Legislatures 1125 17th Street Suite 1500 Denver, CO 80202 State Health Notes State Legislatures National Council on the Aging 600 Maryland Ave., S.W. Washington, DC 20024 Perspective on Aging National Governors Conference 444 North Capitol Street Washington, DC 20001 Society of LaSalle ActuariesStreet 208 S. Chicago, IL 60604 The Actuary Voluntary Effort to Contain Health Care Costs 840 North Lake Shore Drive Chicago, IL 6061 l Washington Business Group on Health 922 Pennsylvania Avenue, S.E. Washington, DC 20003
Federal Government Congress---I-louse Representatives
of
Committee on Appropriations Subcommittee on Labor, Health and
1850 K Street, N.W. Washington, DC 20006
Human Services, and Related Agencies
H1AA Newsletter
2358 Rayburn House Office Building Washington, DC 20515
111-3
Committee on Education and Labor Subcommittee on Health and Safety B345-A Raybum House Office Building Washington, DC 20515
Congress---Joint
Joint Economic Committee G 133 Dirksen Senate Office Building Washington, DC 20510
Department
Committee on Education and Labor
Joint Committee on Taxation
Services
Subcommittee on Labor Standards 518 House Office Building, Annex I Washington, DC 20515 Committee on the Post Office and Civil Service Subcommittee on Compensation and Employee Benefits B345 Rayhum House Office Building Washington, DC 20515 Conlmittee on Ways and Means Subcommittee on Health 1104 Longworth House Office Building Washington,
DC 20515
Select Committee on Aging Subconnnittee on Health and Long Term Care 715 House Office Building, Annex I Washington, DC 20515 Congress--Senate Committee _n Appropriations Subcommittee on Labor, Health and Human Services, and Related Agencie._, 1108 Dirksen Senate Office Building Washington, DC 20510
Committees
1015 Longworth House Office Building Washington, DC 20515 Congress--Support
Agencies
Special Committee on Aging G-233 Dirksen Senate Office Building VCashington, DC 20510
11I-4
and Human
Administration on Aging Office of Research, Demonstrations, and Evaluation 330 Independence
Ave., S.W.
Washington, DC 20201 National Clearinghouse on Aging 330 Independence Ave., S.W. Washington, DC 20201
General Accounting Office Office of the Comptroller General
Assistant Secretary for Planning and Evaluation, Health
44l G Street, N.W. Washington, DC 20548 Government
Plinting Office
Superintendent of Documents Washington, DC 20402 Library of Congress Congressional Research Service James Madison Memorial Building 101 Independence Avenue, S.E. Washington, DC 20540 Office of Technology Assessment 600 Pennsylvania Avenue, S.E. Washington, DC 20510
Executive
Office
of the President
442 East Humphrey Building 200 Independence Ave., S.W. Washington, DC 20201 ltealth Care Financing
Administration
Office of Research, Demonstrations, and Statistics Oak Meadows Building 6340 Security Boulevard Baltimore, MD 21207 Health Care Financing Notes Health Care Financing Program Statistics Health Care Financing Review Health Care Financing Trends Bureau of Health Standards and Quality 330 Independence Avenue, S.W. Washington, DC 20201 Health Resources Administration
Office of Management and Budget Old Executive Office Building Washington, DC 20503
Committee Oil Labor and Human Resources Subcommittee on Aging, Family, and Human Services A624 In;migration Building Washington, DC 20510
of Health
Congressional Budget Office House Office Building Annex I1 Washington, DC 20515
Committee on lqnance St_bcommittee on Health 2227 Dirkseq Senate Office Building Washington, DC 20510
National Technical Information Service 5285 Port Royal Road Springfield, VA 22161
Bureau of Health Planning National Health Planning Information Center 3700 East-West Highway Hyattsville, MD 20782
Department
of Commerce
Bureau of the Census Data Users Services Division Andrews Federal Credit Union Building 5711 Allentown Road Camp Springs, MD 20031
Public Health Reports National Center for Health Services Research 3700 East-West Highway Hyattsville, MD 20782 National Medical Care Expenditures Stud), Data Preview Series Research Management Series Research Report Series Research Summary Series
Health
Care Programs
National Center for Health Statistics Office of Cooperative Health Statistics System 3700 East-West Highway Hyattsville, MD 20782 News of the Cooperative Health Statistics System
Social Security Administration Office of Research & Statistics 1875 Connecticut Avenue, N.W. Washington, DC 20009 Monthly Benefit Statistics Research and Statistics Notes Social Security Bulletin
Department of
3700 East-West Highway Hyattsville, MD 20782 Advaneedata
Assistant Secretary for Policy, Evaluation and Research 200 Constitution Avenue, N.W.
National Institutes
of Health
National Institute of Mental Health Parklawn Building 5600 Fishers Lane Rockville, MD 20857
Agencies
Advisory Council on Pension and Welfare Benefit Programs 200 Constitution Ave., N.W. Washington, DC 20216 Federal Trade Commission
Office of Vital and Health Care Statistics Programs
Health Resources Statistics Monthly Vttal Statistics Report Htal and Health Statistics Series 14talStatistics of the U.S.
Independent
Labor
Bureau of Economics 2120 L Street, N.W.
Washington, DC 20210
Washington, DC 20580 General Services Administration National Archives 8th St. & Pennsylvania Ave., N.W. Washington, DC 20408
Bureau of Labor Statistics Office of Information Washington, DC 20210 Consumer Price Index News
National Labor Relations Board 1717 Pennsylvania Avenue, N.W. Washington, DC 20570
Monthly Labor Review Occupational Injuries and Illness News
National Science Foundation 1800 G Street, N.W. Washington, DC 20550
National Institute on Alcohol Abuse
Office of Occupational Health Statistics
Office of Personnel Management 1900 E Street, N.W.
and Alcoholism
200 Constitution
Parklawn Building 5600 Fishers Lane Rockville, MD 20857
Veterans Administration 810 Vermont Avenue, N.W Washington, DC 20420
National Institute on Aging
Washington, DC 20210 Office of Wages and Industrial Relations 441 G Street, N.W.
9000 Rockville Pike Bethesda, MD 20014
Washington,
State Governments
Natkma[ Library of Medicine 9000 Rockville Pike Bethesda, MD 20205 Office of Disease Prevention and Health Promotion Office of Health Information, Health Promotion and Physical Fitness and Sports Medicine Humphrey Building 200 Independence Avenue, S.W. Washington, DC 20201 Office of Health Maintenance Organizations 12420 Parklawn Drive Rockville, MD 20857 Parklawn Health Library 5600 Fishers Lane Rockville, MD 20857 Parklawn Health Library Bulletin
Safety and
Avenue, N.W.
DC 20212
Occupational Safety and Health Administration 200 Constitution Avenue, N.W. Washington, DC 20210
Washington,
DC 20415
California Department of Health Services State Office Building 8 714 P Street Sacramento, CA 95814
Office of Pension and Welfare Benefit Programs 200 Constitution Avenue, N.W.
Colorado Department of Health 4210 East 1 lth Avenue
Washington, DC 20210 Office of Workers' Compensation Programs 200 Constitution Avenue, N.W.
Denver. CO 80220 Hawaii Department of Health 1250 Punchbowl Street P.O. Box 3378 (96801)
Washington, Department
DC 20210 of the Treasury
Internal Revenue Service Employee Plans and Exempt Organizations Division 1111 Constitution Ave., N.W. Washington, DC 20224
Honolulu, HI 96813 Illinois Department of Public Health 535 West Jefferson Street Springfield, IL 62706 Maryland Department of Health and Mental Hygiene 201 West Preston Street Baltimore, MD 21201
I11-5
New Jersey Department of Health Health Agriculture Building John Fitch Plaza P.O. Box 1540 Trenton, NJ 08625
Index Medicus National Library of Medicine Bibliographies Services Division 8600 Rockville Pike Bethesda, MD 20014
New York Department of Health Tower Building Empire State Plaza Albany, NY 12237
Library of the American Medical Association Asa S. Bacon Memorial 840 North Lake Shore Drive Chicago, IL 60611
Indexes and Clearinghouses
Management
Management Contents, Inc. P.O. Box 1054 Skokie, IL 60077
ABl/Inform Data Base Data Courier, Inc. 620 South Fifth Street Louisville, KY 40202
Medlars Online National Library of Medicine 8600 Rockville Pike Bethesda, MD 20014
Clearinghouse on Health Indexes Center Building, Room 2-27 3700 East-West Highway Hyattsville, MD 20782 Clearinghouse
National Clearinghouse Program of the Community Health Institute National Assn. of Community Health
for Hospital Management
Centers Inc. 1625 Eye Street, N.W., Suite 420 Washington, DC 20006
Engineering American Hospital Association 840 North Lake Shore Drive Chicago, IL 60611 Congressional Information Service Index Congressional Information Service 7101 Wisconsin Avenue Washington, DC 20014 Current Contents Institute for Scientific Information, 325 Chestnut Street Philadelphia,
PA 19106
Dissertation Abstracts International University Microfilms International 300 North Zeeb Road Ann Arbor, MI 48106 Health Education Abstracts Society of Publication Educators 419 Park Ave., South New York, NY 10016 Health Policy Advisory Center 17 Murray Street New York, NY 10007 Hospital Literature Index American Hospital Association 840 North Lake Shore Drive Chicago, IL 60611
111-6
Contents Data Base
National Health Planning Information Center Center Building, Room 6-50 3700 East-West Highway Hyattsville, MD 20782 National Health Standards and Quality Information Clearinghouse 11301 Rockville Pike
Inc.
Kensington,
MD 20895
Smithsonian Science Information Exchange (SSIE) Smithsonian Science Information Exchange, Inc. Room 300 1730 M Street, N.W. Washington, DC 20036 Social Sciences Citation Index Institute for Scientific Information 325 Chestnut Street Philadelphia, PA 19106 Sociological Abstracts Sociological Abstracts, Inc. P.O. Box 22206 San Diego, CA 92122 Weekly Government Abstracts: Health Planning U.S. Department of Commerce National Technical Information Service 5285 Port Royal Road Springfield, VA 22161
Publishers Aspen Systems Corporation Publications Department 1600 Research Blvd. Rockville, MD 20850 Ballinger Publishing Company Harvard Square 17 Dunster Street Cambridge,
MA 02138
Charles D. Spencer & Associates 222 West Adams Street
National Technical Information Service Bibliographic Data File U.S. Department of Commerce NTIS 5285 Port Royal Road Springfield, VA 22161
Health Administration Press M2240 School of Public Health University of Michigan Ann Arbor, MI 48109
New York "limes Information Service 1719A Route 10 Parsippany, NJ 07054
Healtbcare Publications 1080 National Press Building Washington, DC 20045
Parklawn Health Library 5600 Fishers Lane Rockville, MD 20857
Health Care Publishers Harcourt Brace Jovanovich, 757 Third Ave. New York, NY 10017
Resource Center for Health Services Administration Education Accrediting Commission on Education for Health Services Administration One Dupont Circle, Suite 420 Washington, DC 20036
Chicago, IL 60606
Inc.
John Wiley and Sons, Inc. 605 Third Ave. New York, NY 10016
Health
Care Programs
Lexington Books D.C. Heath and Company 125 Spring St. Lexington, MA 02173
Prodist-Neale Watson Academic Publications, Inc. 156 Fifth Ave., Suite 1100 New York, NY 10010
McGraw-Hill Editorial Office
Springer- Verlag, Inc. 175 Fifth Avenue
457 National Press Building Washington, DC 20045
University of Chicago Prc,+ 5801 Ellis Ave. Chicago, IL 60637
New York, NY tO010
Source List of Health Care Program Periodicals The following list includes the periodicals which served as major sources of citations for the bibliography. It also includes other periodicals and newsletters which served as secondary sources of information on research in the health care program area. AARP/NRTA Journal American Association Persons
of Retired
National Retired Teachers Association 1909 K Street, N.W. Washington, DC 20049
Oxford House 1313 21 st Avenue S. Nashville, TN 37212
Abstracts of Health Care Management Studies Health Administration Press School of Public Health Cooperative
Information
Center
M-2226 University of Michigan Ann Arbor, MI 48109 The .4_'luarv Society of Actuaries 208 S. LaSalle Street Chicago, IL 60604 Advan_edata National Center for Health Statistic_ 3700 Ea+t-West Highway Hyatt+ville,
American Economic Review American Economic Association Suite 812
MD 20782
Advanced Data National Health Care Management Center University of Pennsylvania 3641 Locust Walk Philadelphia, PA 19104
Philadelphia,
American Journal of Law & Medicine American Society of Law & Medicine, Inc. 520 Commonwealth Boston, MA 02215
Avenue
American Journal of Psychiatry American Psychiatric Assn. 1700 18th St., N.W. Washington, DC 20009 American Journal of Public Health American Public Health Association 1015 15th St., N.W. Washington, DC 20005 American Medical News American Medical Association 535 N. Dearborn St. Chicago,
IL 60610
American Pharmacy American Pharmaceutical Association 2215 Constitution Ave., N.W. Washington, DC 20037 American Psychologist
A E1 E_'_)nomist American Enterprise Institute Cctlter for Health Policy Research 115(I 17th St., N.W. Washil_L4ton. DC 20036
Annals of Internal Medicine American College of Physicians 4200 Pine Street
American Psychological Association 1200 17th St., N.W. Washington, DC 20036
PA 19104
Benefits International Pension Publications 30 Queen Anne's Gate London SWI H 9AW, England Best's Review Life-Health Insurance Edition A.M. Best Co. Oldwick,
NJ 08858
Brookings Bulletin Brookings Institution Ave., N.W. 1775 Massachusetts Washington, DC 20036 Bulletin of the New York Academy of Medicine New York Academy of Medicine 2 East 103rid Street New York, NY 10029 Business Economics Assn. of Business Economi,'+ts 888 17th St., N.W. Washington, DC 20006 CLU Journal American Society of Chartered Life Underwriters Box 59 Bryn Mawr, PA 19010 Conference Board Record The Conference Board 845 Third Avenue New York, NY 10017
lJ[l-7
Consumer Health Perspectives Consumer Commission on the Accreditation of Health Services, Inc. 37"7 Park Avenue, South New York, NY 10016
18700 West Bluemound Box 69 Brookfield, WI 53005
Consumer Price Index News Bureau of Labor Statistics Office of Information Washington, DC 20210
New York, NY 10023
Current History, Inc. 4225 Main Street Philadelphia, PA 19127 Daedalus
Family and Community Health Aspen Systems Corp. Fulfillment Operations P.O. Box 6018
American Academy of Arts and Sciences 165 Allendale Street Jamaica Plain Station Boston, MA 02130
Gaithersburg, MD 20877 Federation of American Hospitals Review Federation of American Hospitals 1405 North Pierce Street, Suite
Duke Law Journal
311
Duke University School of Law Durham, NC 27706
Little Rock, AR 72207 Gerontologist Gerontological Society
Dun's Review
1835 K St., N.W., Suite 305
Technical Publishing Corp. 666 Fifth Avenue New York, NY 10019 EBPR Research Reports Charles D. Spencer & Associates 222 West Adams Street Chicago, IL 60606 EBRI Notes
Washington, DC 20006 Group Health Journal Group Health Association of America 1717 Massachusetts Ave., N.W. Washington, DC 20036 Hansen News and l_ews A.S. Hansen, Inc. 150 North Wacker Drive
Benefit Research
Chicago, IL 60606
1920 N. St., N.W. Suite 520 Washington, DC 20036
Harvard Business Review Harvard University Graduate School of Business Administration Soldiers Field
Economic Inquiry Western Economic Association California State University Department of Economics Long Beach, CA 90840 Employee Benefit Plan Review Charles D. Spencer & Assoc., 222 West Adams Street Chicago, IL 60606
111-8
Road
Employee Relations Law Journal Executive Enterprises Publications Co., Inc. 33 West 60th Street
Current History
Employee Institute
Employee Benefits Journal International Foundation of Employee Benefit Plans
Boston, MA 02163 Hay/Huggins Bulletin Hay/Huggins 229 S. 18th Street Inc.
Philadelphia, PA 19103 Health and Medical Care Services Review Haworth Press 149 Fifth Avenue New York, NY 10010
Health and Social Work National Association of Social Workers Publications Department 2 Park Avenue New York, NY 10016 Health Care Cost Containment Agenda Frank B. Hall Consulting Co. 549 Pleasantville Road Briarcliff Manor, NY 10510 Health Care Health Care Health Care Health Care Statistics
Financing Review Financing Trends Financing Notes Financing Program
Health Care Financing Administration ORDS Publications Rm I E9 Oak Meadows Building 6340 Security Boulevard Baltimore,
MD 21235
Health Care Management Review Aspen Systems Corp. Fulfillment Operations P.O. Box 6018 Gaithersburg, MD 20877 Health Resources Statistics National Center for Health Statistics 3700 East-West Highway Hyattsville, MD 20782 Health Services Information Healthcare Publications 1080 National Press Building Washington, DC 20045 Health Services Research American Hospital Association Hospital Research and Educational Trust 840 North Lake Shore Drive Chicago, IL 60611 HIAA Newsletter Health Insurance Association America 1850 K Street, N.W. Washington, DC 20006
of
Hospital and Community Psychiatry American Psychiatric Association 1700 18th St., N.W. Washington, DC 20009
Health
Care Progt,tm_,
Hospital and Health Services Administration American College of Hospital Administrators 840 North Lake Shore Drive Chicago, IL 60611 Hospital Financial Management Hospital Financial Management Association 666 North Lake Shore Drive Chicago,
IL 60611
Hospital Progress Catholic Hospital Association 1438 South Grand Boulevard St. Louis, MO 63104 Hospitals American Hospital Association 840 North Lake Shore Drive Chicago, IL 60611 ICF Health Reports ICE Inc. 1850 K Street, N.W. Washington, DC 20009
Journal of Community Health Human Sciences Press 72 Fifth Avenue New York, NY 10011 Journal of Consumer Affairs American Council on Consumer Interests 162 Stanley Hall University of Missouri Columbia, MO 65211 Journal of Consumer Research University of Illinois at Chicago Circle 2152 Behavioral Sciences Building Box 6905 Chicago,
IL 60608
Journal of Dental Education American Assn. of Dental Schools 1625 Massachusetts Ave,, N.W. Washington,
DC 20036
Journal of Long Term Care Administration American College of Nursing Home Administrators 4650 East-West Highway Washington, DC 20014 Journal of Medical Education Assn. of American Medical Colleges One Dupont Circle, N.W. Washington,
DC 20036
Journal of Occupational Medic,ine American Occupational Medicine Association 150 North Wacker Drive Chicago,
IL 60606
Journal of Political Economy University of Chicago Press 5801 South Ellis Avenue Chicago,
IL 60637
Journal of Gerontology Gerontological Society 1835 K St., N.W., Suite 305
Journal of Public Health Dentistry American Assn. of Public Health Dentists
Inquiry Blue Cross Association 840 North Lake Shore Drive Chicago, IL 606 ! 1
Washington, DC 20006 Journal of Health and Human Resources Administration Auburn. University at Montgomery
2209 Lawrence Drive Raleigh, NC 27603 Journal of Risk and Insurance American Risk and Insurance
Interchange National Health Care Management Center University of Pennsylvania
Montgomery, AL 36117 Journal of Health and Social Behavior American Sociological Association 1722 N St., N.W.
3641 Locust Walk C E
Washington,
DC 20036
Association Brooks Hall University of Georgia Athens, GA 30602 Journal of the American Dental
Philadelphia, PA 19104 International Journal of Health Services Baywood Publishing Co., Inc. 120 Marine Street Farmingdale, NY 11735
Journal of Health Politics, Policy and Law Dept. of Health Administration Duke University P.O. Box 3018 Durham, NC 27710
Association American Dental Association 211 East Chicago Avenue
Internist American Society of Internal Medicine 535 Central Tower Building 703 Market Street San Francisco, CA 94103
Journal of Human Resources University of Wisconsin Press Journals Department Box 1379 Madison, WI 53701
American Medical Association 535 North Dearborn Street Chicago, IL 60610 Long Term Care and Health Services Administration Quarterly Panel Publishers
Journal of Ambulatory Care Managemen't Aspen Systems Corp. Fulfillment Operations 1_O. Box 6018 Gaithersburg, MD 20877
Journal of Law and Economics University of Chicago Law School 1111 East 60th Street Chicago, IL 60637 Journal of Legal Studies University of Chicago 1111 East 60th Street Law School Chicago,
Chicago, IL 60611 Journal of the American Medical Association
14 Plaza Road Greenvale, NY 11548 MPR Policy Newsletter Mathematica Policy Research EO. Box 2392 Princeton,
NJ 08540
IL 60637
1II-9
Medical Care J. B. Lippincott Company East Washington Square Philadelphia, PA 19105 Medical Care Review University of Michigan School of Public Health Bureau of Public Health Economics Ann Arbor, MI 48109 Medical Economics Medical Economics Company 680 Kinderkamack Road Oradell, NJ 07649
Monthly l_tal Statistics Report National Center for Health Statistics 3700 East-West Highway Hyattsville,
M D 20782
NBER Reporter National Bureau of Economic Research 1050 Massachusetts Avenue Cambridge, MA 02138 National Journal Government Research Corp. 1730 M St., N.W. Washington, DC 20036
Medical Group Management Medical Group Management Association 4101 Louisiana Avenue Denver, CO 80222
National Medical Care Expenditures Study-Data Preview Series National Center for Health Services Research 3700 East-West Highway
Medical World News McGraw-Hill Inc. 1221 Avenue of the Americas New York, NY 10020
Hyattsville, MD 20782 National Underwriter Life and Health Insurance Edition National Underwriter Company 175 West Jackson Boulevard
Medicare Medicaid Information Healthcare Publications 1080 National Press Building Washington, DC 20045
Occupational Injuries and Illness News Bureau of Labor Statistics Office of Information Washington,
DC 20210
Parklawn Health Library Bulletin Public Health Service Parklawn Health Library Parklawn Building ( 13- 12) 5600 Fishers Lane Rockville,
M D 20857
Personnel Journal A.C. Croft, Inc. Box 2440 Costa Mesa, CA 92627 Perspective on Aging National Council on the Aging 600 Maryland Ave., S.W. Washington, DC 20024 Preventive Medicine Academic Press, Inc. 111 Fifth Avenue New York, NY 10003
Chicago, IL 60604 Nation's Health American Public Health
Program Notes Association of University Programs in Health Administration One Dupont Circle
Meidinger Update Meidinger, Inc. Information Center 17.O. Box 37540 Louisville, KY 40232
Association 1015 15th St., N.W. Washington, DC 20005 New England Journal of Medicine Massachusetts Medical Society
Suite 420 Washington, DC 20036 Public Health Reports Superintendent of Documents Washington, DC 20402
Mercer Bulletin William M. Mercer, Inc. 1211 Avenue of the Americas New York, NY 10036
10 Shattuck Street Boston, MA 02115 News of the Cooperative Health Statistics System National Center for Health Statistics
Quarterly Review of Economics and Business University of Illinois Bureau of Economic and Business Research 428 Commerce West
3700 East-West Highway Hyattsville, MD 20782 Nursing Outlook American Journal of Nursing Co. 10 Columbus Circle New York, NY 10019
Urbana, IL 61801 Regulation American Enterprise Institute Center for Health Policy Research 1150 17th Street, N.W. Washington, DC 20036
Nutshell The Country Press Box 5880
Research and Statistics Notes Social Security Administration Office of Research & Statistics
Milbank Memorial Fund QuarterlyHealth and Society MI'I Press 28 Carleton Street Cambridge, M A 02142 Monthly Benefit Statistics Social Security Administration Office of Research & Statistics 1875 Connecticut Avenue, N.W. Washington, DC 20009 Monthly Labor Review Superintendent of Documents Washington, DC 20402
I11-10
Snowmass
Village, CO 81615
1875 Connecticut Avenue, N.W. Washington, DC 20009
Health
Care
Programs
Research Digest Series Research Management Series Research Report Series Research Summary. Series National Center for Health Services Research
Socio-Economic Planning Sciences Pergamon Press, Ind. Journals Division Maxwell House, Fairview Park Elmsford, NY 10523
Topics in Health Care Financing Aspen Systems Corp. Fulfillment Operations E O. Box 6018 Gaithersburg, MD 20877
Schizophrenia Bulletin Superintendent of Documents Washington, DC 20402
State Health Notes Intergovermental Health Policy Project George Washington University Suite 505 1919 Pennsylvania Ave., N.W.
University of Michigan Business Review University of Michigan Graduate School of Business Administration Ann Arbor, MI 48104
Science American Association for the Advancement of Science 1515 Massachusetts Avenue, N.W. Washington, DC 20005
Washington, DC 20006 State Health Notes National Conference of State Legislatures 1125 17th Street,
U.S. Health Dollar Capitol Publications 2430 Pennsylvania Avenue, N.W. Suite G- 12 Washington, DC 20037
Search The Urban Institute Health Policy Program 21 O0 M Street, N.W. Washington, DC 20037
Suite 1500 Denver, CO 80202 State Legislatures National Conference of State Legislatures 1125 17th Street, Suite 1500
Irttal and Health Statistics Series 14tal Statistics of the U.S. National Center for Health Statistics 3700 East-West Highway Hyattsville, MD 20782
Denver, CO 80202 Statistical Bulletin Metropolitan Life Insurance Co. Statistical Bureau
[4tal Speeches of the Day City News Publishing Co. Box 606 Southold, Long Island, NY 11971
One Madison Avenue New York, NY 10010 Today in Health Planning American Health Planning
Washington Report on Medicine and Health McGraw-Hill 457 National Press Building
3700 East-West Highway Hyattsville, MD 20787
Social Science and Medicine Pergamon Press, Inc. Journals Division Maxwell House, Fairview Park Elmsford, NY 10523 Social Security Bulletin Superintendent of Documents Washington, DC 20402 Social Work in Health Care Haworth Press 149 Fifth Avenue New York, NY 10010
Association 1601 Connecticut Ave., N.W. Suite 700 Washington, DC 20009
Washington, DC 20045 Yale Journal of Biology and Medicine Yale University 333 Cedar Street New Haven, CT 06510
111-11
IV. Author Index Abels, on, Philip H. Health Care. Regulation, Abernethy, David S. Regulating Hospital Abramowitz, National
Economics,
Ethics,
Cost& The Development
Stephen I. Health Insurance,
Practice.
20857 Mental Disorder and Pn'mary Literature. abe. no. 584
abe. no. 377
of Public Policy. abs. no. 782
Psychotherapy,
and the Poor. abe. no. 627
Phase 1 Report. abs. no. 287
abs. no. 159 Allowable Cast (MAC)
Final Design Report
Impact of Rate Regulation tats. abe. no. 485
Technologies
National Health Care Expenditure Survey. abe. no. 8027 National Hospital Rate-Setting Study. A Comparative Review pective Rate-Setting Pro$rams. abe. no. 637 Patient
Outcomes
in Three Alternative
LonB-Term
in Hospi-
of Nine Pros-
Care Sett/_,&
abe. no.
669 Physician Participation in State Medicaid Programs. abe. no. 690 Private Physicians _nd Pubh'c Progntms. abe. no. 732 Study to Determine the Relationship of Community Health Centers, Community Mental Health Centers, and Drn8 Treatment Centers for the Provision of Mental Health Secffces to CHC Registrants. Final ReporL abs. no. 873 What
We Have
grams, Acford,
Jeanne
(And
Haven't)
Learned
From
ProspectivePayment
and Medical
the Costs.
Care Plans. abs.
abs. no. 553
Allan, Carole A Pro/de
of Amenca's
Older Population.
abs. no. 295
AUard, Mary A. Current and Future Mentally
Allison, Theodore National Health Ahenstetter,
Development
Retarded.
of Intermediate
A Survey
Insurance
of State
in Canada.
Care Facilities
Ot_oial&
for the
abs. no. 174
abs. no. 620
Christa
Poh'cy, Politics, end Child Health. State Respons_ abs. no. 704
Airman, Isidore Use of Medicare
Benefits
Experiment.
Four Decades
Under HIP's
of Federal
3- Year Incentive
Im_iative
and
Reimbursement
abs. no. 921
Airman, Stuart H. Medical Technology.
The Culprit Behind
Health
Care Costs.
abs. no. 568
P.
Ackerman, F. Kenneth Competition and Regulation. tire. abs. no. 103
Family
The Consumer
Responsibi_ty.
Choice
Health
Critique
Plan Alterna-
Amado, Anthony Cost of Terminal
A Comprehensive
Portrait.
to the NLRA abe. no. 490
Abuse,
and Mental
in the U.S.A. Health
on Collective
of Foundations Census Survey,
RockviLle,
Coll. of Preventive
Dental
Association,
Chicago, IL 60613 Dental Prepayment
abs. no. 552
Administration,
HMO
for Medical
abs. no. 162
Care, Potomac,
1977. Summary.
MD
Medicine,
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Aaron
abs. no. 58 Doing Better and Feeling abs. no. 223
on the Health
Harvey
Reimb_ent Care Group Practices.
A Developing
Alternatives
fi_r Home
Health
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ModMity
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Wolfe, Prepaid no. 586 Health abs. no.
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Health
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Wollstadt, Loyd J. Disenrollment From
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An Actuarial
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IV-43
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Zimmerman,
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Controversies
abs. no. 580
Zook, Christopher
Reimbursement for Hospital Services. abs. no. 792 Reimbursement for Physicians" Services. abs. no. 793 Working With the Insurer. abs. no. 948
Payments
for Health
Care Services.
Harvey
Prost_ctive Reimbursement/n no. 752
abs. no. 333
and Appeals.
Z_ird-Party
Rhode
Island. Additional
Perspectives.
abs.
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Repeated Hospitalization for the Same Health Costs. abs. no. 798
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A Multiplier
of NaNonal
Zubkoff, Michael Woodward,
Albert
U.S. Health Wooldridge,
Health.
Insurance
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View. abs. no. 917
Judith
Evaluation of Health abs. no. 282 Physician Resurvey
A
Victim or Cause
Public Choice in Health. Manpower
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Acceptance of Me_caid Patients. abs. no. 682 of Private Practice Physicians, 1979. abs. no. 8037
Worthington, Paul N. Alterna_'ves to Prepayment
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Growth
Two Health
Wyatt Co., Washington, DC 20006 Group Benet_t Survey. Plans Coveting ers, 1980. abs. no. 340
Salm4ed
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Zycher, Benjamin Canadian National 63
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Surveys.
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Health
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Poh'tics and Perspectives
abs. no. 449 on Formulat-
abs. no. 761
abs. no. 749
Health
Insurance.
Lessons for the United States. abs. no.
Commum_y
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of U.S. Employ-
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G. and New Health
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Young (Arthur) and Co., Washington, DC 20036 ._Iethods for Setting Pnbtities in Area_'de Health hog, ted Bibliography. abs. no. 589 Young, Mary E. Health Insurance. Public Programs. Abstracts). abs. no. 398 Zapka, Jane: M. Assessment of Member
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IV-44
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Care Planning.
An An-
1980 (A Bibhography
Understano_hg
WTth
the Interac-
abs. no. 44
R.
Third Party Payment Recommendations. Zelten,
Pian on the
for Nonphysician abs. no. 900
Health Practitioners.
Reah'ties
and
A.
Health Care Programs
V. Title Index Access
to Ambulatory
Access 2
to Medical
Care for the Elderly.
Access
to Medical
Care, The Impact
Prepaid
Health
Achievements Achieving
Care and the U.S. Economy.
Insurance
Cost-Effective
Achieving Optimum phy. abs. no. 6 Adding
Practice
Utilization
of Private
Administration
Health
's Program
of Outreach
and Medical
Alcohol
in a Prepaid
of Ancillary
Alcoholism
Alcoholism
Insurance
for Health
Altering
System.
Handbook
of Physicians" Medicaid
of a
Ambulatory Pharmaceutical abs. no. 24 American
Attitudes
American
Biomedical
Future.
Care Industry.
Bibh'ogra-
Toward
Health
for Medicare
Recipients.
Maintenance
Organizatmns.
abs. no. 7
abs. no. 8
Blue
abs. no. 9
Cross Plans
Network.
Health
Health
Care System.
Issues
American Medical Association and The Molda'ng of Pubh'c Opinion, American
Medicine.
America's
Health
A Pilot Prvl'ect.
abs. no. 25
Care Systems
in America
and Problems.
abs. no. 27
Challenges
Compulsory 1920-1965.
Presenl
National Health abs. no. 28
and
Insurance.
for the 1980s. abs. no. 29
Care System,
A Comprehensive
Portrait.
Analysis and Planning for Improved Distribution Services. Final Report. abs. no. 31
abs. no. 30
of Nursing
Personnel
and
Versus ComAnalysis of Case Mix Related Grouping.
Complexity Using Information abs. no. 32
Theory
and Diagnostic
Analysis
of Economic
Performance
Practices.
Analysis
of Programs
abs. no. 11
Data on Utib'zation
for Prepaid
Group
Group
Practice
Services.
Provider
the Operation
in Medical
Group
abs. no 33
of Services.
Oral Health
Alternative Health
Physician Insurance.
Alternative
Services.
Service
Delivery
Payment Methods. abs. no. 19
Methods.
Analysis
of Prospective
Analysis
of Requirements
System abs. no. 16
to Institutinnal
abs. no. 18
Incentives,
Eftlciency,
AltcrtJatJve_
to Nursing
Altcrnatives
to Prepayment
Ambulatory
Care Syswms.
Care. An Analysis
Homes.
Expenditures.
Systems
in Upstate
for a Cost Benel_t Structure
With Initiai Focus
and National
abs. no. 20
Draft
Final Re-
New
York.
abs. nc_.35
on CHAMPUS.
for the Military
Mtxtical
abs. no. 36
Reimbursement
Programs
on Hospital
Analysis
abs. no. 8001
Annotated Aspects
Services.
Volume IV. Designing
Medical
Bargaining.
of Workers"
Impacts
of National
Final Report.
Compensation
Services Review
Laws.
and PSROs.
Health
Insurance
Programs
on
abs. no. 38 abs. no. 39
What Can the Demonstration
Prod;rams
Tell Us. abs. no. 40
of State Initiatives.
for Hospital
of the Potential
Collective
abs. no. 21
Finance
Payment
Analysis of the Effects of Prospective Expenda'tures. abs. no. 37
Ancillary
A /zcrnatives
Capital
abs. no. 17
Systems.
The Case of Free Clinics.
Hospital
abs. no. 13
abs, no. 15
on Length-of-Visit.
Reimbursement
to Limit
port. abs. no. 34
Plans. abs. no. 14
HMOs.
Evidence
of a Computerized
Analysis Alternative
Services
abs. no. 26
American
An Annotated
Cost ContainmenL
Through
1. Actuarial
Within Prepaid
Allocation
on Enrollees
Plan. abs. no. 5
Coverage.
Patterns
Management
Services
Alcoholism
abs. no.
abs. no. 23
abs. no. 12
Program
Information
Services
Services.
to the Health
Care Utilization
and Health.
Barriers Matter.
Organizations.
abs. no. 3
Administrative Costs of Medicare Contractors. mercial Intermediaries. abs. no. 10
Age
Maintenance
of Me_b'caid. abs. no. 4
a Dose of Competition
Adequacy
Do Non-Price
Program.
and Problems
abs. no. 1
abs. no. 22 Services
Bibliography
of Health
of Meab'care in Colorado.
Economics.
abs. no. 41
abs. no. 8002
Assessing Quality of Care and Oral Health ance. abs. no. 42
in a Population
With Dental
insur-
for Health
V-1
Assessing cian's
the Ugh'zaOon and Productivity of Nurse Practitionet_' Assistants. Methodology and Finak'ngs on ProducNvity.
Assessment of Member Satisfaction in an HMO. Understanding of Variables and Their Imph'cations. abs. no. 44
and Physiabs. no. 43
the Interaction
Capital Requirements rice Prepayment Capitation
and Capital Financing Plan. ab:_. no. 65
for Pharmacy
Care of the Aged. Attempts
to Control
Health
Care Costs.
The United States Experience.
on Industry's
Changing
Role in Health
Care Delivery
in MedicMd. An Examination of a BenetTt Recovery System
of the Development and Irain the State of Minnesota. abs.
no. 47 Benetft Rights 48
and Privacy.
BenetTts in Medical
The Insurance
Care Program_
System
and Fertility
Bibliography
on Health
Cross,
What
Policy
Went
and Lifestyle
Wrong.
Business
Behavior
"Personal
Change.
Care" Pro-
abs. no. 51
and Controversy.
Health
on Industry
Facilities
and Health
Commission.
An Exploratory
A Case Study
of Government
Coexist
With Demand
Crea_on.
Can tteahh Mat)_tenanee Organizations Be Successful. erally OuM97ed HMOs. abs. no. 59
Care Deliver.
Approaches
An Analysis
of 14 Fed-
Rates.
abs. no. 69
Case-Mix
Between
Difference
to Health
Care Through
Government.
Policy Decisions.
Where to From
Insurance,
Insurance.
A Review
Lessons
of Publicly
HeMth
Catastrophic
Insurance.
V-2
Exploiting
abs. no, 64
Insurance.
of PnTnary
Hospitals.
abs. no. 70
Center for Health Statisncs.
abs. no. 72
Illness in an H_,tO.
for National
Health
Policy in the
abs. no. 74
Care. abs. no. 75
Changes in the Costs of Treatment no. 76
of Selected
Changing 77
Health
From a New Mech'cM Care Setting.
Changing
MedJcald
Care. Perspectives
Population.
Illnesses.
1951-1964-1971.
abs.
abs. no.
for the United States.
Available
abs. no. 78
and Imph2"ations for Cost and
Role of the Hospit_d.
Characteristics
of Group Health
Charges and Sources of Payment Preview 2. abs. no. 81
of Payment
Options
Ouah'ty of Dental
Plans.
for the Future.
Care. abs.
abs. no. 80
abs. no. 8005
for Dental
Visits With Separate
for ½"sits to Physician
Checkbook "S Guide to Health Insurance District of Columbia, Maryland, and ment Employees). abs. no. 83
Documents.
abs. no. 63
America's
or?ices.
Charges.
Data
Data
Preview
Plans for Federal Employees. For Virginia (Also covers D.C Govern-
Fear for Prot_t. An Examination
Futg_e. abs. no. 84
Children and Dental Care. Charges Characteristics. abs. no. 85
and Probability
of n Visit by Individual
abs. no. 8003 Clup Commission.
Cancer Insurance.
and For-Prolft
Catastrophic Illness Expense. Implications United States. abs. no. 72
Child Health.
Health
NonprotTt
_National Health Insurance.
abs. no. 62
National
Leadership
abs. no. 68
Catalog of Public Use Data Tapes from the National abs. no. 71
Charges and Sources 5. abs. no. 82
abs. no. 60
Canada "s Thirty Years of Health Here. abs. no. 61
A National
abs. no.
Can Health Be Planned. Or, Why Doctors Should Do Less and Patients Should Do ,_ore. Forecasting the Future of Health System Agencies. abs. no. 58
Cancer
Case for Negotiated
Changing
Can Primary
Policy.
Regula.
57
CanadJan
Service.
Changing Patterns no. 79 Reimbursement
abs. no. 66
Care. abs. no. 55
riga. abs. no. 56 Can Fee-lbr-Service
of New Solutions.
and HeMth
Health
Challenge
1979. abs. no. 54
Perspective
California
Canadian
in Need
Case for a National
Catastrophic
abs. no. 52
Brown Lung Disability. Costs, Compensation Policy Study• abs. no_ 53
Build Study
Control. abs. no.
abs. no. 49
Better Services at Reduced Costs Through an Improved gram Recommended for Veterans. abs. no. 50
Blue
Old Problems
abs.
• no. 46 Benetft Recovery plementation
Prac-
Ser_Tices. abs. no. 8004
Carter Adrmnistration, Congress Conference. abs. no. 67 Papers
Group
abs. no.
45 Background
in a Hospital-Based
Final Rel_rt,
abs. no. 86
of Dread Disease Choice Between no. 87
Family
and Individual
Deductibles
in Health
Health
Care
Insurance,
Programs
abs.
Chronic Illness and Health Services Use. A Before-Al_er Study of Canadian NationM HeMth Insurance. sbs. no. 88
ConceptuMization and Measurement of Health for Adults in the Health lnsurance Study. Volume VIII, Overview. abs. no. 110
Clinical Efficacy Assessment Program. abs. no. 8006
Cono_'tions for Change in the Health Care System. abs. no. 111
Coinsurance and the Demand for Physician Services. Four Years Inter. al_. no. 89
Conference and Unresolved Problems. abs. no. 112 Conference on Health Promotion and Disease Prevention, February 16-18,
Community Mental Health Centers. The Federal Investment. abs. no. 90
1978. Volume L Themes and Poh'cy Suggestions. abs. no. 113
Comparative Absence ExpeJqence Among Employees Covered by a Prel_id or a Blue Cross_Blue SMeld Health lnsunmce Progrum. abs. no. 91
Conference on Health Promotion and Disease Prevention, February 16-18, 1978. Volume IL Conference Summaries. abs. no. 114
Comparative Experiences in Controlling Expend'turns for Pre_ription Drags in State Medicaid Prognuns` abs. no. 92
Consequences of lnere&_d Third.Party Payments for Health Care Services. abs. no. 115
Comparative National Policies on Headth C_re. abs. no. 93
Considerations in the Design of Mental Health Benet_ts Under National Health Insurance. abs. no. 116
Comparing Dented Care Systems in C__-M,,Torm'a. abs. no. 94 Constitutinn_'ty of Medical Malpractice Reform Legislation. A Supplemental Comparing the Me_'cM Utih'za_'on and Expenditures of Low Income Health Plan Enrollees With Medicaid Recipients and With Low Income Enrollees Having Medicaid Eligibih'ty. abs. no. 95 Compaffson of Group Meds'eal Care Insurance Benelits to CT_arges`ahs. no. 96 Comparison of Organizational Sponsorslu'p and Selvice Arrangement V&qables Among Prepaid Mec_'cal Group Practices in the United States. abs. no. 97
Report. abs. no. 1lq Consumer Acceptance of HMOs. abs. no. 118 Consumer Attitudes Toward Health Poh'cy and Knowledge About Health Legislation, al_.. no. 119 Consumer Expenditure Patterns. Volume L Food, Household Supph'es, Personal and HeMth Care Products. abs. no. 120
Comparison of the Hospital Cost Expetqence of Three Competing HMOS` abs. no. 98
Consumer Influence on the Qu_'ty of Dental Care. abs. no. 121
Comparison of the Quality of Maternity Care Between a Health-Mttintenance Organization and Fee-For-Service Practices. abs. no. 99
Consumer P&nffeil_tion and Community Organization Practice. Implications of National Health Legislation. abs. no. 122
Comparisons of prepeid Health Care Plans in a Competitive Market. The Seattle PrepaM Health Care Project. abs. no. 100
Consumer Preferences for Health Insurance. abs. no. 8007 Consumer Responsibih'ty in a Prepaid Group Health Plan. abs. no. 123
Compensation Arrangements Between Hospitals and Physicians. abs. no. 101 Consumer Satisfaction. A Model for Health Services Administrators. Competing for Acute Care Dollars. The Economics o£Risk Reduction. abs. no. 102
abs. no.
124 Consumer Satisfaction in a Health MMntenanee OrganizJtion. abs. no. 125
Competition and Regulation. The Consumer Choice Health Plan Alternative. abs. no. 103 Competition in the De#very of Med_'cal Care. abs. no. 104
Consumer-Centered vs. Job-Centered He_dth Insurance. abs. no. 126 Consumer-Choice Health Plan. A National-Health-lnsurance Proposal Based on Regulated Competition in the Pn'vate Sector. abs. no. 127
Competition in the Health Care Sector. Pas_ Present and Future. abs. no. 105 Consumer-Choice Health Plan. Intlation and Inequity in Health CazrcToday. Competitive Response of Blue Cross and Blue Shield to the Health Maintenance Organization in Northern CabYornia and Hawah: abs. no. 106
Alternatives for Cost Control and an Analysis of Proposals for .National Health Insunmce. abs. no. 128
Complex Puzzle of Rising Health Care Costs. Can the Pn'wte Sector Fit it Together. abs. no. 107
Containing Costs in Third Party Drug Progntms. Selected Bibh'ography and Abstracts. abs. no. 129
Comprehensive Bibh'ography on Health MMntenance 1978. Volume 1. abs. no. 108
Containing Health Benefit Costs. The Self-lnsurance Option. abs. no. 130
Organizations, 1974-
Containment of Hospital Costs. A Strategic Assessment. abs. no. 13!L Comprehensive Market and Regulatory Strategies for Medical Care. abs. no. 109
Contrasts in HMO and Fee-for-Service Performance. abs. no. 132
V-3
Control
of Hospital
Controlh'ng
Health
Costs by Rate-Setting.
abs. no. 133
Care Costs. A National
Controlling Health no. 135
Leadersttip
Care Costs. Strengthening
Cost Effective
Conference.
the Private
abs. no. t 34
Sector's
Hand.
Acute
Cost of BeneHts for AlcohoKsm no. 158
Hospital
Costs.
The Revealing
Case of Indiana.
Controlling 137
Hospital
COsts. The Revealing
Controlling
Medicaid
Controlling
Rising
Controlling
the Cost of Dental
Care.
Controlling
the Cost of Health
Care. abs. no. 141
Controlling
the Costs of Retirement
abs. no. 136
Case of lnch'ana. Summary.
abs. no.
Cost of Disease
Hospital
Pattern_
Care Review
Cost of National
abs. no. 140
Income
Cost-Benetit
Health
ence.
and Demand
and Meddoal
Services.
Organization.
Cost and Regulation 146
of Medical
and Health
The New Mexico
A Four-Year
Technology,
Planning.
no.
abs. no.
Medzcald
of Primaqy Mental
Future
Poll'cy Direcffons.
abs. no.
A Bibb'ography,
Payer.
Negotiations
in &aired States
in the Health Care Industry.
Cost Coatamment
?v/echam_s.
Ccm_m_vcnt
Through
abs. no
Employee
for Tlu'rd Party Cover-
abs. no.
abs. no. 164
and Treatment
Drug Formulary,
Healch
Program
at the
Loudsiana
vs. Texas. abs.
Prevention.
abs. no. 167
Fanih'ty. abs. no. 168 Its Effects
on Health
l_'sks, and Benefits
of Surgical
Service
Utilization.
abs.
L_ccnri_'es
of Surgery.
of a Catastrophic
Supplement
to
abs. no. 171
Medt_-M Schoo/s.
Care Costs. abs.
Care. abs. rto. 173
CUrrent Emphasis Current Iss_
P:ogra_a.
Health
Development A Survey
of Intermediate
of State
Oflfcials.
Care Facilities
for the Men-
abs. no. 174
abs. no.
_2_s. no. 151
or Relbrm.
on Rising
Fees. abs.
152
Rehabi_tation
Effects
Council on PPage and Pn_e ,_tability Report no. 172
abs. no. 153
in the National
on Preventive
Health
Medicine.
in _&rational l_sur_ce
Cutting Cost _Tthout 178
Planning
Program.
abs. no. 175
_os. no. 176
for Mental
Health
Services.
CottfiJg the Ough'ty of Care. Shattuck
abs. no. 177
Lecture.
abs. no.
_bs no. 154 Day
CS)st _ O _tainme_lr Through rv ,_" ;he D_'_,tneTt
Participation.
Screening
Costs, Financing, and Dis_;butional Merle'care. abs. no. 170
Current Developments
Cost Containment
Co,t
Medicare
Industry:
abs. no. 147
150
dTo_t C mr_+_n_lenL Meab'cal System
abs. no. 162
in the Hospital
and Secondary
in Health Insutance.
tally Retarded. Efforts
Mandatory
Cost-Effec_veness
Current and Future Educatton
abs. no. 161
Experi-
z49
Cost ContaYnment
abs. no. 160
Experimen-
Case Study.
Crisis in Health by a Third P_ty
abs.
Cadre Costs. abs. no. 145
Cost Containment and Quah'ty Assurance Requirements age for Ambulatory Psyctu'attic C_re. abs. no. 148 Cost Containment
of Quebec.
vs Hospital.
and Price Competition
of a Restrictive
Costs, Cost Containment
Program.
in the Year 2000.
The Province
Hospice
CosC-Effectiveness no. 166
Cost-Sharing no. 169 Health
Insurance
Care Plans. abs. no.
for Mea_'cal Care. The California
Role in Containing
Insurance.
Cost-BeneHt Study of a Hyp,-rteusion Work Setting. abs. no. 165
abs. no. 144
Corporate
Health
abs. no. 159
Care. Home
Analysis
Cost-Financed Copayments
Illness•
Cost Reimbursement 163
Costs. abs. no. 139
the Use and Cost of Me_'cal
in a National
abs. no. 157
abs. no. 138
142
tal Medical 143
in Michigan.
and Illness i_ the United States
Coat of Terminal Utih'zation
Planning
abs. Cost of Catastropttic
Controlling
Controlling
Care Facilities
R.,s._-Sharing oy Ptzm_r). Care Physic:arts. ,._i"L'_;#ea Hea#.__,care. abs. no. !55
A Hi, w-
ll,osl/_._2,'_L_ ::. _ C_:_-EtFec_;v_ Study. ab_. no. 179
22_cZ,vScrm_
".7_,_t_,':bct an_ Bc_cfits. _.ss )c-sated w_t_ Oa_m_5.!i,_ry C_zc _z_d totcr_ed:_c Nur.;L,:g .Ta,-e. ass. _c. 8_".3";
4ltevn_tive
_ei<,sCi.t_t_c_na., z_ri_,t_. (_bmplexiti_s
to Inpatient
in Pcli_y
!_:_sNtt_c_)_e,__L'za_ioc_ -,_:# _4entM HealJ_ 5crv:ces.
ab:_ no
Care. A Pilot
a_d Program
Anal-
18
D.-:.I_;v::_U : ;"hk_e..r)2 ,.7a_¢ in .4,.,;erica. abs. no. 182
"a -_-
Health
Care
Programs
Delivery
of Health
Delivery
Prospers
Care in Urban Underserved in Diversity.
Areas.
abs. no. 183
Disest of Selected Health and Insurance 1977-79 Edition. abs. no. 209 Directions
Care
Practitioner
With Special
Demand
for General
Demand
for Mech'cal Care in a Rural SettinR.
Demand
for Supplemenauy
and Internist
Health
Emphasis
Services.
Racial
Insurance,
on Out-of-Pocket
Dental
Care and the Health
Dental
Care Demand.
Insurance.
Vision Care Benetits
in Health
Comparisons.
Matter.
Plans
Organization
Point Estimates
Statistics
Care for Handicapped
Dental
Insurance.
Dental
Insurance
Dental
Prepayment
abs. no. 189
ConcepL
and Impb'cations
abs. no. 190
for National
Problems
and Proposals.
People.
Special
Report.
Disabih'ty.
From Social Problem
Disability,
Health Status,
abs. no. 195
Program
Disabih'ty
Insurance.
Trends
Disability
Poh'cies and Government
Discounting 216
and DitTerential
and
a_.
Damases
Financing
Health
Model.
A Tool for Cost Estimation.
Care MonitonnR
System.
Policy and the Structure
Determinants
of Pediatric
Care Utih'zation.
Determinants 202
of Physician
and Pharmacist
Needs.
Health
Insurance.
Differences Digest
Group
by Age Groups
of Hospital
abs. no. 212
abs. no. 2 l 3
War II. abs. no. 214
Programs.
Pn'cing Practices
abs. no. 215 in the Health
Care Field. abs. no.
Group Practice.
An Actuarial
and Demographic
Past Events Economic
and Future Models
Implicatioos
Prospects.
of Physician
of
abs. no. 219 Behavior.
abs.
Spend
Too Much
(DRG)
Drug Coverage 225
of Generic
Drugs.
abs. no.
Worse.
of Hospital
Under National
Drug Prescription in am HMO. Earnings 227
Care. abs. no. 222
The Poh_'cal Pathology
of Health Policy.
abs.
Malpractice
Insurance.
abs. no. 224
Health
Insurance.
The Poh'cy Options.
Rates Before and Aider Enrollment abs. no. 226
of Alliod
Health Personnel.
Are Health
of a Medicaid
Workers
abet. no.
Population
Underpaid.
ab=;. no.
abs. no. 204
of Illness in Amezican
Management
in Health
Cost Containment
on Health
abs. no. 200
abs. no. 201
Claim Costs.
View of Me_b'cal Malpractice.
abs. no. 199
of Foderalism.
Support
An Economic
Economic
Analysis
of Alternative
Health
Economic
Class and Risk Avoidance.
Care Innovations.
abs. no. 22g
abs. no. 205
Diagnosis and the Dole. The Function ics. abs. no. 206
Diagnosis Related abs. no. 8009
Services.
abs.
abs. no. 203
and Future
of Health
World
and Deterrence.
Dollars and Sense
Present
of Health
no. 221
Doing Better and F_ling no. 223
Determining
abs. no. 211
abs. no. 196
no. 198
Health
Since
Their Autonomy.
Does America
Determining
Program.
Issues and Research.
Doctors and Their Workshops. no. 220
of the Health
of FaJTure. Health
and Utilization
Insurance.
Doctors
Description
Design
to Federal
Disabi_ty
Doctors,
for a Corporate
the Cooperative
Distribution of Nurse Practitioners and Physician Assistants. Legal Constraints and ReimbursemenL abs. no. 218
abs. no. 193
of Health, Education, and Welfare, Office ot'the Inspector General. Report, January 1, 1979 to December 31, _r979. abs. no. 197
Design
to Evaluate
abs. no. 192
abs. no. 194
Plans.
of the Panel
abs. no. 210
He_dth
Department Annual
Development
System.
Disenrollment From a Prepaid Description. abs. no. 217
Dental
Plans.
for the "80s. Final Report
Health
abs.
abs. no. 191
Care for Everyone.
Bern;Sis.
abs. no. 187
or Do D¢,,ductibles
Insurance
Maintenance
Dental
L Health
abs. no. 186
no. 188 and
Volume
abs. no. 184
Demand Elasticities for Health Price. abs. no. 185
Dental
Plans.
Information
Care Spending. Projects,
Distn'butive
System
Po_t-
Experience
under
Public
Me_'cal
Care
abs. no. 229
Economic
Cost of Illness
Rewsited.
Economic
Foundations
Economic
Issues in Prevention.
abs. no. 230
Stodu'es.
abs. no. 207
Third F,dition,
Insurance.
abs. no. 208
of National
He,clth Poh'cy. abs. no. 231
abs. no. 232
Economic, Social and Environmental Implications for Future Research
Determinants of Adult Health. and Policy. abs. no. 8010
Some
V-5
Economic
Viability of Community-Operated
Economics
and the Chronic
Economics
in Health
Economics
of Cost Containment.
Economics
of Industrial
Economics
of Medical
Care. A Policy
Economics
of Medical
Malpractice.
Effect
oft
Mandatory
Mental
Prepaid Health
Patient.
Plans. abs. no. 233
Second
abs. no. 236 History,
Theory,
Program
Practice.
of Physician-Controlled
Program
Effect
Insurance.
Care Costs.
of SSI on Mech'cald Caseloads
Health
Surgery.
Plan
on the
Findings
and Expenditures.
of an HMO
Effectiveness of Alternative Approaches OtEce Practices. abs. no. 8011
to Utilization
Effects
of Need
and Costs of Day-Care
Experiment.
Programs.
Services
Distribution.
Employee
BenetYts In Industry.
Employee
BenetTts 1979. abs. no. 259
Employee
Health Ber_et_ts. HMOs
Evalua-
of Advertising
Effects
of Financial
Lessons Incentives
Insurance
Policy
After
Review
Cover-
National
of Physicians
abs. no. 8012
for the ChronicMly
From Optometry.
Employer
and Medicaid
Provided
and Location
on the Development
on Access
V-6
and Mandatory
Dual Choice.
abs. no. 260
Related
Health
A Possible
Outcome
Plans and the Unemployed.
Benel_ts
in Private
of Escalat-
abs. no. 262
Non farm Business
Establish-
Related
Health Benefits States.
in Private
Volume
Nonfarm
IL Description
Business
H_gme. Costly
Implications
EpidemiologJc Revolution, National Departments. abs. no. 268
Health
for Medicaid
Insurance
Establish-
of Selected
Data. abs.
and Descnk_abs. no. 265
Enrollment Choice in _ MUIti-HMO Setting. The Roles of HeMth cial Vulnerabih'ty, and Access to Care. abs. no. 266 Entenng a Nursing abs. no. 267
by
Risk, Finan-
and the Elderly.
and the Role
of Health
City. A Comparison
of HMO
Equal Treatment care Services
and Unequal Benefits. A Re-examination by h!ace, 1967-1976. abs. no. 270
Equity
Services.
of the Use of Medi-
in Health
Care
Utilization
and Health
of Health
Cure Delivery
Empirical
Analyses
in Social Policy.
abs. no. 271
Decisions.
and Use of Medical
to and Quality
on the Health
Group Health
meats in the United no. 264
of the MedicM
Estimate of the Impact vices, abs. no. 273
Marketplace.
abs. no. 272
of Deductibles
on the Demand
for Medical
Care Set-
Estimated Cost of lmp;ementing the Regulations Limiting Payment Under Federa] Health Progr_uns to Maximum Allowable Costs (MAC'S) and Estimated Acqm'sition Co:_ts (EAC'S). abs. no. 274
Care. abs. Estimates
,_4echanism
abs. no. 258
Ill. A Randomized
no. 253 Effects of the Payment no. 254
Deducttbles
meats in the United States. Volume L Determinants of the Decision Establishments to Offer a Group Health Plan. abs. no. 263
Erosion
Effects of Income Maintenance on the Medical Status of Rural Families. abs. no. 252 of Medicare
A Pilot Survey.
Episodes of Illness and Access to Care in the Inner and Non-HMO Populations. abs. no. 269
abs. no. 250
Effects
Health
abs. no. 249
on Physicians'Specialty
Effects of Hospital Cost Containment Technology. abs. no. 251
and Individual
Employment, Unemployment, and Health Insurance. Behavioral rive Analysis of Health Insurance Loss Due to Unemployment.
abs. no. 245
abs. no. 248
Effects
The Bn'tish National
Family
Employer Acqmsition of Health Care Facilities. ing Premiums. abe,. no. 261
Employment
and Future
on the Health
Effect on Future Physician Requirements Health Insurance. abs. no. 247
of Certilfcate
Manpower
abs. no. 243
Current
Etfect of Unemployment Insurance Payments age of the Unemployed. abs. no. 246
Effectiveness
System.
Rates. An
for Elective
Group
Care Upon Health
Health
Effect of PSROs on Health tions, abs. no. 244
Delivery
abs. no. 238
Employment
Effect
abs.
abs. no. 237
on Meds'cMd Surgery
Consultation
of MediCal
Care for the Disadvantaged.
abs. no. 239
Effect of Duration of Membership in a Prepaid Utilization of Services. abs. no. 241
Effect of Organization abs. no. 242
on Health
Empiricial Study of the Differences Between in Health Insurance. abs. no. 257
Perspective.
Opinion
Analysis of the Massachusetts abs. no. 240
Recession
Efforts to Restructure a Medical Service. abs. no. 256
Care. abs. no. 235
Health.
Effects of the 1974-Zf no. 255
abs. no. 234
System.
abs.
of HMO
Growth
Estimates of Preventive HMO. abs. no. 276
and Related
Versus
Cost Savings
Nonpreventive
Medical
Health
1978-90.
abs. no. 275
Care Demand
Care
m an
Programs
Estimating Ethical
the Cost of HeMth
and Economic
Care Market.
Aspects
Programs.
of Governmental
abs. no. 277
Intervention
Factors Affecting the Choice Between Prepaid Insurance Programs. abs. no. 297
Hospital
EvMuation
of Alternative
Factors Affecting
Productivity.
abs. no. 279
Payment
Strategies
A Conceptual
of Health
Manpower
Shortage
Area
Criteria. Final Report.
Manpower
Shortage
of Market
Mechanisms
Evaluation
of Medical
Practices.
Evaluation
of the CA T Scanner
Area Criteria.
of Cost Control.
Literature
Review. abs.
abs. no. 283
abs. no. 284 and Other
Health
of Dental
in an Era of Stress.
Feasibility and Cost-Effectiveness no. 302
Federal
Control
Plans. abs. no. 298
Services.
A Review
Diagnostic
and Analysis
Information
on
Long. Term Care Settings.
abs.
Technologies.
abs. no. 301
of Alternative
of Pharmaceutical
Federal Government's ment Perspective.
Costs.
Role in Ambulatory 'abs. no. 304
The MAC
Experience.
abs. no. 303
Services
Development.
A Manage-
abs. no.
285
Federal Health Dollar, 1969-1976. A Charthook Analysis of Activities ,Supported and Strategies Pursued in Federal Expenditures for Health. abs. no. 305
Evaluation merits
of the Effects of National Health Service on MedicM Care Delivery in Rural Areas.
Corps Physician abs. no. 8013
Evaluation of the Formation and Operation of Health Care Delivery for Public Assistance Beneficiaries Enrolled in Prepaid Health California. Evaluation
PlaceFederal Systems Plans in
abs. no. 286
of the Maximum
I Report. 287
Final Design
Evaluation of the National no. 8014
Allowable Report
Aids
Corporate
Expanded
Health
Care Coverage
Expanding 289
Health Benefits
Benefits
Cost (MA C) for Drugs Progrsm.
and Report
Long-Term
Fimess
Expanding Health no. 290
of Pilot Study AnMysis.
Care Channeling
Health.
Fee-For-Service
Alternatives.
Demonstrattbn.
abs.
abs. no. 8015
Health
,Maintenance
Final Report
to the Legislature
Financial Analysis abs. no. 310
of Alternative
Drugs.
abs.
and Youth in the United States.
for Pharmacare
of America's
Older
Population.
Reimbursements
Care. abs. no. 309
A Referenced
Outline
Financial
Management Projection
Under
Third Party
in Prepaid
Dental
Reimbursement.
Care Plans.
Program
Financing
Health
Financing
of Health
Care. abs. no. 316
Financing
of Health
Care. abs. no. 317
abs. no. 312
abs. no. 313
Aider the Social
Security
Amend-
Care. abs. no. 315
and Denticare.
Findings and Imph'cations trative Organizations. Forecasting.
of Field Visits to Six Welfare Benetit First Interim Report. abs. no. 318
A Cost Control Federal
Tool for Health
Long-Term
Care Managers.
Care Expenditures.
Plan Adminis.
abs. no. 319
abs. no. 8016
abs. no. 295 Foreign Hospitals
in Medicare
Their
Financial Management of Health Care Organizations. and Annotated Bibliography. abs. no. 311
Forecasting A Profile
and
abs.
Study of the Acceptance of CUrrent Federal Health Care Policy by Administrators, Trustees, and Physicians. abs. no. 293 Options
Methods
abs. no. 291
no. 292
Health Insurance.
of C_rrent
Benefits.
Financial Status of Social Seeudty merits of 197Z abs. no. 314
Care of Children
abs. no. 307
Group Medical
Volume
for Health
Analysis
Plans. abs. no. 306
of Funding
for the Elderly.
and Their Effects.
Organizations.
Methods
Financial
II. Prescription
Insurance
on Ambulatory
Volume I. Long- Term Care. abs. no.
Expenditures
Factors Affecting Differences vices, abs. no. 296
of Health
for the Elderly.
for Health Care. Federal Programs
Book on Aging.
and Regulation
Phase abs. no.
abs. no. 288
Expenditures
Extending Canadian abs. no. 294
Taxation
Fee-for-Service Physician Payment. Development. abs. no. 308
Executive
Fact
Two Prepaid
abs. no. Family
Evaluation
Exploratory Hospital
Between
Facts At Your Fingertips, A Ginde to Sources of Statistical Major Health Topics. Fourth Edition. abs. no. 300
281
Evaluation of Health no. 282
and Alternative
Ap-
abs. no. 280
Evaluation
the Choice
Factors WhiCh Affect the Utilization of the La'terature. abs. no. 299
for Hospitals.
Group Practice
in the Meda'cal
abs. no. 278
EvMuating
proach,
Insurance
for Physicians"
Reimbursement
Systems.
abs. no. 8017
SerForward
Plan for Health
FY 1978-82.
abs. no. 320
V-7
Foundation
for Health
Foundations
Care Regulation.
for Medical
Health
Services
Framework
PL 92-603 and PL 93-641.
Care. An EmpitCcai
to a MedJ'cald
for Capital Controls
Investigation
Population.
in Health
abs_ no. 321
of the Delivery
Guide to Selected References on National (1930-1973). abs. no. 346
Health
Guidelines 347
An Annotated
Functional Costs. Fundamental
Fundamentals Funding Future
of Second
Opinion
Future Issues in Health vices, abs. no. 331 Future
of New
Health
Future
of private
Insurance.
Health
and Labor
Health
and Retirement.
Health
and
Health
and the War on l_Overty. A Ten-Year
Care. abs. no. 329
Health
Care. An American
abs. no. 330
Health Care Business. lnt,,'rnational Care Systems. abs. no. 356
Future Roles for the Federal no. 334
Government German):
for Reducing
Hospital
Public Health.
for Elective
Care. abs. no.
abs. no. 327
Surgery.
Reimbursement Government
Systems.
abs. no. 328
of Mech_al
and Conversion
Health and Welfare abs. no. 337
Provisions
Programs
States
Graying
Education
of America.
National
Advisory
Dental
Group
Insurance
and
abs.
West
Interim
Report.
Expense
Insurance
Cost Containment
Salaried Employees
Experience. Strategies.
of U.S. Employers,
V-8
Deduction.
Appraisal.
abs. no. 353
abs. no. 354
CHsis. abs. no. 355 Evidence
on Private
abs. no. 8018
Health
Care Cost ContainmenL
Challenge
to Industry.
ExpeHments.
Care Cost Containment
Health Care Cost Elemen_ alas. no. 360
Pol_y,
in West Germany.
Affecting
Legislalive
Versus Public Health
abs. no. 357
Individual
Rights,
and the
Care Cost Increases.
Health
Care Cost lnlTation in the Urn'ted States.
Cause and Control.
abs. no. 359 and Planning
Health
Considerations.
abs. no. 361 Toward
a Unitied
Theory of
abs. no. 362
Care Costs. An Atralysis
of Current
Trends in Health
Costs and Utiliza-
tion. abs. no. 363 Health
Care Costs. Pn'vs_:e Initiatives
Health
Care Costs.
for Containment.
abs. no. 364
Data
Stop-Loss
Sources.
Why Regulation
Health
Care Data Initiattves.
Why Competition
Works,
How
to
abs. no. 8019
Health
Care Dilemma
and Corporate
Health
Care Dilemma.
l_'oblems
Debt
Capacity.
abs. no. 366
abs. no. 342
Insurance.
An Attractive
New
of Technology
in Health
Care Delivery.
abs.
no. 367 Care Financing
Gptiuns
for Colorado.
abs. no. 368
MarHealth Care Guidance. Commercial Policy. abs. no. 369
Volume
Fails,
Get There From Her,'_. abs. no. 365
Health Group SpecilYc and Aggregate ket. abs. no. 344 to Medicaid
of the Medical
abs. no. 352
abs. no. 341
Group Practice Recommendations of the Committee on the Costs of Medical C_re. A New Look at an Old Issue. abs. no. 343
Guide
Taxes. An Assessment
Issues.
abs. no. 339
Group Bcnetit Survey. Plans Coveclng 1980. abs. no. 340 Group
Committee,
and Research
Care Cost ContainmenL
Health Graduate Mechcal abs. no. 338
abs. no. 351
abs.
Under Medi-
in Health Insurance.
in the Um_ed
Policy
Health Care Cost Containment Law. abs. no. 358
of HMO's.
to Physicians
Investigation.
Health
Health Payments
Power. A Theoretical
View. abs. no. 350
Ser-
abs. no. 333
in the Development
The Public's
abs. no. 349
Overhead
abs. no. 332
Geographic Variation in Physl_ians'Fees. care and Mech_ald. abs. no. 335 Going Bare. Continuance no. 336
and Health
Policy and the Rationing
Practitioners.
abs. no.
abs. no. 348
and Health
Care. Social
Third-Party
of Intlation.,
Health
of Economists
Programs
Care Organization.
A Victim or Cause
Care. Policies in Perspective.
of Dental
Practitioner
Bibliography.
of Selected and Health
Technique
Issues in the Practice
Rural Nurse Health
A
I_realth Services.
Health
A History
Value Analysis. abs. no. 326
for Planning
Care. abs. no. 323 Health.
to Reuidivism.
Medicine
of
abs. no. 322
From Charitable Immunity to Public Accountability. A Review Solutions to the Malpractice Problem. abs. no. 324 From Reform 325
Care and Socialized
Health
Insurance
and
National
Health
One. abs. no. 345
Health
Care
Programs
HeMth
Care in the American
Health
Care in the 1980s.
Who Provides.
Health
Care in Transition.
aim. no. 372
Health
Care Issues
Health
Care
Health
Care Policy
Future.
Economy.
for Industry.
Market.
Number
3. aim. no. 370
Who Plans.
Health
Who Pays. aim. no. 37!
and Poetics.
Survive.
Does
Health
Care Pob'cy in a Chan#Ug
Health
Care. Regulation,
Care System
Health
Care Systems
Promise
and Performance.
Health Insurance. Public Programs. Abstracts). aim. no. 398 Health
Insurance
Study.
Health
Insurance.
Health
Interview
Health
Maintenance
aim. no. 397
1978-June,
1980
(A Bibliograp_y
With
aim. no. 8020
the Past
Tell Us Anything
EnvironmenL
Economics,
About
Practice.
Taxation
in the United States.
Survey
and Minority
Organization
Role. aim. no. 399
Health.
Act
Health Maintenance Organization Health Care De, very System
aim. no. 400
Amendments
of 1978. aim. ne.. 401
Planning Mode/to Evaluate an Ah_ernative for the State of Georgia. aim. no. 402
aim. no. 377
of Tax-Exempt
Providers.
aim.
Health Maintenance aim. no. 403
Organizations.
A Guide
Health Maintenance Organizations phy. aim. no. 404
abs. no. 379
in World Perspective.
be the Federal
the
aim. no. 376
Etiffes,
Is Federal
What Should
aim. no. 374
aim. no. 375
Health
Plans.
aim. no. 373
Can Hospitals
Health Care Reimbursement no. 378
Insurance
aim. no. 380
Health
Maintenance
to Planning
and Prepaid
Or3anizations
and
Development.
Group Practices.
as an Instrument
A Bibliogra-
For Cost Containment
Po_'cy.aim.no. 405 Health
Care
Trends.
Minneapo_'s/St.
Health.
Catastropldc
Health
Health
Cost Problem.
Paul. Summary
Insurance.
Is Regulation
Highlight&
Health Maintenance no. 406
aim. no. 382 Our Only
Hope.
aim. no. 383
Health Costs Can Be Reduced by Mllk'ons of Dollars if Federal Carry Out GAO Recommendations. aim. no. 384 Health
Economics
and Health
Health Employment aim. no. 386
Care. Irreconcilable
Requirements
in the Future.
In the Pink
Health
in the United
States.
Health Insurance no. 389 Health
Insurance
Health
Insurance
or in the Red.
Chartbook.
and Cost-Containment
Bibliography. Coverage
State Employees.
Health Maintenance Must Continue
Agencies
Health Insurance
Organizations
Can Help Control
Organizations. Federal Financing Improving Program Management.
Care Costs. abs.
is Adequate But HEW aim. no. 407
Schemes.
aim. no. 387
Health Maintenance
Organization_
Health
Organizations.
Maintenance
Health Manpower for the Nation. merits, aim. no. 410 Health Personnel 411
Meeting
Product
Life Cycle Approach.
Selected
Bibliography.
A Look Ahead
the Explosive
aim. no. 409
at the Supply
Demand
abs. no. 408
and the Require-
for MedJeal
Care. aim. no.
aim. no. 388 Policies.
The Expeaqence
Abroad.
aim.
Health Plan. The Only Practical aim. no. 412
Solution
to the Soaring
Health
Planning
and Regulation.
A Manual
Health
Planning
and Regulation
Effects
for State
Cost of Medical
Legislators.
Care.
abs. no. 413
aim. no. 390
for Alcohol/Drug
A Feasibih'ty
Evaluation.
Health
Insurance
Coverage
for Alcoholism,
Health
Insurance
Coverage
of Veterans.
Health
Insurance
in the Medicare
Addiction
Treatment
abs. no. 391
Health Planning as a Regulatory Current Uses. aim. no. 415
Health Insurance Industry. Structural ronment, abs. no. 396
Costs. aim. no. 414
Strategy.
A Discussion
of its History
and
1975. aim. no. 392
Data Preview
4. abs. no. 393
lmplica_ons
and Strategic
for the United
Kingdom.
Issues in an Uncertain
Issues in Guideline
Developmem_.
aim. no.
416
Years. aim. no. 394
in the United States.
on Hospital
for Vir_'nia
Health Planning in the United States.
Health Insurance aim. no. 395
Health
Fully
Gap. abs. no. 385
Under Alternate
Health
aim. no. 381
Envi-
Health
Promotion
Health
Reform.
Health Services 419 Health
Services,
Programs The Outlook
in Occupational for the 1980s.
and Health Hazards.
Power
Centers,
Settings.
aim. no. 417
aim. no. 418
The Employee's
and Decision-MakJn8
Need
to Know.
Mechanisms
abs. no.
aim. no.
V-9
420 Health
Services
Research.
abs. no. 421
Health Status and Use of Medical Services. and the Rural Elderly. abs. no. 422 Health
Status,
raphy
Medical
Care UHlization,
of Empirical
Studa'es. Volume
Evidence
on the Pc_r, the Black,
and Outcome.
An Annotated
Hospital
Collective
Bargair_ing.
Structure
Hospital
Cost Containment
Act
Hospital
Cost Containment
Programs.
Hospital
Cost Containment.
Selected
Hospital
Cost Control
and Process.
of 1979. abs. no. 447 A Policy Notes
for Future
1. abs. no. 423
in ,_faryland.
Bibhog-
Hospital Cost InlTation and Health Insurance. no. 451
Health Status, MedJ_al raphy of Empirical
Care Utilization, and Outcome. An Annotated Studies. Volume 3. abs. no. 425
Bibliog-
Hospital
Cost Infla6on
Hospital
Inflation.
Health
Care Utilization,
and Outcome.
Bibliog-
Studies.
4. abs. no. 426
Hospital
Production.
Hospital
Rate Setting.
raphy
of Empirical
Volume
An Annotated
Health Status, SocioeconomYc Status, and Utilization of Outpatient Members of a Prepaid Group Practice. abs. no. 427 Health,
United
Health.
What Is It Worth.
HIAA
States,
Reviews
Ser_ces
for
State
Cost Control
of Health
Benefits.
Reguladon.
abs. no,. 429
Cost of Hospitals
and
and Organization
What to Do About
System. HMO
of Pretreatment
Review,
A Transactions
to Provide
a Dental
Health
Utih_ation
In-
HMOs
From
the Management
Home
Health
Care Services.
of Health
Analysis
System
Reform.
Perspec_ve. Tighter
Hospice.
Creating
Hospice
Movement
Essential
and Literature
New
Models
Hospice.
Prescrip_on
Hospital
Backlog.
for Terminal
Hospital
Capital Expenth'ture
Patients
Controls
for the Elderly.
States.
Physicians.
Hospital-Based
Versus
abs. no. 444
V-IO
Care in America.
Employee
Free-Standing
Medabal
Primary
Interference
Preliminary
Benefits.
or a
Bibliogra-
abs. no. 457
Evidence.
Care Costs.
Care Group Practices.
Interviews
and Minority
Can Improve
Health
How Business
Can Stimulate
How Business no. 465
Can Use Specit_c
How Business
Interacts
abs. no. 439 Ill. abs. no. 440
abs. no.
abs. no. 459
A Developing
Modality
of
Health.
The NCHS
Perspective.
Planning and Regulation.
abs. no. 462
Good Health
a Competitive Techniques
Wi_h the Health
for Employees
Health
and
Their Families.
Care System.
to Control
Care System.
Health
abs. no. 464
Care Costs. abs.
abs. no. 466
How Cheap is a Life. abs. no. 467 How Interested Groups Have Responded to a Proposal tion in Health Services. abs. no. 468
for Economic
Competi-
To Go. abs. no. 443
Their Desired
and Expected
Can Business
E_'pect to Earn From Smoking
Cessation.
abs. no. 469
Results. How Much
abs. no. 445
Groups.
Current Issues and Descriptive
for the Elderly.
Provide
How Much
Hospital
Program.
How Business Can Promote abs. no. 463
Care. abs. no. 442
Controls.
Related
,_Iandated
Review.
abs. no. 441
With No Place
abs. no. 454
Rate Review.
by Diagnosis
abs. no. 437
Needed.
of Care for the Terminally
in the United
abs. no. 453
abs. no. 435
Policy to Better
Option
abs. no. 452
abs. no. 436
Fiscal
Home ttealth. The Need for a National al0s. no. 438
Services.
Through State abs. no. 455
Hospital-Based 458
How Business
Homemaker
This Way to Salvation.
Self-Insurance
Household Health abs. no. 461
and the Politics
a'os.
Review
abs. no. 434 HMOs
Model.
abs. no. 8021
Can Costs Be Contained.
Hospital-Sponsored Primary Care. abs. no. 460
Decision.
Market
It. abs. no. 431
abs. no. 433
Fmrollment
abs. no. 449
abs. no. 430
Historical Development of the California Pilot Program surance Coverage for Alcoholism. abs. no. 432 History
Study.
Hospital Reimbursement phy. abs. no. 456 Hospital
High
Policy.
A Complex
A Diagr_,osis and Prescription.
Hospital Regulation Noble Intrusion.
1980. abs. no. 428
Measures
abs. no. 448
abs. no. 450
Care Utilization, and Outcome. An Annotated Studa'es. Volume 2. abs. no. 424
Medical
Analysis.
Bibliog-
Health Status, Medical raphy of Empirical
Status,
abs. no. 446
How
Things
Will U.S. MedJeine Work in the _'eal
Change in the Decade World of Hospital
Ahead.
Finance.
abs. no. 470
abs. no. 47l
Health Care Programs
How
to Improve
Idea
Whose
Illness
Health
and Contain
Time Has Come.
Prevention
Costs.
Less Health
and Mech'cal
Insurance.
Insurance.
Impact of a Change in Regulations no. 475
abs. no. 472
Improving Health in America. abs. no. 495 Incentive 496
on Costs in an Experimental
Program.
abs.
Income
Tax for Medicare,
Impact
of Family
Impact
of Health
Nurses
Structure System
on Children's
Changes
Insur_ce
Health
on Demand
Care
for Health
of liMOs.
Impact
of Long-Term
Impact
of Membership
Health
Evidence
on the Nation's
Requirements
Services
in an Enrolled,
in a Group
of National
Issues.
C_re on Functionally
Health
Insurance
in Hospital Expenses,
Inok'vidual Accident
Adults.
Population
abs. no. 8022 on
Industry
and HMOs.
Industry
Roles in Health
Impact
Health
Services
on the Diffusion
of New
Impact
of State
Utilization
of
Unemployment
Intluence
of Competition
Policy.
abs. no. 502
and the ,_ledicaid
Government
on Financial
Laws on Health
Rate Setting
in California. Technologies
Security
Itealth
of the Rhode
Island
C_tastrophic
Impact
of the 1974
Health
Care Amendments
Impacts Care
in the Health
of Health Costs.
Implementing
Maintenance
Health
Care Industry. Organization
Organization.
Federal,
State, and Local
Oral Health
Policies.
Renal Disease
of an abs. no.
abs. no. 506
Systems.
Management.
Insurance
Older Employees.
abs. no. :508
Out-of-Pocket Payments, and the Demand of the Literature. abs. no. 509
for Mech'cal
abs. no. Insurance 510
Cost Savings Due to an Adequate
Insurance
Coverage
Insurance,
Regulation,
Alcoholism
Health
BenetYL abs. no.
abs. no.
Intensive
Insuring
the Nation's
Implications
and Hospital
Psychotherapy.
Costs.
for Health
Policy.
Program
Interaction of Supply no. 51:5
on Community
of Medicare.
abs. no. :512
abs. no. 513
Health.
An Evaluation
of Three Approaches.
abs. nc,. 514
and Demand
in the Market
for Physician
Services.
abs.
Health Why Health
abs. no. 492 Interim
the Poor. The Neighborhood
Report
to Congress
The Role
on Occupational
Diseases.
abs. no. :517
Health International Dental abs. no. 518
Areas.
abs. no. 511
on Collective
abs. no. 490 Growth
Insuring
and Access.
Plan, abs. no. 489
to the NLRA
Care in Underserved
of Principles,
in Hospitals.
Interfacing National Health Insurance and Income Maintenance. and Weffare Reform Go Together. abs. no. :516
Improving Access to Health Care Among Center Experience. abs. no. 493 Improving Access to Medical Practice. abs. no. 494
on the Development
Maintenance
abs. no. 484
abs. no. 491 the End-Stage
abs. no. 504
Care Costs and Utilization.
on Hospital
Impact
Bargaining
Program.
for Sight Correc-
abs. no. 487 Impact of State 488
abs. no. 503
by Prepaid Group Practice
Practice Association.
Insurance Benetlts, Care. A Review
Certitlcate-of-Need
abs. no. 500
Information Needs of National Health Insurance. A Discussion Issues, and Legislative Recommendations. abs. no. :507
Changes
Cost
Care. abs. no. 501
Injuries at Work Are Fewer Among
Impact of Social and Economic 486
With Man-
Mandatory
abs. no. 499
Co_ts and Charges in Maryland.
Intlation,
Influencing
Impact of Rate Regulation abs. no. 485
abs. no.
York. abs. no. 482
on the Use and Spending
13 on Mental
Alhanee.
of States
Without
Loss Ratio Dilemma.
A Natural
Voice in Health
Individual 505
Impact of National Health Insurance tion Services. abs. no. 483 of Proposition
1976.. 1979. A Comparison
and Health
IntTation in Hospital
abs. no. 481
on New
Health Insurance.
for Registered
abs. no. 480
Disabled
Prepaid
Practice.
and National
datory Cost Containment Programs and States Containment Programs. abs. no. 498
Industry's
and Research
MecUcald
Care Use. abs. no. 478
in 1985. abs. no. 479
Impact
Impact
Health Treatment on Medical Literature. abs. no. 476
Health
of 1977-80.
and Illness. abs. no. 497
Increases
tmpaet of Comprehensive National Manpower. abs. no. 477
Highlights
abs. no. 473
abs. no. 474
Impact of Alcohol, Drug Abuse and Mental Utilization. A Re_'ew of the Research
U.S. Public Health Service
Care Delivery
Systems.
Issues
in Dental
Health
Po,'icies.
of Group Issues
in Dental
Health
Poh'cies. abs. no. :519
V-11
Issues in Health
Care Regulation.
abs. no. 520
542
ls_ues in Regulating OualJty of Catrc and Containing Policy. abe. no. 521 Issues Involved in the Development Care Serv/cc_ abs. no. 522
of a Prepaid
Japan _ High-Cost
Program.
Costs Within Pn'vatc Sector
Capitation
Plan for Long- Term
Manpower
Mc_urcmcnt of Expcnc_'urcs Methodological Findings Measuring
1974-76.
Illness
Insurance
A Study of Its First Three
Program.
Hospital
Utilization
ReporL
abe no.
Medicaid. Medicaid
Justiee for the Patient and the Dcmt£st. Ou,_b'ty Ass_
Kaiser's
Fin_mcial
and the Amcr/cJn
Fund for Dcnta/He__ti_
and Some Cues for Other
Strategies
Law and Legislative
Activities
Summa_c¢
Federal
HMOs.
1979. First Session,
o[the
Summarie&
Laws of Motion in the For-Profit pin ab_ no. 529
States
1979. abs. no. 528
Health
Industry.
LegiMativc Response to the Medical tion_ abe. no. 530 Licensing Life
Cycle
Restrictions
Malpractice
abe no. 525
and the Cost t_'Dcntal
Preventive
Services
Study.
Ninety-Sixth
Program.
LinkJ'ng Physicians, Hospital cal Care. abs. no. 533
Management,
Magmtude and Determinants ab,_. no. 534 Mail-Order munity
the Elderly
Major Issues
Crisis.
Malpractice.
Funding
The Malpractitioners.
in the Community.
What
and
Was It All About.
Emerges
as a Critical
in HMO
Community-Rati_
An Empin'cal
._nd Potential
Reforms.
Study.
ab_ no. 546
abs. no. 547
abs. no. 548
Mcdicai_ Medicare, and Pn'vate Health Low-/ncomc Arc_ abe. no. 549
Insurance
CoveraSe
McdicMd
Millx Fact or F_ctio_
in Five
Urban,
Mcdicaid
Pa_ipation
abs, no. 550
and Medical
Care. ab_ no. 551
Exam-
Medical
Care Plan& How to Control
the Cost& ab& no. 553
Medical 554
Cam System
Health Insurance.
lmplica-
Medical 555
Care Use by a Group
to Preventive
and Bctter Me_h.
Cost Con_ui_ment
Under National
of Fully Insured
and Health
McdJ'cal Malpractice
Insuranee_
Mc_'cal
Law
Malpractice
in the U.S.A_ abe. no. 552
Agc_
MalnwJumcc
A Legislatur's
Four Modeds. abe. no.
A Case Study.
Organization&
abs, no.
abs. no. 556
View. abs. no. 557
2rid Ech'tion. abs. no. 558
Medical Malpractice IJ'_gation Expendable. abe no. ,_i59
Under National
Medical Malpractice abs. no. 560
Prc-Trial
Soreenin8
Medical
SuJa:. abs. no. 561
Health
Insurance.
Essential
or
Visits in the United States.
Foundation
of Health
Panels.
A Review
of the Evidence.
"sComMalpractice
Medical Malpractice. The Response California. abs. no. 562
of Physicians
to Premium
Mcclical Risks.
and Survival.
abs. no. 563
Increases
m
Care. abs. no. 536 Patterns
of MortMity
abs. no. 537 Issue.
Medical
Self-Care
Medical
Technology.
Prognu_s.
abe. no. 564
abs. no. 538
abs. no. 539
and Policy Issues
Experience.
Recipient&
Benefit
abs. no. 8024
Management
Managing MedJ'caid Drug Expenditures. aKs. no. 541
V-12
Cost Containment
Initiated
Current Issues
Mco_'cal Group Practice Approach
abs. no. 545
Medial
Catrc. abs. no. 531
Practical
of Physician
in the Financing
Malpractice
Mandated
Constitutional
Meo_'cine. An Analysis of the Sears Roebuck Medical Assistance Program. abs. no. 535
Maintaining
Management
A
Surveys.
Con-
abs. no. 8023
Lifetime Health-Monitoring Medicine. abs. no. 532
Two Health
and Dental Service& Study. abe. no. 544
abe. no. 526
A Theory and Three
CrisP.
Physician Insurance
W.K.
abs. no. 527 Law and Legislative
for Outpatient from the Health
and Utilization.
MedJczu*d and Cash Welfare
Cost Containment
Kellogg Foundation
Disabi_ty
Care. abs. no. 543
Years,
abs. no. 523
Joint Health 524
Policy for Prio_ary Health
A Different
View of the Contentious
Debate
Over Costs.
abs. no. 565 Development,
1979. abs. no. 540
An AnalysJs of Divergent
and Undctlvi_
Reimbursement
Approaches.
Medical
Technology
and Hospital
Costs.
MedYcal Technology.
Policies
Mc_'cM
The Culprit Behind
Technology.
abe. no. 566
and Problems.
abs. no. 567
Health
Care Costs.
abe. no. 568
Issues. abe. no.
Health Care Programs
Medical
Technology.
Medically
Indigent.
Medicare After no. 571
Who's A State
To Say
When
Perspective
and Medicaid
Amendments
Medicare
and Metticaid
Physician
a Broken
Coverage
abs. no. 569
Problem.
Promise
abs. no. 570
to the Elderly.
abs.
of 1980. abs. no. 572 Payment
Incentives.
Medicare Assignment Rates of Physicians. Reimbursement Policy. abs. no. 574 Medicare
Had Enough.
on a National
15 Years. Has It Become
Medicare
We've
for the Treatment
Model for Assessing Model
Wellness
Their Responses
to Changes
Practice,
and Disabled, 1975. Section Program. abs. no. 576
Medicare
Reimbursement.
Medicare
Reimbursement
and the Medical
2. Per-
1977. Section
Profession.
1. Reim-
abs. no. 578
Medicare.
Controversies Opinion
of Federal
Medigap. States Response abs. no. 583
and Appeals.
Demonstration
Hospital
to Problems
Mental Disorder and Primary Literature. abs. no. 584
Mental Health Services Plan. abs. no. 585
and Benefits.
Commission
Commission no. 599
Medical 197Z
Care Survey.
National Commission Collected Papers.
Summary.
Care.
Task Force Reports
C_,e
Cost
and E_tra
United
States,
1976-197Z Research
Volume
1.
Agenda.
abs.
on the Cost of Medical abs. no. 600
Care.
1976-1977.
Volume
2.
for Med_'caid
Project.
Insurance.
with Health
Medical
abs. no. 580
Care.
An
Enrollees
Commission
Literature
Greater New
York.
Reffews
on the Cost of Medical
Care.
1976-1977.
Volume
3.
Data
Bases. a_.
National
Health
Care Expenditure
National
Health
Care in Great Britain.
National
Health
Care Strategy
no. 601
Survey.
Lessons
Insurance
Series
Update.
Analytical
Review
in a Prepaid
Group
Short-Term
National
Health
Expen_'tures,
1979. abs. no. 604
Practice
National
Health
Insurance.
abs. no. 605
abs. no. 607
Mental
National
Health
Insurance.
A Social
National
Health
Insurance
and Corporate
National
Health
Insurance
and Health
National
Health Insurance
and Income
National
Health Insurance
and Primary
abs. no. 587
Methodology Used to Measure Health Care Consumption of the Health Insurance ExpetCment. abs. no. 588
Comprehensive
Care Demonstration
Metropolitan Comprehensive Care Program. Demonstration. abs. no. 590 Care Units. Mechanisms and Length
for Hospital
During
Care Planning.
Proposal.
A Health
Systems
More
and
Long-Term
Projec-
the First Year
An Annotat-
Placebo.
abs. no. 608
Benefit
Resources.
Plans.
abs. no. 609
The European
Experience.
abs. no. 610 DistHbotion.
abs. no. 611
abs. no. 8025
Cost Containment.
of Stay in the Hospital.
Outlook
of the
Insurance.
Priorities in Area wida Health abs. no. 589
abs. no. 602
abs. no. 8028
National Health ExpendJ'tures. tions, abs. no. 603
Health
for Employees.
for the USA.
for the Elderly.
National
Programs
abs. no. 8027
abs. no. 582
abs. no. 606
Mode of Payment abs. no. 592
in Health
of Dread Disease abs. no. 597
1977
on the Cost of MedJ_al
Recommendations
Insurance.
Minimal
abs.
abs. :no. 598
Health
Metropolitan
Initiative
The Overlap of Coverage.
National
Methods for Setting ed Bibliography.
States.
abs. no. 595
Administration
Mental Health Services. Utilization by Low Income Enrollees in a Prepaid Group Practice Plan and in an Independent Practice Plan. abs. no. 586 Wellness
in the United
abs. no. 579
Surgical
The Pofitics
Ambulatory
January-December
National
Medicare Second abs. no. 581
Insurance
in
National
Medical
abs. :co. 593
abs. no. 575
Medicare. Health Insurance for the Aged and Disabled, hursement by State and County. abs. no. 577 Medicare,
Eligibility
Health
Multiple Health Insurance Coverage. Cash Poh'cies With Other Types
of Alcoholism.
Insurance for the Aged in the Health Insurance
Medicaid
Closure. Final Report.
abs. no. 8026
Multilevel Care. A Veterans Control. abs. no. 596
National Medicare. Health sons Enrolled
Program.
Hospital
Modelling the Et_ects of National no. 594
MedifyYng
abs. no. 573
and Effecting
MedJ'cal Care for CIuTdren. abs. no. 612
Organization National Health Insurance no. 613
and the Market
National
as an Agent
for Private
Psyclu'atHc
Services.
abs.
abs. no. 591
Work for PSR Os.
Health Insurance
for Containing
Health-Care
Costs. abs.
no. 614
V-13
National Health Insurance as an Issue in Political Economy. The Implications of the Kennedy Health SecuNty Act for Developing a Strategy to Etl'eet Major Reorganization National
He.alth
of Health
Insurance.
Care Delivery
Benelits,
Costs,
in America.
abs
and Consequences.
no. 6]5
abs. no. 616
Negotiating Neighborhood Net
Health
Insurance.
Can
We Learn
From
National
Health
Insurance.
Canada _ Path, Amen'ca
National
Health
Insurance.
Conflicting
Goals and Policy Choices.
National
H,.'alth Insurance
in Cbnada.
abs. no. 620
National
Health
Insurance
in the Federal
]V_nbnal
Health
Insurance
National
Health Insurance
's Choices.
abs. no. 61 g abs. no. 619
Republic- of Germany
New
Group
New
The Adequacy
of Coverage.
:ssues. The Cost of a National
abs, no. 622
Prescn)_tion
Health
Insurance
Issues.
The Unprotected
National Health no. 625
Insurance
issues,
_Tabitity of the Cost-Sharing
National
Insurance
Congress
Proposals.
as of February
Provisions
Health
Insurance,
Psychotherapy,
National
Health
Insurance,
Some
Health
of Experience.
tbr Accident-Only
abs, no, 640
abs. no. 641
and
Intensive-Care-Only
abs. no. 642
Insurance.
Prntessionals,
Population.
Jersey Diagnosis
New Jcrsey Hospital abs. no. 646
Care. A Prescription
for the 1980_. abs. no.
abs. no. 644
Nur:;e Practitioners
abs
no. 624
Concept.
of Bills Introduced
Related
and Physician's
Group (DRG)
Reimbursement
abs.
New
York Case _[ix Study.
New
York State Long
Ntfl
Won't
Assistants.
abs.
Evaluaobn.
Under S.446.
abs. no. 8030
Elements
and Effects,
1980.
Control
ab:_. no. 8031
Term Health
Costs,
Quality,
and the Demand
Care Program. or Access,
abs. no. 647
abs, no. 648
for MecScal
Care. abs. no. 649
in the 94th Note
on the Compa_son of the Hospital HMO's. abs. on. 650
Cost Experience
of Three
Competing
and the Poor. abs. no. 627 Nurse
Costs and
Effects
of Mandated
Nurslbg
1Vatl,mal Health
Insurance.
What No_;
_¢77at Later,
NationM
Health
Insurance,
t979. abs. no. 630
National
HeMth
Insurance.
96th Congress
What Never.
Practitioners.
abs. no. 629
Home
session,
Cost Studies
.Vursing Home Occupational no. 654
second
A Review
of the Literature
1965-1979.
abs. no. 65 l
_mployee
abs. no. 628
Coverag:'.
Reserve_
Experience.
Program.
1976. abs. no. 626
National
A Decade
in Public Hea#h
_Norms Hypothesis Health
The Michlgan
and its Implica-
abs. no. 623 National
Centers.
Coverages.
Directions 643
New Health no. 645
abs. no. 621
Issues.
Contracts.
Canada. abs. no. 617 New
tions fo," &:S. Consumers.
Health
Cla_in Costs and Hospital
National
Rmmbursement
Utthzation
and Reimbursement Patterns.
Implicatlbns
Issues.
abs. no. 652
for Policy.
Injuries and lllnes:;es in the United States
abs. no. 653
by Industry,
1978. abs.
Volume ,7: abs. no.
631
Office
of Health
_Iaintenance
Organizations.
5th Annual
Report
to the Con-
gress, abs. no. 655 National
Health
Insurance.
96th Congress
second
session,
Volume
5. abs. no.
632
O?tice of Personnel ,_Ianagemen,r Should Promote Medical Necessity for Fede:al Employees" Health Insurance. abs. no. 656
National
Health
Program
for Infants,
Children
National
H3¢O
Census
Survey,
National
HA10
Census
1980. abs. no. 635
National
H._tO
Development
and
Youth.
abs. no. 633 Office of Personnel
197Z
Strategy
Summary.
Through
abs. no. 634
Use of Health
Nationwide
Study
Resources,
of Domicdiary
Expet_nent.
._lanagement's
1979. abs. no. 638
Review
of AYne Prospec-
Regulatory
On Having Your Cake and Eating It Too. Econometric the Demand tbr Health Services. abs. no. 659
Plans
Network
Barriers to a Com-
Problems
in Estimating
On Paying the Fiddler to Change the Tune. Further Evidence From Ontario Regarding the Impact of Universal Health Insurance on the Organization and Patterns of Medical Practice. abs. no. 660
Care. abs. no. 8029 Health
Insurance
in Quebec,
abs. no. 661
of the &Tderly. abs. no. 639 On the Rationing
V-14
._Iedical
1988. abs. no. 636
On the Cost of National N_eds
Comprehensivw
abs. no. 657
On Broadening the DeITnition of and Removing petitive Health Care System. abs. no. 658
National Hospital Rare-Setting Study. A Comparative tire Rare-Setting Programs. abs. no. 637
Nation's
Programs
of Health
SeF/ices
and Resource
Availability.
abs. no. 662
Health Care Programs
Opening
Up the Health
System.
Public and Private Sector Friction.
abs. no. 663
Ordering Social Objectives. National Health Servlce and ]_tional Health Insurance as Policy Options in Organizing the Medical Care System. abs. no. 664 Overview
of Group
Practice HMOs.
Overview
of Health
Insurance
Study
Pain and ProtYt. The Politics Participation
of Private
Survey
Results,
Publications.
of Malpractice.
Practice
March
Dentists
abs. no. 667
Payer,
Outcomes Provider,
in Three Alternative Consumer.
Paying
for Physician
Paying
for Primary
Industry
Services
Long-Term Confronts
abs. no. 668
Under Medicare
Payment
for Hospital
Serwces.
Pediatn'c
Care. Charges,
Per-Case
Reimbursement
Objectives
Payments
abs. no. 669
Care Costs. abs. no. 670
and MedYcald.
Care. Time for a Change.
abs. no. 671
abs. no. 672
and Alternatives.
and the MetKcal
Physician
Reimbursement
Physician 692
Responsibility
Physicians
Impact of Three abs. no. 8032
Care Settings.
Health
Participation
Physician-Induced
Paths to Alternative Service Modalities and Differential Modalities on Familiar Groups of Vulnerable Elderly. Patient
Physician
Health
Insurance
abs. no, 673
Setting.
Care. Final Report.
Coverage.
Demand
Personal 678
of Medical
Key
to Effective
Physicians Physicians"
Knowledge for Posthospital
Planning
o£ Health
and
Doing
Perspectives on Health abs. no. 680
and Disease
Perspectives
on Medicines
Physician
Acceptance
Physician
and Cost Control.
Physician
Control
Physician
Extender
Physician
Glut
in Society.
Assignment
for the 1980s.
abs. no. 694
Rates and Bene[iciary
Liabil-
The Case of Diagnostic
Care Delivery.
Study.
Tests.
abs. no. 697
abs. no. 698
abs. no. 699
of Health
Care Costs and Expen_'ture,_:.
abs. no.
abs. no. 674
abs. no. 677
Cost-Effective
Something
_ffth Social
Secadty
Research
Files. abs. no. 701
in Financing
Mental
Health
Services.
abs. no. 702
About
Prevention
Health.
Health
of National
Health
Insurance
Revisited.
abs. no.
703 abs. no.
Care
Cost
in the United States.
Policy, Politics, and Ctu'ld Health. Response. abs. no. 704
Four Decades
Political Economy of Federal Health Programs cal Review. abs. no. 705 Poh'_cs and Economics
of Hospital
of Federal
in the United States.
Cost Containment.
Politics
of Health
Care. abs. no. 707
PoK_cs
of Health
Care Delivery.
Initiative
and State
An HistoH-
abs. no. 706
abs. no. 681
of ,_Ied_caid Patients.
abs. no. 708
abs. no. 682 Insurance.
abs. no. 709
abs. no. 683 Potential
of Blue Shield
Plans. Staff Report.
Re_nbursement
Expen_nent.
Will Force Hospitals
to Look
abs. no. 684
Outward.
and Monopoly
in American
Physician M_gration Health Insurance
in Response to Income Opportunities in Quebec. abs. no. 688
Care System
in Boston,
Potential Impact of Mandatory Cost of Health Insurance.
(_eteria Style Health abs. no. 8033
Medicine.
abs.
Potential
Massachusetts.
abs.
in the MedicM
Benel_t Programs
for the
Under
Universal
Competition
Care System
of Baltimore,
Mary-
and Health.
Economic
Causes
and Consequences
of Health
Problems.
abs. no. 712 Prediction
on Blue Shield.
Market
land. abs. no. 711 Poverty
Plans. Evidence
Health
abs. no. 686
Competition
in Health Insurance
for a Competitive
no. 710
abs. no. 685
Physician Licensure. no. 687
Participation
Issues
Care. A Followup
PoKcies for the Containment 700
PoIls. Health
Physician
abs. no.
abs. no. 696
of Cos_
Planning
Services.
Care. abs. no. 693
Practitioners.
for the Future.
Medical
abs. no. 675
of Prepayment.
Personnel Leadership in Action. Contmnment. abs. no. 679 Promotion
abs. no. 691
abs. no. 676
Care. The Impact
Responsibih'ty.
abs. no. 690
Use in HMOs.
for Medical
Policy Options and the Impact Perceptions
Programs.
for the Cost of Unnecessary
Physicians" Charges Under Medicare. ity. abs. no. 695
Policy Issues Perceived
Medicaid
and Hospital
and New Health
Poh'cy Analysis for MediCal
in State
1979. abs. no. 665
abs. no. 666
in Mech'cald.
no. 689
and Incentives
in HeMth
Care Policy.
abs. no. 713
abs.
V-15
Preliminary Analysis of the Coats of Maintaining in Selected Plans. abs. no. 714 Preliminary Results abs. no. 715
From a Risk-Sharing
Pension
Health
and Health Benefls
Mmntenance
Organization.
Professional 738
Standards
Profile of Employee
Revte_
Benefts.
Profile of Health-Care Preliminary Study abs. no. 716 PrepaM
Health
Pressures
and
Decade. Prevention.
of Disenrollees
From Health
Service
Problems
for
Maintenance
Organized
OrganizaNons.
Ambulatory
abs. no. 7 l 7
Services
in
the
in AtedlZ-ine. A Context
Care tb the HAIO
Preventive 8034
Health
Servtces
Preventive
Medicine
Cost Benefit
For Chffdren.
are Learning.
and Consumer
abs. no.
Pn'ce Setting in the ,_4arket for Physicians'Services. abs. no. 722
Health
A Review
of Health Who
Care in an Academic
Primer
on A,_titrust
and Hospital
Private
Cost Conta_nmunt.
Private HeM;h Insurance Illnesa. abs. no. 728
Gives
of the Literature.
Care to Whom.
Medt_sl
Regulation.
Center.
abs. no. 724
abs. no. 725
abs. no. 726
for Alcoholism,
Drug
Heal;b
Insurance
Plans in 1976: An Evaluation.
Private
Health
Insurance
to Supplement
Private
hTdustry
Insurance
._4edicare.
Plans.
Abuse
and
MentM
abs. no. 729
Volume/.
abs. no. 730
Type of Administration
Private
Sector Perspective
Proceedings Health
June
and Pubhc" Programs.
of the 28th Annual 18-21,
Proceedings. 19-22. Professional
abs. no. 732
on the Problems
of the National Conference hTsurance, abs. no. 734
Proceedings
Group
of Health on Drug
Care Costs. Coverage
Health Institute,
New
abs. no. 733
Under
Naobnal
York, New
York,
1978. abs. no. 735
27th Annual
Consumer
Proposals
for the Regulation
Proposals
to Restrncture
Proposed
Framework
Industry.
The Role
Education
and National
of Health
Policy.
Planning.
abs. no. 744
of ._tospital
Origins and Evolution,
and
Costs. abs. no. 746
the Financing for Health
Medicine.
of P_vate
and Health
Health Insurance.
Care Policies.
abs. no. 747
abs. no. 748
abs. no. 749
Prospective Rate Reimbursemen_ and Cost ContMnment. meat in New York. abs. no. 750
Prospective
Rate
Prospective 752
Reimbursement
Setting.
Formula
Reimburse-
abs. no. 751 in Rhode
Group Health Institute,
Review
Prospective Reimbursement System Hospitals. abs. no. 8035
Island. Additional
Perspectives.
abs. no.
Based on Patient
Case _h)l for New Jersey
Prospective Reimbursement System Based on Patient Hospitals 1976-1981. abs. no. 753
Case-._dix for New Jersey
Prospective Reimbursement Through Budget Review. land and Western Pennsylvania. abs. no. 754
New
Prospects
and Problems
abs. no. 755
Prospects
for Health
Providing
More
in Health
Services
h_formation
Servtces
PSR O An Evaluation
Los Angeles,
California,
Research.
in the United States. on Work Injury
Provision of Long- Term Care Setw_es no. 758
Program.
Rhode
Is-
by Community
of the Professional
abs. no. 756
and Illness.
Standards Context
Public Capabiliues and Health Care Effectiveness. paraNve Perspective. abs. nc. 760 Organization
Jersey,
abs. no. 757
Hospitals
Review
for PSRO
in Virgl)_.
Orgamzation Utilizatlbn
abs.
Pro-
Control
June Implicatlbns
from a Com-
abs. no. 737 Public
V- 10
Health.
grams, Volume IZ A Cost-kteneft Activities. abs. no. 759
197Z abs. no. 736 Standards
in the Health
and Insurer
in 1974. abs. no. 731 Physicians
of Program
Care. abs. no. 723
Private
Pn'vate
Surgical Experience
abs. no. 727
Benefts
Health
abs. no. 741
Proposals for National Health Insurance in the USA. some Percepttbns for the Future. abs. no. 745
Prospective and the Supply
Primary
_tnd an Accoantl)_g.
Health Education.
abs. no. 721
County.
abs. no. 740
Issues. abs. no. 720
What States
USA. Health Promotion
Care in Durham
and Have-Nots.
Program for Elective Surgical Second Opinion. PartiCipants, 1976-197Z abs. no. 742
Promoting Health
Primary
The Haves
abs. no. 719
Preventive
PtT_ing, Demanders,
ab¢_. no. 739
Coverage.
Promoting Competition abs. no. 743
and Reality:
abs. no.
Ne._t
abs. no. 718 Rheton_
1979 Program Evaluation.
Plan of Penn,_vlvania. Profts
Plans and Health
O,'ganizatlbn
Choice
in Health.
Problems,
Politics
and Perspectives
Health
on Formulating
Care
Programs
National Public
Health Policy.
Health
abs. no. 761
and the Law. Issues
Public Hospital
and
and its LocM Ecology
Trends. abs. no. 762
in the United
Between the "Plight of the Public Hospital" abs. no. 763 Public
insurance
Health
in Private
Insurance.
Public" Regulation
Medical
Some
Problems
Care Providers.
abs. no. 765
Public Versus Private Administration of Heatlth InsurB, nc¢. A Study in Relative Economic Efficiency. abs. no. 766 Quality
Assurance
in a Prepaid
Quality
Assurance
in HeMth
Quality
Health
Group
Practice.
Regulation 788
of Health Facilities
Regulatory
Environment
of Medical
Rapid
Rise
Rates
Process
Health
Medical
Education.
al_. no. 769
Reimbursement
for Durable
MedicM
Reimbursement
for Hospital
Services.
Reimbursement
for Physicians"
Reimbursement
Management.
Relationship
for Developing
Plans.
abs. no. 772
Policy VM_'ty.
Island
Experience
abs. no. 791
abs. no. 792
Services.
abs. no. 793
abs. no. 794
Between
Diagnostic
Information
in One PSRO
Administrative
Expediency
A vMlable at Admission
Setting.
or
and Dis-
sbs. no. 796
Between Utih'zation of Mental HeMth and Somatic HeMth Services Low Income Enrollees in Two Provider Plans. abs. no. 797 fur the Same Diseese. A Multiph'er
of National
Health
Report of the HEW Task Force on Implementation of the Report to the President From the President's Commission on Mental Health. abs. no. 799
_,qth Prosl_etive
on CoMitions
System
Development Family
in Denve, ar. a_. Responsibility.
no. 777
Regulating
Hospital
Care Coverage.
in Long-Term
and Health
Health
Care Costs.
Cn'tique of a
Policy.
abs. no. 8036
and Demonstrations
Research
abs. no. 780 for Control.
The Development
of Public Policy.
Regulating Hospital Labor Costs. A Case Study Commissions. abs. no. 783 Regulating 784
the Cost of Health
Rcgulatmn
and the Quality
Regulation
of Health
Care.
of Dental
Care Delivery.
abs. no. 781
in the Politics
abs. no. 782 of State
Can We Learn from Expetien_.
Care. abs. no. 785 abs. no. 786
Rate
in Health
in Heatlth Economics. of Canadian
Care Insurance.
Care. abs. no. 779
Care. The Struggle Costs.
abs. no. 800
Commission
on Mental
Health.
Care Financing,
1978-1979.
ztbs. no.
802
Responses in Public Health
Regulating
MedicM
Care. abs. no. 776
Delivery
and Regulation
to Contain
Reimbut_mcnt. Report to the President From the President's Volume I. abs. no. 801
Reducing Medicaid Expenditures Through Recent Proposal. abs. no. 778
Rcgionalization
Equipment.
Setting.
Research Alternative
Reform
Care. abs. no. 790
Care. abs. no. 774
of Rural Primary
Reductions
abs. no. 789
Health
Under Drug Insurance. abs. no. 795
Repea_ted Hospitalization Costs. abs. no. 798
Report
Recent
by 'CertilTcate of Need• _ _Lbs no.
Compensation.
for Home
Relationship Among
Costs. abs. no. 771
Re-examining the Rhode abs. no. 775 Realities
for Physician
Alternatives
Reimbursement Economic
of Surgical Care in Prepaid Group Practices and the lndel_ndent "hat Are the Reasons for the Differences. abs. no. 773
Ratmm)Tg
abs. no. 787
Care. abs. no. 770
of Hospital
Rate-Making
and Services
Reimbursement
charge for Patients Quality
States.
abs. no. 767
Care. abs. no. 768
Care. The Role of Continuing
Care in the United
of National
abs. no. 764
of Health
of Health
States. Some Relationships
and the "Pb'$ht of the CYties':
Markets.
Regulation
A Survey.
Physicians
abs. no. 803
to the Introduction
The First Five
Years in Quebec.
Responsibility
of Families
Responsibility
of the Inth'viduai.
abs. no. 806
Restructuring
Federal
Controls
Resurvey
of Private
for Their Severely
Meth'cMd Practice
Rettu'nking
Employee
Rethinla'ng
Health
Rethinking
National
Disabled
Elders.
and Incentives.
Physicians,
Benetits
of Universal
_Iedical
abs. no. 804 abs. no. 805
abs. no. 807
1979. abs. no. 8037
Assumptions.
Poh'cy for the Elderly.
abs. no. 808 A Six-Point
Program.
abs. no. 809
a_. no.
Review Rising
of the Medical
Health
Insurance.
Malpractice
Cost of Catastrophic
Illness.
abs. no. 810
Problem
in the United
States. abs. no. 811
abs. no. 812
V-17
Rising
Health
Costs.
Pubbc and Pn'vate
Responses.
Rising Hospital Costs Can Be Restrained _hg Management. abs. no. 814
by Regulating
Risk Differential Between Medicare an HMO. abs. no. 815
Beneficiaries
Role
of Fee Schedules
Reimbursement.
Role
of Health
Role
of lISA
in Physician
Insurance
in the Health
"s in Development
abs. no. 813 Payments
Enrolled
and lmprov-
and Not Enrolled
in
Sector.
abs. no. 816
Care Services'.
Perspective
SociM Security
Role Role
of Phkxician
Education
Nursing
Home
of the PIivate
Rx 6Jr Health
Care Economics.
Sav_)_gs to CHAMPUS mls. abs. no. 822
Health
Residents,
to Fersonai
Insurance.
Competition,
From
Requirement
Opinions.
What Have
Health
Selected and Selected
Bibliographic Research Prepaid Group Practice. Bibhbgraphlc
Not
Rigid NttL
We Learned.
Selecced Studies in ._ledical 1975. abs. no. 827
Guide
Care and
Services.
abs. no. 821 Services
Hospi-
Organizati
:_Iaintenance
to the M_cticaid Medical
Topics in Federal
Health
Services Shared by Health abs. no. 829 Setting Short.Run
NatiOnal
Priorities.
Hospital
Statistics.
Agenda
Responses
Socia+ Aspects
Program.
abs. no. 826
Annual
An Annotated
Report,
Bibliography.
abs. no. 830
to Reimbursement
of the Rate Structure
Rate
Changes.
in the Federal Employees
Effects
V- 1 _;
of Quebec Health
State
and Federal
Book of Health
of Organized
Malpractice
Health
of Chronic
Disease
and
Disability.
Insurance.
Year 1977. abs. no.
in New
Advance
York
City. abs. no.
in Medical
Care. The
abs. no. 844
insurance
Cost Reimbursement.
on Medicaid.
Data,
South
Carolina
Voluntary
Effort Report
South
Carolina
Volunta(y
Effort,
SpecitTc Issues Related 849 Spy in _he House
A Maryland
Experi-
abs. no. 846
1979-1980.
Standards
abs. no. 847
Services
abs. no. 831 Health
for Adequate
State
of Care in HMOs.
abs. no.
abs. no. 850
?dinimum
Employee Health insurance nancing, abs. no. 852 Guide
abs. no. 848
Personal
Health
Health
Insurance
Plans. A Survey
to ,_Iedicaukl Cost Containment.
Services.
abs. no. 851
Programs.
of Coverage,
An
Over-
Bcnel?ts,
Fl-
abs. no. 8042
State Health Legislation Report Vol. g No. 3. State Comprehensive trophic Health Insur_mce Legislation. abs. no. 853
and Catas-
Bene-
abs. no.
m America.
abs. no. 835
abs. no. 8040
and Content
Comprehensive and Catastrophic viev_ abs. no. 8041
State
Insurance.
1980-81.
1980-81.
to Utilization
of Medicine.
Hospital
Cost ContMnment
State of Hawaii Prepaid Health and Regulations.
The Advance
Fiscal
Insurance.
abs. no. 841
Care Under Medicaid
Perspectives
abs.
State State
Soci_J Nature
of Ambulatory
Some
State
of Medical
lbr Malpractice.
Hospital
853 SocJaJ Medwme n¢,. 834
Responsibility
Some Issues in Limiting ence. abs. no. 845
abs. no. 828
for the 1980's.
Simultaneous Logit of Plan _lembership l%s Program. abs. no. 832
Health
1974-
Organizations
Economics.
Care Orgamzations.
Under Public Program_;
Some Economic Conseqaences of Technological Case of a New Drug. abs. no. 843
State SelecJ:ed
for National
abs. no. 823
:_lalntenanee
Guide to Health abs. no. 825
Research
Implications
States,
abs. no. 820
to Use Uniformed
Selected, Annotated Bibliography on Health 1978. Volume If. abs. no. 824
Policy.
in the United
Services,
Source Scco+Td Surgical
1977. abs. no. 837
abs. no. 818
in Relation
Sector in National
the World,
abs. no. 8039
Some Role
Throughout
Social Welfare Expenditures 840
Some Aspects 842
in Cost Containment.
of State and Local Governments abs. no. 819
Programs
abs. no. 836
Social Structure and the Diffusion of Medical Innovations Great Britain, Sweaen and France. abs. no. 838
Societal Role of Payment Source in Differentiating and Payments. abs no. 817
on Risk Reduction.
Social Surveys and Hea;th abs. no. 839
abs. no 8038
Services
of Ambulatory
Social
Policies
Programs.
Care Act (Chapter
393, FIRS) and Related
Rules
abs. no. 855
and FederM Programs.
Regulation no. 857
abs. no. 854
of Healih
Services
Pziorities Utilization.
and Constraints. Lessons
Health
abs. no. 856
From Michigan.
Care
Programs
abs.
Status of Children,
Status Steps
Youth
of Competition to Control
Strategies
and Families,
in the Health
lnllation
for Controlling
in Health
1979. abs. no. 858
Industry. Care
SurgicM Innovation
abs. no. 859
Survey of Hospital Semi-Private
Costs. abs. no. 860
the Cost of State
Medical
Assistance
Programs.
Health
Insurance.
Stronger Management Needed to Improve Plans' Payment Practices. abs. no. 863
Employee
Structure of Health Insurance and the Erosioh Marketplace. abs. no. 864
Study of Dental no. 865
Service
Prepayment
Study
of Health
Maintenance
Study
of Physician
Survey Results, 883
Organization
System
Sector.
Health
in the Medical
Final Report.
abs.
Under Meda'care and Meda'cald.
Reimbursement
Under Medicare
of Physicians'
Health
and MecffcMd.
Volume
Welfare
and
Welfare
Trust Fund
Operations
Trust Fund Operations
Cost. Sum-
Uniform
of the UoTization
of the Employee
Retirement
Income
Security
Act.
and Effect
of Temporary
Nursing
Services.
Systems
Development.
(SHUR).
Trends, Issues
Taking
Action
To Contain
Health
Taking
Ac_on
to Contain
Health
for Meddcal
to Determine
the Relationship
Health Health
of Community
Centers, and Drug Treatment Services to CHC Registrants.
Substitution of Outpatient abs. no. 874
Care for Inpatient
Summary Cost,
of Impact of Alcoholism 1979. abs. no. 875
Summary
of Rate
Technology and the Governance Reform. abs. no. 891 Technology
and the Quality
Technology
in Hospitals.
Ten
abs. no. 884 A Preliminary Tax. Problems and Solu-
and Implications.
Care Costs. Care Costs.
abs. no. 886
Part 1. abs. no. 887 Part II. abs. no. 888
Treatment
Health
Centers,
abs.
Insurance
and Medical
on Meda_al
Review
Hcalth
in Maryland.
Insurance
for Physician
The Dilemma
of
Care. abs. no. 892
Medical
Ten Years of Short-Stay Hospital 1976). abs. no. 895 Care. Issues
Advances
and Their Diffusion.
on the Covered
Population.
abs. no. 893
abs. no. 894
Utih'zation and Costs Under Medicare
and Alternatives.
(1967-
abs. no. 896
BeeetTt Plan
Trustees,
Adm}m'strators
and Advisors.
and Experience.
Care Utilization
and
Theoretical Analysis of the Impact of National Health Insurance Behavior in the Health Care Market. abs. no. 898 Theory
and Practice
in Minneapolis-St.
Third Party Payment Recommendations.
Paul. abs. no. 899
for Nonphyalcian abs. no. 900
Reimbursement
Aspects
on Consumer
Health
of Physician
Practitioners.
Compensation.
Realities
and
abs. no. 901
abs. no. 876
and Cost-Consciousness Services.
Care Industry.
Communi-
Centers for the Provision Final Report. abs. no. 873
Care. Problems
of the Health
of Health
Years of Meda'care. Impact
Third Party
ElastJcitlbs
in the b:S. abs. no.
Care. 6_n'rent Poh'cies and Possible Alternanves.
Textbook for Employee abs. no. 897
Supplementary
Reporting
and Utilization
abs. no.
8044
ty Mental of Mental
Enrollment
abs. no. 882
Systems Approach to Health Insurance Policy Information. onomy of Health Insurance Issues, Program Options, tions, abs. no. 885
Terminal
Supply
July 1980. HMO
Economics.
Cost. Techni-
Study of the Responses of Cannda'an Physicians to the Introduction of Universal Medical Care Insurance. The First Five Years in Quebec. abs. no. 872
Study
Organi-
11.
abs. no. 870
Study of the Admim_tration abs. no. 871
Study
Maintenance
Fees. abs. no. 868
of Taft-Hartley
cal Report.
in Health
Taxation and Its Effect Upon Public and Pn'vate Health Demand. abs. no. 890
Study of Ta12-Hartley Health and mary Report. abs. no. 869 Study
Within Health
1981. abs no. 880
Volume I.
abs. no. 867 Study
Research
of Hospital
Tax Subsidies no. 889
of Physician
Coverage
as of January
abs. no. 8043
abs. no. 866 Study
of Recent
Wins and Who Loses.
of Competition
in the Private
Organizations.
Reimbursement
Who
Charges
abs. Survey
National
abs. no. 879
Room
Survey of Mental Health Service zations, abs. no. 881
no. 861 Strategies for Eb_ancing abs. no. 862
and Its Evaluation.
abs. no. 878
Strategy.
abs. no. 877
Third-Party Payments for New Health Professionals. An Alternative tional Reimbursement in Outpatient Care. abs. no. 902 Tlu_ty-To-One no. 903
Paradox.
Health
Needs
of the Aged and Medical
to Frac-
Solutions.
abs.
V-19
Tbre¢
_]_rld Spas'terns of Aledical
Too Old, Toward
Too Sick,
Too Bad
a Commum'ty-Based
Toward a National Health Costs. abs. no. 907
Care.
Treuds
and Prospects.
abs
Nuzsing
Homes
in America
abe. no
Nathmal
Health
Servicc.
nc,. 906
abs
Policy. Pubh2" Policy and the Control
no. 004
Vertlcall_
905
Veterans .._Jmtmstrdt:on Hospltal_ terprzst abs. no. 930
of Health-Care
Linked
tion Program.
Pohc)_ Evidence
From
the Eco._omie
Trends m .,$4cdical Care Costs. Do HMOs 910
in ._IulttTJospital
Trenas
in State Admin_Stratzbo
Dollars.
Systems.
Lower
A ._tultiyear c,f Medicaid
the Rate
Programs.
Type, Length. Discharge
abs. no.
abs. no. 911
What 14e Have (And abs. no. 935
tLS. ltospice
Industry.
.,14ovement.
_c o.r Hospital
Services
Hal en "t) Learned
When a Solution Is Not a Solution. zations, abs. no. q36
Under Two PrcpaM
kbr_bt,Dns m State
of an HMO
_ledical
3- Year lr_centive
Mcd_ca_t
by New
Programs.
Variat,,ons in L'tih_ation
of a _¢ulti-State
Var_at bns in Utilizaoon
of Health
Benel_ts. abs.
Insurance,
and
DetTnitlon.
Guide (1904-
abs. no. 934
From Prospective
_/Iedicaid and Health
Data Preview
Payment
Programs.
_/[aintenance
Orgar_L
1. abs. no. 937
Rein_bur_eraent
_r.x-
With Saliety and
Health
m the Fed,__'ral Employees
abs. no
Data Preview
Seem to Provide More
Enrollees
Choose
from
Two AIar_etings
_'brk, and HeaL'h.
Challenges
Compensation
Third-Party
Maintenance
Health
to Corporate Alten_atives
Workers" Compensation 946
hsurance.
Recent
Trends
Workers'
Research
Studies.
Working
With the lnsure, zabs.
abs. no.
Pohcy.
abs. no. 943
to ,_/Ied_cal C,mtrol, abs. no.
Illnesses
Working Papers on 34ajot Budget grams, abs. no. 947
Services.
Plan, Inc. abs. no. 942
a_d Work-Related
Compensation
Party Payment.s
and Diseases. in Employer
abs. no. 945 Costs. abs. no
abs. no. 8045
and Program
Issues
in Selected
Health
no. 948
925
abs. no. 926 Company
Scrvt_'es
Dental
by Children.
,_t
3. abs. no. 939
and
Health
to Join Group
Women's Health ._Vlovement. Feminist 944 Workers'
Plans. abs. no. 922
Enrollees.
Why Do H3/lOs 941
Women,
Care Expenditure
Visits to a Physician.
1_77o Pays for Pediatric Care. Out of Pocket for Physician Visits. abs. no. 940
Why New
Plans. abs. no. 920
L,2_hz_.ttbn and Cost o! AIental Illness _bverage H_mlth Benetits Program, 1073. abs. no. 924
V-20
Who Ininates
Health
£ seot" 7-a_ SubsM_c.s for the Cost of Comphance Regulations. ahs r_o. 923
otlSc,'viccs
Research
of the
abs. no. 918
l"2,om the National
o." Ph) siciat_ 5'er_ ices L;nder Two Prepaid
Ut_hz_tzDo
A Report
View. abs. no. 917
in Dcvelopmen_
l _c o" Med_'are Bcaetits Under HIP's perimeut, abs. no. 921 l+e
National
An Alternative
Issues
L,ge and E._pcnd_ture.* Analyses S_r_ey. abe. no. 919
Health
Who Chooses Prepaid ,ited_cal Care. Survey Results Three New Prepayment Plans. abs. no. 938
Crisis in the L_nited States. Hospitals. abs. no. 916 Insurance
Bibtiographie
Trends m Lse a,d Expenditure.
Eh_,oibihty Rules and the Loss of Health Insurance
L'rbat; Fiscal J_unicipal
sis _:t O,_ c: :',._cat E,_-
abs. no. 912
and Cost of Care lbr Home Health Patients. Summary Feasibthty Stud)'. abs. no. 914
l_ctnployment, m,. 915
L;.S. ttealth
Nocial Survey
A Selected
Welfare St,'_tus, Illness and Subjective
Who Are t,5e Uninsured. Two Decades of Health Services. abs. no. 913
.4n Ec'ozJ,_mic AnS)
Economic
of tYrowth
Comparison.
no. 929
abs. no. 932
Welfare ,_Iedicine in Ameciea. 77). abs. no. 933
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Department of Health, Educatio;t, and Welfare, Washington, DC. Blue Cross. What Went Wrong. abs. no. 52 Choice Between Family and Individual Deductibles th Health abs. no. 87
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Canada Dept. of National Health and Welfare, Ottawa Economt_: Class and Risk Avoidance. Experience Care Insurance. abs. no. 229 Carnegie Corp., New York, NY. Benefits m Medical Care Progrnms.
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California Univ., Parttcipation
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733 Prospective Rate Reimbur_ment and Cast Containment. Formula Reimbursement in New York. abs. no. 750 Research in Health Economics. A Survey. abs. no. 803 Social Structure and the Did'on of Medical Innovations in the United
Department of Labor, Washington, DC. Office of Policy Planning and Research. Preh'minary Analysis of the Costs of Maintaining Pension and Hc._lth Benefits in Selected Plans. abs. no. 714
State& Great Britain, Sweden and France. abs. no. 838 Strategies for Financing NationM HeMth Insurance. Who Wins and Who Loses. abs. no. 862 Structure of HeMth Insurance and the Erosion of Competition in the Mcch-
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cM Marketplace. Department
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Department of Health, Education, and Welfare, Washington, DC., Div. of Regional Medical Programs. Impact of National Health Insurance on New York. abs. no. 482
Department Insuring
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Edna McConneU Clark Foundation, New York, NY. Costs, Risks, and Benefits of Surgery. ahs. no. t7 l
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Methods. abs. no. 17 System and Fertility' Control.
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Health Status and Use of MeddcM Settees. Evidence on the Poor, the Black. and the RurM Elderly. abs. no. 422 Insuring the Nation's Health. An Evaluation of Three Approaches. abs. no. 514
Ezuployment Related Health Benefits in Private Nonfarm Business EstabIAhmcnts in the United States. Volume I1. Description of Selected Data. abs. no. 264
Modifying Medicaid Eh_bi_ty and Benefits. abs. no. 595 National HeMth Insurance. Conflicting Goals and Policy Choicen. 619
Findings and hnplications of Field Visits to Six WeltStre Bentd_t Plan Administratiee Organizations. First InteMm Report. abs. no. 318
NatinnM Health Implications
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101 Cost Containment
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German Marshall Fund of the United States, Washington, DC. Efforts to Restructure a Meefl'cal Delivery System. The British Health Service. abs. no. 256
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Ancillary Services Review and PSROs. What Can the Demonstration Programs Tell Us. abs. no. 40 Assessing the Utilization and Productivity of Nurse Practitioners and Physician's AssJstants. Methodology and Findings on Productivity. abs. no. 43 Can Fce-tor-Survice Reimbursement Coexist With Demand Creation. abs Compcn._ation
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Use in HMOs. abs. no. 691 What States are Learuing. abs. no.
Comprehensive and Catastrophic Health Insurance Overview. abs. no. 8041 State Guide to Medicaid Cost Containment. abs. no. 8042
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Evaluation of the Maximum Allowable Phase I Report. Final Des_n Report
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Health Insurance Association of America, Washington, DC. I-aTe Cycle Preventive Services Study. abs. no. 8023 Major Issues in the Financing and Management of Health Care, abs. no. 536 Role of the Pn'vate Sector in National Health Insurance. abs. no. 820
Fee-for-Service Physidan Payment. Analysis of Current Methods and Their Development. abs. no. 308 Health Plan. The Only Practical Solution to the Soaring Cost of Medical C_'e. abs. no. 412 Impact of HMO& Evidence and Research Issues. abs. no. 480
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Potential for a Competitive Health Care System in Boston, Massachusetts. abs. no. 710 Potential Market Competition in the Medical Care System of Baltimore,
Health Planning in the United State& Issues in Guideline DevelopmenL abs. no. 416 Medical Technology. The Culprit Behind Health Care Costs. abs. no. 568 Physicians and New Health Practitioners. Issues For the 1980s. abs. no. 694
Maryland. abs. no. 711 Regulating Health Care. The Struggle for Control. alas. no. 781 Repeated Hospitah'zation for the Same Disease. A Multiplier of National He._dth Costs. abs. no. 798
Promoting Competition in the Health Industry. The Role of Health Planning. abs. no. 743 Proposed Framework for Health and Health Care Poh'cies. abs. no. 748
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Administration,
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Insurance Standards Context
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Henry J. Kaiser Family Foundation, Palo Alto, CA. American Attitudes Toward Health Maintenance Or3anJzations. abs. no. 25 Changing Health Care. Perspectives From n New Medical Care Setting. abs. no. 77 Conference and Unresolved Problem& abs. no. 112 Consumer-Centered vs. Job-Centered Health Insurance.
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International Foundation of Employee Benefit Plans, Brookfield, Potential Impact of Mandatory Cafeteria Style Health Benefit the Cost of Health Insurance. abs. no. 8033
Ithaca Colt., New York, NY. Health Economies and Health James Picker
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Health Resources Administration, Washington, DC. Div. of Manpower Analysis. Evaluation of Health Manpower Shortage Area C_7"teria.Final ReporL abs. no. 281 Health Services
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John A. Hartford Foundation, New York, NY. Clim'cal Eflfeacy Ass_ment Program. abs. no. 8006 PotantiM for a Competitive Health Care System in Boston, Massachusetts. abs. no. 710 Poten_M Market Competition in the Medical Care System of Baltimore, Maryland.
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John Simon Guggettheim Memorial Fotmdation, New York, NY. Prospects and Problems in Health Services Research. abs. no, 755 Johnson Foundation, Inc., Racine, WI. Pubh'c Insurance in Private Medical Health Insurance. abs. no. 764
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Josiah Macy, Jr. Foundation, New York, NY. Effect on Future Physician Requirements of an HMO Health Insurance. abs. no. 247 Strategies for Financing Loses. abs. no. 862
National
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National
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Kellogg (W.K.) Foundation, Battle Creek, MI. Changing Health Care. PerspecOves From a New MedJcai no. 77 Changing Patterns abs. no. 79
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Compnlqson of the Quality of Maternity Care Between a Health-Maintenance Organization and Fee-For-Service Practices. ahs. no. 99 Diagnosis Related Group (DR G) Management Information System Studies. abs. no. 8009
Bene.qts in Medical Care Programs. abs. no. 49 Effects of Medicare and ,_ledicaid on Access to and Quality of Health Care. abs. no. 253 Factors Affecting the Choice Between Prepaid Group Practice and Alterna-
Financial ._Ianagement of Health Care Organizations. A Referenced h)Te and Annotated Bibliography. abs. no. 311 International Dental C__re Delivery Systems. Issues in Dental Health cies. abs. no. 518
tire Insurance Progrnms. abs. no. 297 Health. A Victim or Cause of Inflation. abs. no. 348 HeMth Care Guidance. Commercial Health Insurance and National Policy. abs. no. 369
Manpower Policy for Primary Health Care. abs. no. 543 New Jersey Diagnosis Related Group (DRG) Evaluation. Planning of Health Care Delivery. abs. no. 699 Politics of Health Care Deh'very. abs. no. 708 Regulation of Health Care Delivery. abs. no. 786
OutPoll-
Health
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Current and Future Development of Interment'ate Care Facilities Mentally Retarded. A SuJwey of State Officials. abs. no. 174
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Findings and Implications of Field Visits to Six We_fare BenelTt Plan Admimstrative Organizations. First Interim ReporL abs. no. 318 Impact of the 1974 Health Care Amendments Bargaining in the Health Care Industry.
to the NLRA abs. no. 490
Louisiana Hospital Association, New Orleans, LA. Hospital Regulation Through State Rate Review. a Noble Intrusion. abs. no. 455
Mandated
Maurice Falk Medical Fund, Pittsburgh, PA. Chronic Illness and Health Services Use. A Before-ABet National Health Insurance. ahs. no. 88 McDonalds Delivery Delivery
McKnight
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Minneapolis,
Interference
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or
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Research
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Ch_u_ging Health Care. Perspeetive_ From a New Medical Care Setting. abs. no. 77 Chronic Illness and Health Services Use. A Before-After Study of Canadian National Health Insurance. abs. no. 88 Cost of NaObnal Health Insurance. The Province of Quebec. abs. no. 161 to a
Health Status, Socioeconomic Status, and Utilization of Outpatient Services for Members of a Prepaid Group Practice. abs. no. 427 Regulation of Health Facih'ties and Services by "Certil_cate of Need." abs. no. 788
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A Multiplier
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VI-6
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the Det_nition of and Removing Regulatory Health Care System. abs. no. 658
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Cancer
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National Center for Health
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On Broadening Competitive
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abs.
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Hyattsville,
MD.
Access to Ambulatory Care and the U.S. Economy. abs. no. l Access to Medical Care. The Impact of Outreach Services on Enrollees of a Prepaid Health Insunmce Progrnm. abs. no. 3 Age and Medical Care Utih'zation Patterns. abs. no. 11 Allocation of Physicians" Services. Evidence on Length-of-Visit. abs. no. 16 Altelqng Medicaid Provider Reimbursement Methods. abs. no. 17 Ambulatory Care Systems. Volume IV. Designing Medical Services for Health Maintenance Organizations. abs. no. 23 America's Health Care System. A Comprehensive Portrait. abs. no. 30 Analysis of Economic Performance in Medical Group Practices. abs. no. 33 Analysis of Programs to Limit Hospital Capital Expenditures. Draft Final Report. abs. no. 34 Catastrophic Illness Expense. Implications for National Health Policy in the
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America's
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abs. no 675 on Blue Shield.
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s/ups Between the "'Plight of the Public Hospital"and _'ties". abs. no. 763
the "'Plight of the
Comtutrisons of Prepaid Health C_re Plans in a Compet_'ve Marke_ The Seattle Prepaid Health Care ProjecL abs. no. 100 Controlling Health Care Costs. Strengthening the PtT"vate Sector's Hand. abs. no. 135 Controlling Medz'caid Utilization Patterns. abs. no. 138 Cost of Catastrop/u'c Illness. abs. no. 159
Rates of Surreal Care in Prel_id Group Practices and the Independent Setting. What Are the Reasons for the Differences. abs. no. 773 Regulation and the Quality of Dental Care. abs. no. 785 Relations/ut7 Between Utilization of Mental Health and Somatic Health Services Amon 8 Low Income Enrollees in Two Provider Plans. abs. no. 797
Demand
Responses
Elasticities
for Health
Care
With Special
Emphasis
on Out-of-
of Canadz'an Physicians
to the Introduction
of Universal
Medical
Pocket Price. abs. no. 185 Demand for Medical Care in a Rural Setting. Racial Compan'sons. abs. no. 187 Disenrollment From a Prepaid Group Practice. An ActuzuiM and Demogrsplu'c Deseript_bn. abs. no. 217
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Health Personnel.
Are Health
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Effects of Advertising Lessons From Optometry. abs. no. 249 Effects of the Payment Mechanism on the Health Care Delivery abs. no. 254 Effects of the 1974-75Recession no. 255 Employment, scnptive
on Health
abs.
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Care for the Dlsadvants#ed.
abs.
Unemploymen_ and Health Insurance. Behavioral and DeAnalysis of Health Insurance Loss Due to UnemploymenL abs.
no. 265 Enrollment Choice
in a MUIti-HMO
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The Roles
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R£_,
Financial Vulnerability, and Access to Care. abs. no. 266 Episodes of lllness and Access to Care in the Inner City. A Comparison HAlO and Non-HMO Populations. abs. no. 269
of
Equity in Health Services. Empit_cal Analyses in Social Po/t'cy. abs. no. 271 Factors Affecting the Choice Between Two Pretasid Plans. abs. no. 298 Group Practice
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A
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Re-
Hospital.Based Versus Free-Standing PrL_ary Care Costs. abs. no. 459 Impact of a Change in Regulations on Costs in an Experimental Program. abs. no. 475 Impact of State Certi_cate-of-Need tion. abs. no. 487 Income
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Laws on Health
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Care Expenditure
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a Competitive
How Business Can Use SpecitTc abs. no. 465
Techniques
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Health
abs. no.
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How Business Interacts With the Health Care System. abs. no. 46,6 How to Improve Health and Cont_,l Costs. abs. no. 472
Inflation,
Unemployment
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Insurance Insurance,
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National
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National Council of Community Hospitals, Washington, DC. Payment for Hospital Services. Objectives and Alternatives.
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New York, NY. From a New
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Poh'cy. abs. no. 744
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National Pharmaceutical Council, Inc., Washington, DC. Cost-Effectiveness of a Restrictive Drug Formulary, Louisiana abe. no. 166
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,,Care Demonstration
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Health
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The British
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at
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Washington,
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Physician Responsibility no. 692
Health Pew Memorial Regularng
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PA. Leonard Davis Inst. of Health
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National Science Foundation, Washington, DC. Costs. R_ks. and Benefits of Surgery. abs. no. 171 _Tforts to Restructure a Medical Delivery System.
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An Economic Oro
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The MAC An Analysis
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105
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Financing Health Care. abs. no. 315 From Reform to Recidivism, A History no. 325
_st-Fihanced Determinants no. 202
Health and Labor Power. A Theoretical Investigation. Health Care in the 1980s, Who Provides. Who Planx 371
,_lcntal Health Facility, abs. no. 168 of Physician and Pharmacist Support of Generic Drugs.
Distribution of Nurse PracO_bners and Physician Assistants. of Legal Constraints and Reimbursement. abs. no. 218 Earnings of Allied no. 227
Health Personnel.
Are Health
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abs.
Implications
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and Health
Care, abs.
abs. no, 351 Who Pays, abs, no.
Does the Past Tell Us Anything
About
the
Care. Regulation, Economics, Ethics, Practice. alas. no. 377 Reform. The Outlook for the 1980s. abs. no. 418
Funding Rural Nurse Practitioner Care. abs. no. 329 Future of New Health Practitioners. alas. no. 332
Health Services, no. 420
Graduate MedJ_al Education Nattbnal Advisory Committee, Interim Report. abs. no, 338 Health Care in the 1980s. Who Provides. Who Plans. Who Pays. abs. no. 37 l Health Manpower for the Nation. A Look Ahead at the Supply and the Requirements. abs. no. 410 Health, United States, 1980. abs. no. 428
Health Services Research. abs. no. 42 i Hospital Care in America. abs. no. 445 Medically Indigent. A State Perspective on a National Problem. abs. no. 570 Methods for Setting Priorities in AreavHde Health Care Planning. An Annotated Bibliography. abs. no, 589 Preventive Medicine USA. Health Promotion and Consumer Health Education. abs. no. 721
Homemaker Serw'ces. Essential Option for the Elderly. abs. no. 439 Maintaining the Elderly in the Community. alas. no. 8024 Management and Policy Issues in HMO Development, 1979. abs. no. 540 Manpower Policy for Primary Health Care. alas. no. 543 Mental Wellness Programs for Employees. abs. no. 587 Neighborhood Health Centers. A Decade of Experience. abs. no. 641 New Health ProtVssionals, Nurse Practitioners and Physician's Assistants. abs. no. 645 ,Vur_c Practiuoners. A Review of the Literature 1965-1979. abs. no. 651
Protlts in Medicine. A Context and an Accounting. alas. no. 741 Prospects for Health Services in the United States. abs. no. 756 Selected Studies in Medical Care and Medical Economics. Annual Report, 1975. abs. no. 827 Social Medicine, The Advance of Organized Health Services in America. abs. no. 834 Spy in the House of Medicine. alas. no. 850 Toward a National Health Policy. Public Policy and the Control of HealthCare Costs. abs. no. 907
Ph)'3_Z'_an L_tcnder Reimbursement Experiment. Physicians for the Future. abs. no. 696
Power
Centers,
and Decision.Making
Mechanisms.
abs.
abs. no. 685 Claims
Planning for Pasthospital Care. A Followup Study. abs. no. 698 Rcgulation and the Quality of Dental Care. alas. no. 785 Spy in the House of Medicine. abs. no. 850 Third Party Payment for Nonphysician Health Practitioners. Realities and Recommendations. abs. no. 900 Third-Party Payments for New Health Professionals, An Alternative to Fractional Reimbursement in Outpa_¢nt Care. abs. no. 902 Characteristics of U.S. health care system American Biomedical Network. Health Care Systems in America and Future. abs. r_o. 26 American Health Care System. Issues and Problems. abs. no, 27 Azn,'rl_'a:_ ,_lcdJbinc. Challenges for the lggOs, abs. no. 29
Present
America "_ Health Care System. A Comprehensive Portrait. abs. no. 30 Bluc C_o._s. What Went Wrong. alas. no. 52 Compclm_,:: I_-i the Health Care Sector. Past, Present and Future. abs. no.
administration
Cost Containment Through Risk-Sharing by Primary Care Physicians. A History of the Development of United Healthcare. abs. no. 1_,5 Design for a Corporate Health Care Mordtoring System. abs. no. 199 Determining Present and Future Health Claim Costs. abs. no. 204 Fee-for-Service Physician Payment. Analysis of Current Methods and Their Development. alas. no. 308 Findings and Implications of Field Visits to Six Welfare Benelit Plan Administrative Organizations. First Interim Report. abs. no. 318 Fundamentals of Second Opinion Programs for Elective Surgery. abs. no. 328 Group Specitlc and Aggregate Stop-Loss Insurance. An Attractive New Market. abs. no. 344 Health Care Costs. Private Initia_ves for Containment. abs. no. 364 Health Care Data Initiatives. abs. no. 8019 Health Care Guidance. Commercial Health Insurance Policy. abs. no, 369
and National
Health
VII-1
Hospital Self-Insurance Program. Employee Ho_ Business Can Use SpecilTc Techniques abs. no. 465 ,_ledicare Reimbursement
Controversies
Medical Benelits. abs. no. 457 to Control Health Care Costs.
and Appeals'.
Comparing Health
abs. no. 580
,glcd/caid Prog[etm_. abs no. 92 (are S)'stems In Calitbrnt_. abs. _,_. 94
the MedicM Plan Enrollees
Utih_atiozt and E._pcndtturcs il )th _ledicaJLt R_'mpicnt_ and
or" L,,_* I,l,-,mtc li tth l _,,_ Itlcollle
Private Industry Health Insurance Plans. Type of Administration and lnsurer in 1974. abs. no. 731 Prospective Reimbursement in Rhode Island. Adafftional Perspecuves. abs. no. 752
Enrollees Having Medicaid Eligibih'ty. abs. no. 95 Comparison of Orgamza_ional Slx)nsorsh_io and Sere'ice Arrangement __ righies Among Prepaid Mech_al Group PracttL'cs in the LJnitcd Stat¢_. abs. no. 97
Public Versus Private Administration of HeMth Insurance. A Study in Reintire Economic Efticiency. abs. no. 766 Reimbursement Management. abs. no. 794 Some Aspects of Ambulatory Care Under Me
Comparisons of Prepaid tlealth Care Plans in a CompctitiL'c Market. Seattle PrepaM Health Care Pro)cot. abs. no. 100 Consumer Preferences h Jr tIeahh Insurance. abe. lit). 8()t)7 Contrasts in HMO and Pee-h>r-Service Performance. abs. no. 132
no. 842 Steps' to Control InlTation in Health Care Costs. alas. no. 860 Stronger Management Needed to Improve Employee Organizaffon Plans" Payment Practices. abs. no. 863
Cost Containment Through Risk-Sharing by Primary Care Physicians. A History of the Development of United Healthcare. abs. no. 155 Cost-Effectiveness of a Restn_'tive Drug Formulary. Louisiana vs. Texas. abs. no. 166
Study of Taft-Hartley Summary Report.
Cost.
CostoEffectiveness Dental Insurance
Study of Talt-Hartley Health and Welfare Trust Fund Operations Technical Report. abs. no. 870 System of Hospital Uniform Reporting (SHUR). abs. no. 884
Cose
Disability Policies and Government Programs. abs. no. 215 Episodes of Illness and Access to Care in the Inner City. A Comparison HMO and Non-HMO Populations. abs. no. 269
Pariations Commercial
Health and abs. no. 869
for Employee abs. no. 897 in State
BenetTt Plan
Medicaid
health insurance
Administrative
Costs
Welfare'
Trust
Trustees,
Programs.
Administrators
and Advi-
abs. no. 926
vs. Job-Centered
HeMth
of Primary and Secondary Plans. abs. no. 195
Prevention.
Factors AffecNng the Choice Between Prepaid dve Insurance Progr,_rns_ abs. no. 297
abs. no. 167
of
Group Practice and Alterna-
Factors AffecNng the C_,oice Between Two Prepaid Plans. abs. no. 298 Feasibility and Cost-Effe,=tiveness of Alternative Long- Term Care Settings. abs. no. 302
plans
of l_teds'care Contractors.
Blue
Commercial Intermediarie_ abs. no. 10 Changing Patterns and Implications for Cost and abs. no. 79 Consumer-Centered
Fund
Health
"1he
Operations
Textbook sots.
Cross Plans
Quality
Insurance.
Versus
of Dental
Care.
abs. no. 126
Health
Care Financing
Options
for Colorado.
abs. no. 368
Health Insurance in the United States. Implications dora. abs. no. 395 Health Insurance Plans. Promise and Performance. HeMth Maintenance
Orgamzadon
Planning
Model
for the United
King-
abs. no. 397 to Evaluate
an Alterua-
Discounting and Differential Pricing Practices in the HeMth Care Field. abs. no. 216 Evaluation of Alternative Payment Strategies for HospitM& A Conceptual Approach. abs. no. 280 FiudJ)Tgs and Implications of Field Visits to Six Welfare Benefit Plan Ad-
rive Health Care Delivery System for the State of Georgia. abs. no. 402 HeMth Maintenance Organizations as an Instrument for Cost Containmem Policy. abs. no. 405 Health Status, Mea_'cal Care Utih'zation, and Outcome. An Annotated Bibliography of Empiricaa' Studies. Volume 3. abs. no. 425
mmtstrative Organizations. Group Specific and Aggregate l_larket, abs. no. 344
Home Health Care Services. Tighter Fiscal Controls Needed. abs. no. 437 How to Improve Health and Contain Costs. abe,. no. 472 Impact of liMOs. Evidence and Research Issues. abs. no. 480
Health Care Costs. An Analysis L tilization, abs. no. 363 Health ttealth
First Interim Report. Stop-Loss Insurance. of Current
abs. no. 318 An Attractive
Trends
in Health
Care Data Initiatives. abs. no. 8019 Car=, Guidance. Commercial Health Insurance
Private Prtvate Private
New
Costs and
and National
Health
Policy. abs. no. 369 th'alth Insurance Plans. Promise and Performance. abs. no. 397 How Interested Groups Have Responded to a Proposal for Economic petition in Health Services. abs. no. 468
Corn-
Cost Containment. abs. no. 727 Health Insurance Plans in 1976: An Evaluation. abs. no. 729 Industry Health Insurance Plans. Type of Administration and lnsur-
Impact of Membership in an Enrolled, Pret_ffd Population Health Services in a Group Practice. abs. no. 481
on Utilization
Impacts of Health Maintenance Orgtmization Health Care Costs. abs. no. 491
on
Growth
of
Community
Increases in Hospital Expenses, 1976-1979. A Comparison of States With Mandatory Cost Containment Programs and States Without Mandatory Cost Containment Programs. alas. no. 498 Industry Roles in Health Care. abs. no. 501 Intluence of Competition by PrepMd Group Practice on the Development of an Individual Practice Association. Health Maintenance Organization. abs. no. 505
ct h_ 1,;74, abs. no. 731 Prol[l_, of Employee Benet_ts. abs. no. 739
Insuring 514
RcJ)tt_orsemcnt Reimbursement
Interim Report to Congr¢.ss on Occupational Diseases. abs. no. 517 Japan 's High-Cost Illnea_ Insurance Program. A Study of Its First Three Years, 1974-76. abs. _ao. 523
for Hospital Services. abs. no. 792 t_r Physicians' Services. abs, no. 793
Comparisons of health em'e programs Bcnch:t R_,hts and Privacy. The Insurance abs. no. 48 Can Health Maintcnance Organizations Ft'd_'ra/ly Qu:dified H,l, lOs. abs. no. (_n Pri,_aty C_ze Deli_'er abs. no. 60 CP,c_'Ab,_o_ 'S G_'ide to Health Insurance l)_st, ict of Columbia, Maryland, and crtm_cnt Employees). abs. no. 83 Comparative Eapcrienees in Controlling
VII-2
Drugs in State Comparing Dental
System
and Fertility
Be Successful. 59
Control.
An Analysis
of 14
Plans for Federal Employees. For Virginia (Also covers D.C GovExpendJtures
for Prescription
the Nation's
Health.
An Evaluation
of Three Approaches.
abs. no.
Kaiser's Financial Strategies and Some Cues for Other HMOs. abs. no. 526 Managing Medicaid Drug Expen(h'tures. An Analysis of Divergent Approaches, abs. no. 541 Medigap. States Response to Problems with Health Insurance for the Elder. ly. abs. no. 583 ,_eIental HeMth Services. UnTizadon by Low Income Enrollees in a Ptepat_t Group Practice Plan and in an Independent Practice Plan. abs. no. 586 Modelling the Effects of National Health Insurance in the United State.,. abs. no. 594 National Health Insurance. abs. no. 606
Health
Care
Programs
National National
Health Health
Insurance Insurance
National National
Health Insurance. Health Insurance
and Corporate Benefit Plans. abs. no. 609 and Income Distribution. abs. no. 611
Canada's Thirty Years of Health From Here. abs. no. 61
Benefits, Costs, and Consequences. abs. no. 616 Issues. The Cost of a National Prescription Pro-
Canadian Approaches ance. abs. no. 62
to Health
Care
Through
Government.
Policy Decislbns.
,_'ational
½"here" to He,dth
lnsur-
gram. abs. no. 623 National Health Insurance Proposals. Provisions of Bills Introduced in the 94th Congress as of February 1976. abs. no. 626 New Directions in Public Health Care. A Prescription for the 1980s. abs. no. 643
Canadian National Health Insurance. Lessons for the United States. abs. no. 63 Care of the Aged. Old Problems in Need of New Solutions. abs. t_. 6o Carter Administration, Congress and Health Policy. A National LcaJcrship Conference. abs. no. 67
New York Case Mix Study. abs. no. 8031 Ordering Social Objectives. National Health Service and National Health Insurance as Policy Options in Organizing the Medical Care System. abs. no. 664
Child Health. America's Future. abs. no. 84 Chronic Illness and Health Services Use. ,4 Before-After Study National Health Insurance. abs. no. 88 Comparative National Policies on Health Care. abs. no. 93
Overview 665
Cost Containment. Medical System Cost of National Health Insurance.
of Group Practice
Patient Outcomes 669
in Three
HMOs.
Survey
Alternative
Results,
Long-Term
March
1979. abs. no.
Care Settings.
abs. no.
Rehabilitation The Province
or Reform. of Quebec.
of Canadian
abs. no. 153 abs. no. 161
Disability Insurance. Trends Since World War II. abs. no. 214 Drug Coverage Under National Health Insurance. The Policy Options.
abs.
Paying for Physician Services Under Medicare and Medicaid. abs. no. 671 Perceptions of Medical Care. The Impact of Prepayment. abs. no. 677 Policies for the Containment of Health Care Costs and Expen_'tures. abs. no. 700
no. 225 Economic Class and l_'sk Avoidance. Experience Care Insurance. abs. no. 229 Efforts to Restructure a Medical Delivery System.
Policy, Politics, and Child Health. Four Decades of Federal Initiative and State Response. abs. no. 704 Proposals for National Health Insurance in the USA. Origins and Evolution, and some Perceptions for the Future. abs. no. 745 Prospective Reimbursement Through Budget Review. New Jersey, Rhode Island and Western Pennsylvania. abs. no. 754 Public Capabilities and Health Care Effectiveness. Imp_eations from a Comparative Perspective. abs. no. 760 Re-examining the Rhode Island Experience with Prospective Reimbursement. abs. no. 775 Risk Differential Between Medicare BeneSciaries Enrolled and Not Enrolled in an HMO. abs. no. 815
Health Service. abs. no. 256 Evaluation of Health Manpower Shortage Area Criteria. Final Report. abs. no. 281 Extench'ng Canadian Health Insurance. Options for Pharmacare and Denticare, abs. no. 294 Foreign Hospitals Reimbursement Systems. abs. no. 8017 Government Health and Welfare Programs in the United States and West Germany. abs. no. 337 Gvdde to Selected References on National Health Care and Socialized Me_'cine (1930-1973). abs. no. 346 Health and Health Care. Policies in Perspective. abs. no. 349 Health Care Business. International Evidence on Private Versus Public
Role
of Payment Source in Differentiating Nursing Home Residents, Setvices, and Payments. abs. no. 817 Simultaneous Logit of Plan Membership in the Federal Employees Health
Health Care Systems. abs. no. 356 Health Care Cost Containment in West Germany. abs. no. 359 Health Care Systems in World Perspective. abs. no. 380
BeneHts Program. abs. no. 832 Social Medicine. The Advance of Organized abs. no. 834
Health Insurance abs. no. 389 Health Insurance
Health
Services
in America.
State
and Cost-Containment in the Urn'ted States.
Policies.
under The
Public
Medical
British
National
The Experience
Imph'catioos
Abroad.
for the United
Employee Health Insurance Plans. A Survey of Coverage, BaneSts, Financing. abs. no. 852 State Health Legislation Report Vol. 8 No. 3. State Comprehensive and Catastrophic Health Insurance Legislation. abs. no. 853 State Hospital Cost Containment Programs. abs. no. 854 Status of Competition in the Health Industry. abs. no. 859
dora. abs. no. 395 HospitaI Cost Containment. Selected Notes for Future Policy. Insurance BeheSts, Out-of-Pocket Payments, and the Demand Care. A Review of the Literature. abs. no. 509 International Dental Care Delivery Systems. Issues in DentaI cies. abs. no. 518
Study to Determine the Relationship of Community Health Centers, Cornmunity Mental Health Centers, and Drug Treatment Centers for the Provision of Mental Health Services to CHC Registrants. Final Report. abs. no 873
Japan's High-Cost Ilh_ess Insurance Program. A Study of Its First Years, 1974-76. abs. no. 523 Me_cal Risks. Patterns of Mortality and Survival. abs. no. 563 Mental Disorder and Primary Medical Care. An Analy_cal Review
Survey Results, no. 883
Literature. al0s. no. 584 National Health Care in Great Britain.
July 1980. HMO
Enrollment
and Utilization
in the U.S. abs.
Lessons
for the USA.
Three
of the
abs. no. 602
abs. no. 614 National Health National Health National Health 619 National Health
Why D¢_ HMOs no. 941
National Health Insurance in the Federal Republic of Germany and its Implications for US. Consumers. abs. no. 621 New Directions in Public Health Care. A Prescription for the 1980s. abs.
Health
Maintenance
Comparisons regarding foreign health policies Alternative Oral Health Service Delivery Systems.
Services.
abs. no. 18
al0s.
for Contaim'ng
Poll-
U_c of Hospital Services Under Two Prepaid Plans. abs. no. 920 Use of Physician Services Under Two Prepaid Plans. abs. no. 922 When a Solution Is Not a Solution. Medicaid and Health Maintenance Organizations. abs. no. 936 Who Chooses Prepaid Medical Care. Survey Results from Two Marketings of Three New Prepayment Plans. abs. no. 938 More
as an Agent
Health
National Health Insurance enae. abs. no. 610 National Health Insurance
to Provide
Resources.
abs. :no. 449 for Medical
Three World Systems of Medical Care. Trends and Prospects. abs. no. 904 Trends in Medical Care Costs. Do HMOs Lower the Rate of Growth. abs. no. 910
Seem
and Health
King-
The European Health-Care
ExperiCosts.
Insurance. Insurance. Insurance.
Can We Learn From Canada. abs. no. 617 Canada's Path, America's Choices. abs. no. 618 ContHcting Goals and Po_'cy Choices. abs. no.
Insurance
in Canada.
no. 643 On Paying the Fiddler
abs. no. 620
to Change the Tune. Further
Evidence
From Ontario
VII-3
Regarding the Impact of Universal Health Insurance on the Organizalion and Patterns of Medical Practice. abs. no. 660 On the Cost of National Health Insurance in Quebec. abs. no. 661 Physician Migration in Response to Income Opportunities Under Universal Health Insurance in Quebec. abs. no. 688
Enrollment Choice in a Multi-H,4dO Setting. The Roles of Health Rls_. Financial Vulnerability, and Access to Care. abs. no. 266 Erosion of the Medical Marketplace. abs. no. 272 Health Care Business. International Evidence oa Pri_ arc _'cr3us Publli" Health Care Systems, abs. no. 356
Policies for the Containment no. 700
abs.
Health Care Costs. Why Regulation Fails, Why Con_pctit, on to Get There From Here. abs. no. 365
abs.
Health
Policy
Options
of Health
and the Impact
no. 703 Public Capabilities
and
Care Costs and Ezpendl_ures.
of National
Health
Care
Health Insurance
Effectiveness.
Revisited.
Implications
from
a
Comparative Perspective. abs. no. 760 Rationing Health Care. abs. no. 774 Regionalization and Health Policy. abs. no. 780 Regulating Responses
Care Issues
for Industry.
Health Care Reimbursement abs. no. 378
Works, How
abs, no, 373
Is Federal
Taxation
of Tax-Exempt
Providers.
Health Care Trends. Minneapolis/St. Paul, Summary ttighlights, 381 Health Insurance in the Medicare Years. abs. no. 394
Health Care. The Struggle for Control. abs. no. 781 of Canadian Physicians to the Introduction of Universal
Medical
Health Plan, The Only Care. abs. no. 4 | 2
Practical Solution
to the Soaring
Cost of MedJcal
Care Insurance. The First Five Years in Quebec. abs. no. 804 Rethinking National Health Insurance. ,abs. no. 810 Role of Health Insurance in the Health Services Sector. abs. no. 816
Hospital Cost Inflation and Health Insurance. A Comple_ Marhet abs. no. 451 Hospital Production. Can Costa Be Contained. abs. no. 453
Setting National Priorities, Agenda for the 1980"s. abs. no. 830 Social Security Programs Throughout the World, 197Z abs. no. 837
Hospital Regulation Through State Rate Review. a Noble Intrusion. abs. no. 455
Social Structure and the Diffusion of Medical Innovations in the United States, Great Britain, Sweden and France. abs. no. 838 Some Effects of Quebec Health Insurance. abs. no. 844
How Business How Business 464
Spy in the House of Medicine. abs. no. 850 Study of the Responses of Canadian Physicians to the Introduction versa/_Iedical Care Insurance, The First Five Years in Quebec.
of Uniabs. no.
How Interested Groups Have Responded to a Proposal for Economic petition in Health Services. alas. no. 468 Impact of HAlOs. Evidence and Research Issues. abs. no. 480
872 Technology
abs.no.
Impact of the Rhode 489
in Hospitals.
Medical
Advances
and Their Diffusion.
893 Three World Systems of Medical Care. Trends and Prospects. abs. no. 904 Workers" Compensation and Work-Related Illnesses and Disc&ms. abs. no. 945 Competition/interaction
among
third-party
Mandated
Model
Interference
or
Can Improve Health Planning and Regulation. abs. no. 462 Can Stimulate a Compotitive Health Care System. abs. no,
Island
Catastrophic
Health
Insurance
Corn-
Plan. abs. no,
Interim Report to Congress on Occupational Diseases. abs. no. 517 Major Issues in the Financing and Management of Health Care. abs. no. 536 Mandated Community-Rating and Underlying Reimbursement Issues. abs. no. 542 National Health no. 631
imyors
abs, no.
Insurance.
96th Congress
second
session,
Volume
2. abs.
Adding a Dose of Competition to the Health Care Industry. abs. no. 7 BeneHt Recovery in Medicaid. An Examination of the Development and Implementation of a Benel_t Recovery System in the State of ?dinnesota, abs. no. 47 Changing Medicaid Population. abs. no. 78 Comparisons of Prepaid Health Care Plans in a Competitive Market. The Seattle Prepaid Health Care Project, abs. no. 100 Competing for Acute Care Dollars. The Economics of Risk Reduction. abs. no. I02
National Health Insurance. 96th Congress second session. Volume 3. abs. no. 632 Note on the Comparison of the Hospital Cost Experience of Three Competing HMO's. abs. no. 650 On Broadening the DetYnition of and Removing Regulatory Barriers to a Competitive Health Care System. abs. no. 658 Physician Reimbursement and Hospital Use in HMOs. abs. no. 691 Potential for a Competitive Health Care System in Boston, .Massachusetts. abs.no. 710
Competition and Regulation. tire. abs. no. 103
Potential Market Competition Maryland. abs. no 711
Competition Competition 105
The Consumer
Choice
Health
Plan Alterna-
in the Delivery of Medical Care. abs. no. t04 in the Health Care Sector. Past, Present and Future.
abs. no.
in the Medical
Care System
Pressures and Problems for Organized Ambulatory Decade. abs. no. 718 Private Cost Containment. abs. no. 727
Competitive Response of Blue Cross and Blue Shield to the Health Maintenancc Organization in Northern California and HawML abs. no. 106
Proposals 747
Consumer-Centered Consumer-Cholce
Recent Alternative Delivery System Development Regulation of Health Care in the United States,
vs. Job-Centered Health Plan. A
Health Insurance. abs. no. 126 N_tional-Health-Insurance Proposal
to Restructure
the Financing
of Private
Services
Health
of Baltimore, in the NcM
Insurance.
abe. no.
in Denver. abs. no. 777 alas. no. 787
Based on Regulated Competition in the Private Sector. abs. no. 127 ConsumcroChoice Health Plan. Inflation and Inequity in Health Care To-
Reimbursement Role of Health
day. ,41teruatives for Cost Control and an Analysis of Proposals for Naaonal Health Insurance, abs. no. 128 Cost Reimbursement and Price Competition in the Hospital Industry. abs.
Rx for Health Care Economic_ Short-Ran Hospital Responses 831
no, 163 Discounting and Differential Pricing Practices in the Health Care Field. abs. no. 216 Doing Better and Feeling Worse, The Political Pathology of Health Policy. abe. no. 223 L_Yc'ct _Jf Physician-Cnurrolled Health Insurance. abs. no. 243 Et_cts of the Payment Mechanism on the Health Care Delivery System. abe. no. 254
Status of Competition in the Health Industry. abs. no. 859 Structure of Health Insurance and the Erosion of Competition in the Medical Marketplace. abs. no. 864 Systems Approach to Health Insurance Policy Information. A Prclimina 0" Taxonomy of Health Insurance Issues, Program Optinns, Problems a,,/ Solutions. abs. no. 885 Taxation and Its Effect Upon Public and Private Health Insurance _nd Medical Demand. abs. no. 890
VII-4
for Hospital Services. abs. no. 792 Insurance in the Health Services Sector.
abs. no. 816
Competition, Not Rigid NHI, alas. no. 82 l to Reimbursement Rate Changes. abs. no.
Health Care Program._
Theory and U.S. Health Cost
Practice in Minneapolis-St. Paul. abs. no. 899 Insurance Industry. An Alternative View. abs. no. 917
containment efforts Achieving Cost-Effective Adding a Dose Administration's
Practice
in a Prepaid
pezience, abs. no. 144 Corporate Role in Containing Cost ConlMnment Cost Containment abs. no. 149
Plan. abs. no. 5
of Competition to the HeMth Care Industry. abs. no. 7 Program for Health Cost Containment. abs. no. 9
Cost Containment no. 150
Health
Care Custs.
abs. no. 145
and Health Planning. A Bibliography. by a Third Party Payer. Negotiations Education
Efforts in United States
abs. r_o 147 of S_lt_ical _k',_.
#tedical
Altering MedicaM Provider Reimbursement Methods. abs. no. 17 Analysis of Programs to Limit Hospital Capital Expenditures. Drat_ Final Report. abs. no. 34
Cost Containment Cost Containment Cost Containment.
Analysis of Prospective Payment Systems in Upstate New York. abs. no. 35 Analysis of the Effects of Prospective Reimbursement Programs on Hospital Expenditures. abs. no. 37 Attempts to Control Health Care Costs. The United States Experience. abs. no. 45
Cost Containment Through Employee Incentives Program. Cost Containment Through Risk.Sharing by P_mary Care History of the Development of United Heaithcare. abs. Cost Control Challenge for Hospitals. abs. no. 156 Cost Effec_ve Acute Care Facilities Planning in Michigan.
BeneSt Recovery in Medicaid. An Examination of the Development and Implementation of a Benetit Recovery System in the State of Minnesota, abs. no. 47
Council on Wage and Price Stability abs. no. 172 Crisis in Health Care. abs. no. 173
Better Services at Reduced Program Recommended
Current Developments 175
Costs Through an Improved for Veterans. abs. no. 50
"Personal
Care"
Sc'hool_, abs.
in the Health Care Industry. abs. no. 151 ,_lechanisms, abs. no, 152 Medical System Rehabilitation or Retorm. abs. no. 153
in the National
Report
abs. no. 154 Physicians. A no. 155
on Rising Health
Health
Planning
abs. no, 157 Care Costs.
Program.
a0s. no.
Business Perspective on Industry and Health Care. abs. no. 55 California Health Facilities Commission. A Case Study of Government Regulation. abs. no. 56
Cutting Cost Without Cut_'ng the Quality of Care. Shattuck Lecturt_ abs. no. 178 Dental and Vision Care Benel_ts in Health Insurance Plans. abs. no. 189
Canada's Thtrty Years of Health Care Through Government, Where to From Here. abs. no. 61 Canadian Approaches to Health Policy Decisions. National Health lnsurante. abs. no. 62 Carter Administration, Congress and Health Policy A National Leadership Conference. abs. no. 67
Department of Health, Education, and Welfare, OtNce of the Inspector General. AnnuM Report, January 1, 1979 to December 31, 197_). abs. no. 197 Design for a Corporate Health Care Monitoring System. abs. no. 199 Determinants of Physician and Pharmacist Support of Generic Drugs. abs. no. 202
Case for Negotiated Rates. abs. no. 69 Characteristics of Group Health Plans. abs. no. 8005 Chip Commission. Final Report. abs. no. 86
Determining Present and Future Health Clam Costs. abs. no, 204 Digest of Hospital Cost Containment Projects, Third Edition. abs. no. 208 Does America Spend Too Much on Health Care. abs. no. 222
Competition and Regulation. live. abs. no. 103 Competition 105
in the Health
The Consumer Care Sector.
Choice
Past, Present
Health
Plan Alterna-
and Future.
abs. no.
Doing Better and Feeling abs. no. 223
Worse.
The Political
Pathology
Dollars and Sense of Hospital Malpractice Insurance. Economics of Cost Containment. abs. no. 236
of Health
Policy.
abs. no, 224
Complex Puzzle of Rising Health Care Costs. Can the Pn'vate Sector Fit it Together. abs. no. 107 Conference on Health Promotion and Disease Prevention, February 16-18, 1978 Volume 1. Themes and Policy Suggestions. abs. no. 113 Consequences of Increased Third-Party Payments for Health Care Services. abs. no. 115 Consumer-Centered vs. Job-Centered Health Insurance. abs. no. 126 Containing Costs in Third Party Drug Programs. Selected Bibliography and Abstracts. abs. no. 129 Containing Health Benetlt Costs. The Self-Insurance Option. abs. no. 130 Containment of Hospital Costs. A Strategic Assessment. abs. no. 131 Control of Hospital Costs by Rate-Setting. abs. no. 133 Cootrolliog Health Care Costs. A National Leadership Conference. abs. no. 134 Corltrollir_ B H_'alth Care Costs. Strengthening the Private Sector's Hand. abs. no. 135 Controlhng Hospital Costs. The Revealing Case of Indiana. abs. no. 136 Controlling Hospital Costs. The Revealing Case of Indiana. Summary. abs. no. 137 Ctmtrolling Medicaid Utilization Patterns. abs. no. 138 Contrtdh_g Rising Hospital Coats. abs. no. 139 Controlhng the Cost of Dental Care. abs. no. 140 Controlling the Cost of Health Care. abs. no. 141 Controlling the Co_ts of Retirement Income and Medical Care Plans. abs. no. 142
Economics of IndostHal Health. History, Theory, Practice. abs. no. 237 Economics of Medical Malpractice. abs. no. 239 Effect of a Mandatory Second Opinion Program on Medicaid S_rgery Rates. An Analysis of the Massachusetts Consultation Progr_rm for Elective Surgery. abs. no. 240 Effect of Physician-Controlled Health Insurance. abs. no. 243 Effect of PSROs on Health C_re Costs. Current Findings and Future Evaluations. abs. no. 244 Effectiveness of Alternative Approaches to Utih'zation Review of Physiclans OftTee Practices. abs. no. 8011 Effects of Hospital Cost Containment on the Development and Use of Medical Technology. abs. no. 251 Entering a Nursing Home. Costly Implications for Medicaid and the Elderly. ads. no. 267 Evaluafon of Market Mechanisms of Cost Control. abs. no. 283 Evaluation of the Maximum Allowable Cost (MAC) for Drugs Program. Phase I Report. Final Design Report and Report of Pilot Study Analysis. abs. no. 287 Executive Fitness Aids Corporate Health. abs. no. 288 Expenditures for Health Care, Federal Programs and Their Effects. abs. no. 291 Feasibility and Cost.Effectiveness of Alternative Long-Term Care Settings. abs. no. 302 Federal Control of Pharmaceutical Costs. The MA C Experience. _Lbs.no. 303
Controllittg toe Use and Cost of Medical Services. The New Mexico Experimental Medical Care Review Organization. A Four-Year Case Study. abs. no. 143 ('_p_yment,_ and Demand for Medical Care. The California Medicaid Ex-
Financial Management of Health Care Organizations. A Referenced Outline and Annotated Bibh'ography. abs. no. 311 Financing of Health Care. abs. no. 316 Forecasting. A Cost Control Tool for Health Care Managers. abs. no. 319
VII-5
Forward Plan for Health FY 1978-82. Foundation for Health Care Regulation. 321
abs. no. 320 PL 92-603 and PL 93-641. abs. no.
Hospital Rate Setting. 7"his Way to Salvation. abs. no 454 Hospital Regulation Through State Rate Rcvtew. ._ldndalcd ln_crt_'ren,'c a Noble Intrusion abs. no. 455
Foundations for Medical Care. An Empirical Investigation of the Delivery of Health Services to a Medicaid Population. abs. no. 322 Framework for Capital Controls in Health Care. abs. no. 323
How Bosinesa Can Improve How Business Can Promote lies. abs. no. 463
Functional Costs.
How Business 464
Fundamentals 328
Value Analysis. abs. no. 326 of Second
A
Technique
Opinion
for Reducing
Programs
HospitM
for Elective
Overhead
Surgery.
Future Issues in Health Care. Social Policy and the Rationing Services. abs. no. 331 Group Insurance Cost Containment Strategies. abs. no. 342
abs. no.
of Medtcal
Health. Health Health Health the
A Victim Care Cost Care Cost Care Cost Law. abs.
or Cause of Intlation. abs. no. 348 Containment. abs. no. 8018 Containment. Challenge to Industry. abs. no. 357 Containment Expetimen'ts. Policy, Individual Rights, no. 358
Health Health
Care Cost Containment in West Germany. abs. no. 359 Care Cost Elements Affecting Legislative and Planning Considera-
and
or
Health Planning and Regulatt,m abs. no. 402 Good Health for Employec, and Their Fatal-
Can Stl)nulate
a Competitive
How Business Can Use Specific abs. no. 465
Health
Teehmques
Care" System.
to Control
How Business Interacts With the Health Care System. How _Wueh Can Business Expect to Earn From Smoking 469
Health
abs. no.
Care Costs.
abs. no. 466 Cessation. abs. no.
How Things Work l"n the Real World of Hospital Finance. abs. no. 471 How to Improve Health and Contain Costs. abs. no. 472 Idea Whose Time Has (;brae. Less Health Insurance. abs. no. 473 Impact of State Certil_ca;e-of-Need Laws on Health Care Costs and Unhzadon. abs. no. 487 Improving Health in America. 1977-80. abs. no. 495
U.S. Public" Health
Service
Htghhghts
of
tions, abs. no. 360 Health Care Cost Increases. abs. no. 361 Health Care Costs. Private lnittatives for Containment. abs. no. 364 Health Care Costs. Why Regulation Fails, Why Competition Works, How to Get There From Here. abs. no. 365 Health Care Dilemma and Corporate Debt Capacity. abs. no. 366
Increases in Hospital Expenses, 1976-1979. A Comparison of States With Mandatory Cost Cor,tainment Programs and States Without _tandatory Cost Containment Programs. abs. no. 498 lndustry's Voice in Health Policy. abs. no. 502 Insurance, Regulation, and Hospital Costs. abs. no 512 Issues in Health Care Regulation. abs. no. 520
Health Care Dilemma. abs. no. 367
Joint HeMth no. 524
Problems
of Technology
in Health
Care Delivery.
Health Health
Care in the American Economy. Number Care Issues for Industry. abs. no. 373
3. abs. no. 370
Health Heaith
Care Market. Can Hospitals Survive. abs. no. 374 Care Policy in a Changing Environment. abs. no. 376
Health Care S)_tem in the United States. abs. no. 379 Health Costs" Can Be Reduced by Millions of Dollars if Federal Fully Carry Out GAO Recommendations. abs. no. 384 Health Insurance and Cost-Containment Policies. The Experience abs. no. 389 Health Insurance in the Medicare team, abs. no. 394
Cost Conta/nment
Lifetime Health-Monitoling Medicine. abs. no. 532
Program.
Program.
Hospital
A Practical
Linking Physicians, Hosoital Management, Medical Care. abs. no. 533 Agencies Abroad.
Utilization Approach
Report.
abs.
to Preventive
Cost Containment
and Better
Major Issues in the Financing and Management of Health Care. abs. no. 536 Management and Policy Issues in HMO Development, ! 979. abs. no. 540 Managing Medicaid Drug Expenditures. An Analysis of Divergent Approaches, abs. no. 541 MediCal Benefit Cost Containment in the U.S.A. abs. no. 552 Medical Care Plans. Ho_, to Control the Costs. abs. no. 553
Health Insurance. What Should be the Federal Role. abs. no. 399 Health ._dalntenance Organizations and Prepaid Group Practices. A Bibliography, abs. no. 404 Health Matntenance Organizations as an Instrument for Cost Containment Policy. abs. no. 405 Health Maintenance Orgamzations Can Help Control Health Care Costs. abs. no. 406 Health Plan. The Only Prac_cal Solution to the Soaring Cost of Meab_al ('are, abs. no. 412 Health Planning and Regulation. A Manual for State Legislators. abs. no. 413 Health Planning and Regulation Effects on Hospital Costs. abs. no. 414 Health Planning as a Regulatory Strategy. A Discussion of its Histo(y and Current Uses. abs. no. 415 Health Reform. The Outlook £or the 19gOs. abs. no. 418
Medical Care System Under National Health Insurance. Four Models. abs. no. 554 Meda_al Malpractice Stats. abs. no. 561 MedicM Self-Care Programs. abs. no. 564 Medical Technology. A Different View of the Contentious Debate Over Costs. abs. no. 565 Medical Technology and Hospital Costs. abs. no. 566 Medical Technology. The Culpnt Behind Health Care Costs. abs. no. 568 Medical Technology, Who's To Say When We "ve Had Enough. abs. no. 569 Medicare and Mech'caid Physician Payment Incentives. abs. no. 573 Medicare. The Politics 6f Federal Hospital Insurance. abs. no. 582 Minimal Care Units. Mechanisms for Hospital Cost Containment. abs. no. 591 Mode of Payment and Length of Stay in the Hospital. More Work for PSROs. abs. no. 592
HIAA Revle_,s State Cost Control Regulation. High Cost of Hospitals and What to Do About
Modifying Multilevel
History and Organization of Pretreatment R ewew System. abs. no. 433 Hospital Capital Expenditure suits, abs. no. 444 Hospital Hospital tlospita/ Ito_pital tlospital Hoap,tal
VII-6
Controls.
abs. no. 430 It. abs. no. 431
Review, Their Desired
a Dental
Utilization
and Expected
Re-
Collective Bargaining. Structure and Process. abs. no. 446 Cost Containment Act of 1979. abs. no. 447 Cost Containment Programs. A Policy Analysis. abs. no. 448 Cost Containment. Selected Notes for Future Policy. abs. no. 449 Cost Control in Maryland abs. no. 450 Production. Can Costs Be Contm)_ed. abs. no. 453
Medicaid Eligib_Tity and Benefits. abs. no. 595 Care. A Veterans Administration Initiative in Health
Control. abs. no. 596 National Commission on the Cost of Medical Commission Recommendations abs. no. 599
Care. 1976-197Z
Task Force Reports
Research
Care Cost Volume
1.
Agenda.
National Commission on the Cost of Medical Care. 1976-197Z Volume 2. Collected Papers. ab_. no. 600 NaNonM Health Care Strategy Series Update. abs. no. 8028 National Health Insurance. A Social Placebo. abs. no. 608 National Health Insurance as an Agent for Containing Health-Care Costs. abs. no. 614
Health Care Programs
National National 619
Health Insurance. Health Insurance.
Canada's Path, America's Choices. abs. no. 618 Conlh'ctin8 Goals and Policy Choices. abs. no.
National Health Insurance. 629 National Health Insurance. no. 631
What Now,
96th Congress
second
session,
Volume 2. abs.
National Health no. 632
96th
second
session,
Volume
Congress
What Never.
abs. no.
no. 784 Regulation of Health Regulation of Health no. 788
Care Delivery. abs. no. 786 Facilities and Services by "Certi[icate
of Need. : abs.
3. abs.
Regulatory Environment for Physician Compensation. abs. no. 789 Reimbursement Alternatives for Home Health Care. abs. no. 790
National Hospitat Rate-Setting Study. A Comparatl"ve Review of Nine Prospective Rate-Setting Programs. abs. no. 637 • New Dir_tions in Public Health Care. A Prescription for the 1980s. abs. no. 643
Reimbursement for Hospital Services. abs. no. 792 Report on Coalitions to Cont_un Medical Care Costs. abs. no. 800 Research and Demonstrations in Health Care Financing, 1978-1979. no. 802
New
Insurance.
What Later,
Regulating Hospital Labor Costs. A Case Study in the Politics of State Rate Commissions. sbs. no. 783 Regulating the Cost of Health Care. Can We Learn from Experience. abs.
Jersey Hospital Reimbursement 1980. abs. no. 646
Under
S-446. Elements
and Effects,
abs.
Restructuring Federal Medicaid Controls and Incentives. abs. no. ,$07 Rethinking Health Policy for the Elderly. A Six-Point Program. abs. no. 809
NHI Won't Control Costs, Quality, or Access. abs. no. 648 Oftice of Health Maintenance Organizations. 5th Annual Report to the Congress. abs. no. 655 Office of Personnel Management Should Promote Medical Necessity Programs for Federal Employees" Health Insurance. abs. no. 656 Opening Up the Health System. Pubh'c and Private Sector Friction. abs. no. 663
Rising Heslth Costs. Public and Private Responses. abs. no. 8 [3 l_'sing Hospital Costs Can Be Restrained by Regulating Payments and Iraproving Management. abs. no. 814 Role of Physician Education in Cost Containment. abs. no. 818 Role of the Private Sector in National Health Insurance. abs. no. 820 Rx for Health Care Economics. Competition, Not Rind NH1. abs. no. 821 Second Surgical Opim'ons. What Have We Learned. abs. no. 823
Payer, Provider, 670
Selected, Annotated Bibliography on Health 1974-1978. Volume If. abs. no. 824
Consumer.
Industry
Confronts
Health
Care Costs. abs. no.
Maintenance
Organizations,
Paying for Physician Services Under Meals'care and Medicaid. abs. no. 671 Personnel Leaders)up in Action. Doing SometMng About HeJlth Care Cost Containment. abs. no. 679
Societal Responsibility for Malpractice. abs. no. 841 Some Issues in Lizm'ting Hospital Cost Reimbursement. ence. abs. no. 845
Perspectives on Medicines in Society. abs. no. 681 Policies for the Containment of Health Care Costs and Expenditures. no. 700
Some State and Federal Perspectl"ves on Medicaid. abs. no. 846 South Carolina Voluntary Effort Report 1980-81. abs. no. 8040 South Caroling Voluntary Effort, 1980-81. abs. no. 848
abs.
A Maryland
Policy Issues in Financing Mental Health Service& abs. no. 702 Politics and Economics of Hospital Cost ContainmenL abs. no. 706 Potential for a Competitive Health Care System in Boston, Massachusetts. abs. no. 710
State State Status Steps
Pressures and Problems for Organized Ambulatory Decade. abs. no. 718 Preventive Health Care in the HMO. Cost Benefit Private Cost Containment. abs. no. 727
Study of Taft-Hartley Health and Welfare Trust Fund Summary Repor_ abs. no. 869 Summary of Rate Review in Maryland. abs. no. 876 Supplementary Health Insurance and Cnst-Consciousnoss
Services Issue&
in the Next
abs. no. 720
Private Physicians and Public Programs. abs. no. 732 Private Sector Perspective on the Problems of Health C&'e Costs.'abs. 733 Proceedings Health Professional Program gram Promoting ning. Proposals Proposals 747
of the National Conference Insurance. abs. no. 734 Standards
Review
on Drug Coverage
Organization
Program.
no.
Under National
abs. no. 737
to Restructure
the Financing
of Private Health
Insurance.
Guide to Medicaid Cost Containment. abs. no. 8042 Hospital Cost Containment Programs. abs. no. 854 of Coml_tition in the Health Industry. abs. no. 859 to Control IntTation in Health C&,v Costs. abs. no. 860
877 Taking Acu'on Taking Action
abs. no.
Operations
Strategy.
Cost.
abs. no.
To Contain Health Care Costs. Part I. abs. no. 887 to Contain Health Care Costs. Part If. abs. no. 888
Taxation and Its Effect Upon Public Medical Demand. abs. no. 890 Textbook
for Elective Surgfcal Second Opinion. Surgical Experience of ProParticipants, 1976-197Z abs. no. 742 Compe_tion in the Health Industry. The Role of Health Planabs. no. 743 for the Regulation of Hospital Costs. abs. no. 746
Experi-
for Employee
Benefit
Plan
and Pn'vate Trustees,
Health
Administrators
Insurance
and
and Advi-
sorx abs. no. 897 Third Party Payment for Nonph ysician Health Practitioners. Realities Recommendations. abs. no. 900 Third-Party Payments for New Health Prof_ionals. An Alternative Fractional Reimbursement in Outpatient Care. abs. no. 902 Toward a Physician Payment Policy, Evidence zation Progt2tm. abs. no. 908
From the Economic
and to
Stabili'-
Proposed Framework for Health and Health Care Policios. abs. no. 748 Prospective Rate Reimbursement and Cost Containment Formula Reimbursement in New York. abs. no. 750
Trends in Medical Care Costs. Do HMOs Lower the Rate of Growth. no. 910 Use of Huspital Services Under Two Prepaid Plans. abs. no. 920
Prospective Rate Setting. abs. no. 751 Prospective Reimbursement System Based on Patient Case-Mix for New Jersey Hospitals 1976-1981. abs. no. 753 Prospective Reimbursement Through Budget Review. New Jersey, Rhode Island and Western Pennsylvani& abs. no. 754 PSRO. An Evaluation of the Professional Standards Review Organization
Utilization and Cost of Mental Illness Coves'age in the Federal Employees Health Benefits Program, 1973. abs. no. 924 Veter_s Administration Hospitals. An Economic Analysis of Government Enterprise. abs. no. 930 Wgsted He_alth Dollar& abs. no. 932 What We Have (And Haven't) Learned From Prospective Payment Pro-
Programs, Volume Control Activities. Public
Health
Regulating Regulating
II. A Cost-Benefit abs. no. 759
and the Law.
Issues and
Context
for PSRO
Utilization
Trend& abs. no. 762
Health Care. The Strnggle for Control. abs. no. 781 Hospital Costs. The Development of Public Policy. abs. no. 782
/_ms. abs. no. 935 Workir_ Papers on Major Programs. Cost/benefit
Budget
and Program
Issues
in Select_t
abs.
Health
abs. no. 947
analyses
VII-7
Achieving Cost-Eft'votive Practice in a PrepaM Administrative Costs of Medicare Contractors. Commercial Intermediaries. abs. no. 10
Plan. abs. no. 5 Blue Cross Plans
Versus
tals. abs. no. 485 Impacts of Health Maintenance Orgamzation Health Care Costs. abs. no. 491
Growth
on
_'(lllnnullity
Allocation of Physicians' Services. Evidence on Length-of- Visit. abs. no. 16 Alternatives to Institutional Care. An Analysis of State Initiatives. abs, no, 8001 Analysis of Requirements for a Cost BenelTt Structure for the Military Medical System With Initial Focus on CHAMPUS. abs. no. 36 Aunlyais of the Potential Impacts of National Health Insurance Programs on Collective Bargaining. Final Report, abs. no. 38 Can Primary Care Deliver. abs. no. 60 Changes in the Costs of Treatment of Selected Illnesses. 1951-1964-1971. abs. no. 76
Insurance Cost Savings D_'e to an Adequate Alcohohsm Hcalth BenelTt. abs. no, 510 Life Cycle Preventive Services Study. abs. no. 8023 Maintaining the Elderly iJ7 the Commum_y. abs. no. 8024 Major Issues in the Financ/ng and Management of Health Care. abs. no. 536 Medicare Second Surgical Opinion Demonstration Project. Greater New York, abs. no, 581 Mental Wellness Programs for Employees. abs. no. 587 National Health Insurance. Benefits, Costs, and Consequences. abs. no. 616 National Health Insurance, Conflicting Goals and Policy Choices. abs. no.
Compamsons of Prepaukt Health Care Plans in a Competitive Market. The Seattle Prepaid HeMth Care Project. abs. no. 1(30 Cost Containment and Quality Assurance Requirements for Third Party Coverage for Ambulatory Psychiat_c Care. abs. no. 148 Cost Effective Acute Care Facihlies Planning in Michigan. abs. no. 157 Cost of BenetTts for Alcoholism in a National Health Insurance Program. abs. no. 158
619 Naoonal Health Insurance Issues. The Cost of a National PrescrJl)t_on Program. abs. no. 623 New York Case Mix Study. abs. no. 8031 Nursing Home Cost Studtes and Reimbursement Issues. abs. no. 652 Per-Case Reimbursement for Medical Care. Final Report. abs. no. 675 Physician and Cost Control. abs. no. 683
Cost.Benelit Analysis Cost-Benel_t Study of the Work Setting. Cost-£Tfectiveness of abs. no. 166
Physician Control of Blue Shield Plans. Staff Report. abs. no. 684 Physician Extender Reimbursement Experiment. abs. no. 685 Potential Impact of Mandatory Cafeteria Style Health Benet_t Programs the Cost of Health Insurance. abs. no. 8033 Prediction and Incentives in HeMth Care Policy. abs. no. 713
Mandatory Medicare Participation. abs. no. 164 a Hypertension Screening and Treatment Program at abs. no. 165 a Restrictive Drug Formulary, Louisiana vs. Texas.
for
Cost-Effectiveness of Primary and Secondary Prevention. abs. no. 167 Cost-Financed Mental Health Facility. abs. no. 168 Costs, Risks, and Benelits of Surgery. abs. no. 171 Day Hospitalization as a Cost-Effective Alternative to Inpatient Care. A Pilot Study. abs. no. 179 Dental Care for Everyone. Problems and Proposals. abs. no. 192 Dlsabt_ity Policies and Government Programs. abs. no. 215 Doctors and Thetr Workshops. Economic Models of Physician Behavior. abs. no. 220
Preliminary Analysis of the Costs of Maintaining Pension and Health Beaufits in Selected Plans. _bs. no. 714 PrevenO've HeMth Care in the HALO. Cost BenelTt Issues. abs. no. 720 PSRO. An Evaluaffon of the Professional Standards Review Organization Programs, Volume IL A Cost-Benetit Context for PSRO Utilization Control Activities. abs no. 759 Public Versus Private Administration of HeMth Insurance. A Study in Reintive Economic Ef_ciency. abs. no. 766 QuslityAssurance in Health Care. abs. no. 768
Economic Analysis of Alternative Health Care Innovations. abs. no. 228 Econom&" Class and Risk Avoidance. Experience under Public Medical Care Insurance. abs. no. 229 Economic issues in Prevention. abs. no. 232 Economics and the Chronic Mental Patient. abs. no. 234 Economics in Health ('are, abs. no. 235
Quality Health Care, The Role of Continuing MediCal Education. abs. no. 769 Rapid Rise of Hospital Costs. abs. no. 771 Some Aspects of Ambulatory Care Under Medicaid in New York City. abs. no. 842 Some Economic Consequences of Technologienl Advance in Medical Care.
Economics of Industrial Health, History, Theory, Effects of Advertising Lessons From Optometry. Evaluation of Medical Practices. abs. no. 284
The Case of a New Drug. abs. no. 843 Study of Tat_-Hartley Health and Welfare Summary Report. abs. no. 869
Extending _are.
Canadian Health abs. no. 294
Insurance.
Feasibility and Cost-Effectiveness abs no. 302
Options
of Alternative
Practice. abs. no. 237 abs. no. 249 for Pharmacare Long-Term
and Den-
Care Settings.
Study of Taft-Hartley Technical Report.
Health and Welfare abs. no. 870
Substitution of Outpatient cote. abs. no. 874
Care for Inpaaent
Trust
Fund
Operations
Cost.
Trust
Fund
Operartons
Cost.
Care. Problems
Foundations for Medical Care. An Empirical Investigation of the Delivery of Health Services to a Medicaid Population. abs. no. 322 Health Care Cost Elements Affecohg Legislative and Planning Consideratio_s, abs. no. 360
Theory and Practice in Minneapolis-St. Third Party Payment for Nonphysician Recommendations. abs. no. 900 Utilization and Cost of Mental Illness
Health Mai_)tenance Organization Planning Model to Evaluate an Alternaff_ c Health Care Delivery System for the State of Georgia. abs. no. 402 Health )laintenance Organizations and Prepaid Group Practices. A Bibliography, abs. no. 404 Health Alaintcnancc Orgamzations Can Help Control Health Care Costs. _bs. no. 406 Health. What Is It Worth, Measures of Health Benefits. abs. no. 429 Home Health. The Need for a National Policy to Better Provide for the Elderly. abs. no. 438 Hospital _7)st Containment. Selected Notes for Future Policy. abs. no. 449 Hosplta/ SaltZlnsurance Program. Employee Medical Benefits. abs. no. 457 lmpJ,'t _t'a Change in Regulations on Costs in an Experimental Program. abs. no. 475
Health BenelTts Program, 1973, abs. no. 924 Veterans Administration H_spitals. An Economic Enterprise. abs. no. 930
hnpact
VII-8
of Rate Regulation
on the Diffusion
of New
Technologies
in Hospi-
Paud. abs. no. 899 Health Practitioners. Coverage
Experi
Realities
in the Federal Analysis
and
and
Employecs
of Government
Deduetible/coinsuranee Ambulatory Pharmaceutical Services for Medicare Recipients, A Ptlot Project. abs. no. 24 Choice Between Family and Individual Deductibles in Health Insurance. abs. no. 87 Coinsurance and the Demand for Physician Services. Four Years Later. abs. no. 89 Companion of Group Medacal Care Insurance BeheSts to Charges. abs. no. 96 Consumer
Preferences
for Health
Insurance.
abs. no. 8007
Health Care Programs
Controlling
Health
Care Costs.
abs. no. 135 Controlling Medicaid
Strengthening
Utilization
Patterns.
the Private
Sector's
Hand.
abs. no. 138
Controlling the Costs of Retirement Income and Medical Care Plans. abs. no. 142 Col_ymeots and Demand for Mech'cal Care. The California Medicaid Experience,
abs. no. 144
to Medicare.
and Distributional
Effects
Service
of a Catastrophic
Benefits in MedicM Can Fee-for-Service no. 57
Care Programs. Reimbursement
Utilization.
Health
With Special
Insurance,
Emphasis
on Out-of-
or Do Deductibles
Be Planned.
Can Pninary Catastrophic
Supplement
Changing Care
in Colorado. Health
,_Iatter.
abs. no. 8002
Care Costs.
The United States Experwncc.
abs. no. 49 Coexist With Demand
Or, Why Doctors
Should Do More. Forecasting abs. no. 58
abs. no. 170
Demand Elasticities for Health Pocket Price. abs. no. 185 Demand for Supplementary abs. no. 188
of Medicare
Attempts to Control no. 45
Can Health
Cost Containment Mechanisms. abs. no. 152 Cost-Shying in Health Insurance. Its Effects on Health abs. no. 169 Costs, Financing,
Aspects
Should
the Future
Patients
System
Agencies.
Care Deliver. abs. no. 60 Illness in an HMO. abs. no. 74
Mecficald
Population.
abs. no. 78
Chronic Illness and Health Services Use. A Before-After National Health Insurance. abs. no. 88 Coinsuranee no. 89
Crcatio._. abs.
Do Less and
of Health
abs.
and the Demand
for Physician
Services.
Study
of Canadian
Four Years Later. abs.
Economic Class and Risk Avoidance. Experience under Public Medical Care Insurance. abs. no. 229 Empiricial Study of the Differences Between F_ily and Inch'vidual Deductihles in Health Insurance. abs. no. 257 Estimate of the Impact of Deductibles on the Demand for Mech'cal C_e Services. abs. no. 273 Group Specific and Aggregate Stop-Loss Insurance. An Attractive New
Comparative Absence Experience Among Employees Covered by a prep_ or a Blue Cross/Blue Slueld Health Insurance Program. abs. no. 91 Comping the Medical U_h'zation and Expenditures of Low Income Health Plan Enrolle_ With Me_'caYd Recipients and With Low hTcome Enrollees Having Medicaid Eligibility. abs. no. 95 Comperison of the HospitM Cost Experience of Three Competing HMOS` abs. no. 98
Murket. abs. no. 344 Health Care Cost Inflation in the United States. Toward a Unified of Cause and Control. abs. no. 362 Hospital Cost Inflation and Health Insurance. A Complex M_rket abs. no. 451
Coml_uison of the Quality of Maternity Care Between a Health-Malntcnanee Organization and Fec-For-Serviee Practices. abs. no. 99 Consumer Satisfac_on. A Model for Health Services Administrators. abs. no. 124 Contrasts in HMO and Fee-for-Service Performance. abs. no. 132
How Business Can Use Specific abs. no. 465 Insurance Benefits, Out-of-Pocket
Techniques
to Control
Payments,
Theory Model.
Health
Care Costs.
and the Demund
for Medical
Controlling Medicaid Utilization Patterns. abs. no. 138 Copayments and Demand for MedJ'cal Care. ]he California perience, abs. no. 144
Medicaid
Ex-
Care. A Review of the Literature. abs. no. 509 Medicare Reimbursement. abs. no. 579 Methodology Used to Measure Health Care Consumption During the First Year of the Health Insurance Experiment. abs. no. 588 National Health Insurance and Corporate Benefit Plans. abs. no. 609 National Health Insurance. Canada's Path, America's Choice_ abs. no. 618
Cost ContMnment and Quah'ty Assurance Requirements for Third Party Coverage for Ambulatory Psyclu'atric Care. abs. no. 148 Cost of National HcMth Insurance. The Province of Quebec. abs. no. 161 Cost.Sharing in Health Insuranee. Its Effects on Health Service Utilization. abs. no. 169 Crisis in Health Care. abs. no. 173
National Health Insurance Issues. Viability of the Cost-Shz_ing Concept. abs. no. 625 On Having Your Cake and Eating It Too. Economet_c Problems in Es-
Demand Elasticities for Health Care With Special Emphasis on Out-ofPocket Price. abs. no. 185 Demand for General Practitioner and Internist Services. abs. no. 186
timating the Demand for HeMth Services. abs. no. 659 Overview of Health Insur_ce Study Pubb'cations` abs. no. 666
Demand 187
Physicians" Charges Under Medicare. Liability. abs. no. 695
Dental Care Demand. Point Estimates Insurance. abs. no. 191
and Implications
Dental Dental
and Proposals.
Assignment
Rates and
Beneficiury
Responsibility of Families for Their Severely Disabled Elders. abs. no. 805 Role of Health Insurance in the Health Services Sector. abs. no. 816 Demand/utilization
for Medl"CM Care in a Rural Setting.
Care for Everyone. Problems Insurance. abs. no. 194
Racial Comparisons. for National
Access to Medical Care. The Impact of Outreach Services a Prepaid Health Insurance Progrnrn. abs. no. 3 Achievements and Problems of Medicaid. abs. no. 4
on Enrollees
of
Determining Health Needs. abs. no. 203 Diagnosis and the Dole. The Function of Illness Pob'tics` abs. no. 206
Health
abs. no. 192
Design for a Corporate Health Care Monitoring System. Determinants of Pediatric Care Utilization. abs. no. 201
of health care programs
abs. no.
abs. no. 199
in American
Distributive
Achieving Cost-Effective Practice in a Prepaid Plan. abs. no. 5 Achieving Optimum Utih'zation of Ancillary Services. An Annotated Bibhography, abs. no. 6 Age and Medical Care UD'lization Patterns. abs. no. 11 Alcoholism Program Management Through the Operation of a Computerized Information System. L Actuarial Data on Utilization of Services. abs. no. 13
Disability, Health Status, and Utih'zation of Health Services. abs. no. 212 Disability Poh'cies emd Government program& abs. no. 215 Doctors and Their Workshops, Economic Models of Physician Behavior. abs. no. 220 Does America Spend Too Much on HeMth Care. abs. no. 222 Drug prescription Rat_s Before and At_er Enrollment of a Medicaid Population in an HMO. abs. no. 226
Alternative tional
Economic Class and Risk Avoidance. Care Insurance. abs. no. 229
Physician Payment Methods. Health Insurance. abs. no. 19
Incentives,
Efficiency,
and Na-
Experience
under
Public
Medicad
Ambulatory Pharmaceutical Services for Me_'c_re Recipients. A l_'lot Project. abs. no. 24 American Attitudes Toward Health Maintenance Organizations. abs. no. 25 America 'S Health Care System. A Comprehensive PortrMt. abs. no. 30
Economics in Health Care. abs. no. 235 Economics of Mech'cal C_re. A Po_'cy Perspective. abs. no. 238 Effect of Duration of Membership in a Prepaid Group Health Plan un the Utilization of Services. abs. no. 241
Annotated
Effect
Bibliography
of Health
Economics.
abs. no. 41
of Organization
of Medical
Care Upon He_dth Manpower
Distribu-
VII-9
tion. abs. no, 242
view. abs. no. 434
Elrocts of Income Maintenance on the Medical Care Utilization and Health Status of Rural Families. abs. no. 252 Elrocts of the 1974- 75 Recession on Health Care for the Disadvantaged. abs. no. 255
Home Health. The Need for a National PohLy to Better Provide t'o: the Elderly. abs. no. 438 Hospital-Sponsored Primary Care GrotJp Praclic_. A D¢'_ elopit_g Modalil y of Care. abs. no. 460
Equal Treatment and Unequal BenelTts. A Re-examination of the Use of Medicare Services by Race, 1967-1976. abs. no. 270 Equity in HeMth Services. Empirical Analyses in Social Policy. abs. no. 271 Erosion of the Medical Marketplace. abs. no. 272 Estimate of the Impact of Deductibles on the Demand for Medical Care Services. abs. no. 273
How Much Will U.S. NIedicine Change in the Decade Ahead. abs. no. 470 Impact of Alcohol, Drug Abuse and Mental Health Treatment on Med_L'al Care Utilization. A Review of the Research Literature. abs. no. 47b Impact of Comprehe_sive National Health Insurance on Demand for Health Manpower abs. no. 477 Impact of Family Structure on Children's Health Care Use. abs. no. 478
Estimates of Preventive Versus Nonpreventive Medical Care Demand in an HMO. abs. no. 276 Evaluation of Health Manpower Shortage Area Criteria. Final Report. abs. no. 281
Impact of Membership in an Enrolled, PrepaM Population on Utilization of Health Services in a Group Practice. abs. no. 481 Impact of National Health Insurance on New York. abs. no. 482 Impact of National H_._alth Insurance on the Use and Spending for S_ght
Evaluation of Health abs. no. 282
Correction Services. abs. no. 483 Improving Access to _qealth Care Among
Manpower
Shortage
Area Criteria.
I.a_erature Review.
the Poor.
The Neighborhood
Exp¢nda'tures for Health Care. Federal Programs and Their Effects. abs. no. 291 Fact Book on Aging, A Prot_le of America's Older Popula_on. abs. no. 295 Factors Affecting the Choice Between Prel_id Group Pran6ee and Alternatire Insurance Programs. abs. no. 297 Factors Which Affect the Utilization of Dental Services. A Review and
Health Center ExpetT_nce. abs. no. 493 Improving Access to _ledieal Care in Underserved Areas. The Role of Group Practice. abs. no. 494 Income and Illness. ab:i. no. 497 Insurance Benetlts, Ou,'-of-Pocket Payments, and the Demand for Medical Care. A Review o[ the Literature. abs. no. 509
Analysis of the Literature. abs. no. 299 Final Report to the Legislature on Ambulatory Care. abs. no. 309 Forecasting. A Cost Control Tool for Health Care Managers. abs. no. 319 Foundations for Medical Care. An Empirical Investigation of the Dub'very of Health Services to a Medicaid Population. abs. no. 322 Futare Health Care Organization. abs. no. 330 Futare Issues in Health Care. Social Policy and the Rationing of Medical Servsces. abs. no. 331
Insurance Coverage andAccess. Imph'cations forHealth Policy. abs. no. 511 Insuring Intensive Psychotherapy. abs. no. 513 Interaction of Supply and Demand in the Market for Physician Services. abs. no. 515 Japan's ttigh-Cost Illness Insurance Program. A Study of Its First Three Years, 1974-76. abs. no. 523 Joint Health Cost Conz_inment Program. Hospital Utilization Report. abs. no. 524
Group
Dental
Magnitude
Health Health
and the War on Poverty. A Ten-Year Appraisal. abs. no. 354 Care Business. International Evidence on Private Versus Public
Expense
Insurance
Experience.
abs. no. 341
Health Care Systems. abs. no. 356 Health Care Costs. An Analysis of Current Utilization. abs. no. 363
Trends
in Health
Costs
and
and Determinant_
no. 555 Medicare. Health Reimbursement
Health Employment Requirements Schemes. abs. no. 386
Mental Disorder and Primary Literature. abs. no. 584
Health Health
Health
Insurance
in the United States. Charthook. abs. no. 388 Insurance Plans. Promise and Performance. abs. no. 397
Health Insurance. Public Programs. Abstracts). abs. no. 398 Health Health no. Health
Alternate
197g-June,
Insurance Study. abs. no. 8020 Personnel Meeting the Explosive 411 Status and Use of Medical Services.
With
Demand
for Medical
Evidence
on the Poor, the Black,
and the Rural Elderly. abs. no. 422 Health Status, Medical Care Utilization, and Outcome.
Care. abs.
Visits in the United
lnsur._nce for the Aged and Disabled, by State nnd County. _bs. no. 577 Medical
Mental Health Services _'or Medicaid Plan. abs. no. 585
1980 (,4 Bibhbgraphy
Initiated
Measu_ng Disabi_ty az_d Utilization. Two Health Surveys. abs. no. 545 Me_'caid Participation and Medical Care. abs. no. 55t Me_al Care Use by a Group of Folly Insured Aged. A Case Study. abs.
Health Care Trends. Minneapolis/St. Paul. Summary Highhghts. abs. no. 38 l Health Economics and Health Care. Irreconcilable Gap. abs. no. 385 Under
of Physician
States. abs. no. 534 The Malpractitioners. abs. no. 539
197Z
Care. An Analytical Enrollees
in a Prepaid
Section
Review Group
of the Practice
Mental Health Services. Utilization by Low Income Enrollees in a Prepaid Group Practice Plan and in an Independent Practice Plan. abs. no. 586 Methodology Used to Measure Health Care Consumption During the First Year of the Health Insurance Experiment. abs. no. 588 Model for Assessing ano' Effecting Hospital Closure. Final Report. abs. no. 593
An Annotated
Bibli-
National Ambulatory January-December
ograpby of Empirical Studa'es. Volume I. abs. no. 423 Health Status, Medical Care Utilization, and Outcome. An Annotated
Bibli-
National Commission or_' the Cost of Medical Care. Literature Reviews Data Bases. abs. no. 601
ography of Empirical Studies. Volume 2. abs. no. 424 Health Status, Meak'cal Care Utilization, and Outcome. An Annotated
Bibli-
National National
ography of Empirical Stuo_'es. Volume 3. abs. no. 425 Health Status, Medical Care Utilization, and Outcome. An Annotated
Bibli-
Nation's Use of Health Resources, 1979. abs. no. 638 Norms Hypothesis and the Demand for Medical Care. abs. no. 649
ography of EmpiriCal Studies. Volume 4. abs. no. 426 Health Status, Socioeconomic Status, and Utilization of Outpatient t_,r Members of a Prepaid Group Practice. Health, United States, 1980. abs. no. 428 History and Organization of Pretreatment Review System. abs. no. 433 HMO
VII-IO
Enrollment
Decision.
A Transactions
Services
abs. no. 427
Review, Analysis
a Dental
Medical Care Survey. 197Z abs. no. 598
and Literature
Re-
1977 Summary.
United States,
I976-1977.
Volume
3.
Health Care in Great Britain. Lessons for the USA. abs. no. 602 HMO Census ,_urvey, 1977. Summary. abs. no. 634
Nursing Home Utilizatic_ Patterns. Implications for Policy, abs. no. 653 OBfce of Health Maintenance Orgamzations. 5th Annual Report to the Congress. abs. no. 655 On Having Your Cake _d
Utilization
1.
Eating
It Too. Econometric
Problems
m Es-
timating the Demand for Health Services. abs. no. 659 Overview of Health Insurance Study Publications. abs. no. 666 Participation
of Private
Practice
Dentists
in Medicaid.
abs. no. 668
Health Care Programs
Paying for Physician Services Under Medicare and Mech'cMd. abs. no. 671 Pediatric Care. Charges, Payments and the Medical Settin 8. abs. no. 674 Per-Case Reimbursement for Medical Care. Final ReporL abs. no. 675 Perceptions of Mesh'ca/Care. The Impact of Prepayment. abs. no. 677
Trends in Facility Use. An Evaluation of the Impact of Adverse Economic Conda'tions on the Status of the Poor. abs. no. 909 Trends in Medical Care Costs. Do HMOs Lower the Rate of Growth. abs. no. 910
Perspectives on Medicines in Society. abs. no. 681 Physician-Indoced Demand for Medical Care. abs. no. 693
Two Decades of Health ture. abs. no. 913
Planning for Posthospital Care. A Followup Study. Poh'cy Issues in Financing Mental Health Services.
Urban Fiscal Crisis in the United States, Municipal Hospitals. abs. no. 916
abs. no. 698 abs. no. 702
Services.
Social Survey
Trends in Use and Expendi-
National
Health
lnsur_Jnce,
and
Pressures and Problems for Organized Ambulatory Sea,vices in the Next Decade. abs. no. 718 Price Setting in the Market for Physicians'Services. A Review of the La'tersture. abs. no. 722 Primary Care in Durham County. Who Gives Care to Whom. abs. no. 724 Primer on Antitrust and Hospital Regulation. abs. no. 726 Proceedings of the 28th Annual Group Health Institute, New York, New
Use and Expenditures Analyses From the National Medical Care Expendi. ture Survey. abs. no. 919 Use of Hospital Services Under Two Prepaid Plans. abs. no. 920 Use of Physician Services Under Two Prepaid Plans. abs. no. 922 Utilization and Cost of Mental Illness Coverage in the Federal Employees Health Benefits Program, 1973. abs. no. 924 Utib'zation of Scrviees of an HMO by New Enrollees. abs. no. 925
York, June 18-2L 1978. abs. no. 735 PSRO. An Evaluation of the Professional Standards Programs, Volume II. A Cost-Banefit Context Control Activities. abs. no. 759 Rapid Rise of Hospital Cost_ abs. no. 771 Rationing Health Care. abs. no. 774
Variations in Utilization of a MultiState Company Dental Plan. abs. no 927 Variations in Utilization of Health Services by ClnTdren. abs. no 928 Voluntary Hospitals Suffer From Fiscal Erosion. Their EMstenee is Being Threatened. City Could Lose 5,200 Beds, 20,000 Jobs. abs. no. 931 Who Initiates Visits to a Physician. Data Preview 3. abs. no. 939 Why Do HMOs Seem to ProtYde More Health Maintenance Services. abs.
Review Orgamization for PSRO Utib'zation
Recent Alternative Delivery System Development in Denver. abs. no. 777 Relationship Between Utilization of Mental Health and Somatic Health Services 797 Repeated
Among
Low Income
Hospitah'zation
Enrollees
for the Same
in Two Provider
Disease.
A Multiplier
Plans. abs. no. of National
no. 941 Women's Health Movement.
Feminist
Alternatives
to Medical
Coatrol.
abs.
no. 944 Demographic
features
of population
Health Costs. abs. no. 798 Risk Differential Between Medicare Beneficiaries Enrolled and Not Enrolled in an HMO. abs. no. 815 Role of Health Insurance in the Health Services Soctor. abs. no. 816 Role of Payment Source in Differentiating Nursing Home Residents, Setvices, and Payments. abs. no. 817 Role of State and Local Goverlzments in Relation to Personal Health Ser-
Age and Medical Care Utilization Patterns. abs. no. 11 Alcoholism Within Prepaid Group Practice HMOs. abs. no. 15 America's Health Care System. A Comprehensive Portrait. abs. no. 30 Build Study 1979. abs. no. 54 Catastroptu'c Illness Expense. Implications for National Health Po;icy in the United States. abs. no. 73 Changing Medicaid Population. abs. no. 78
vices, abs. no. 819 Setting National Pnoritics_
Charges and Sources of Payment Data Preview 2. abs. no. 81
for Dental
Charges and Sources of Payment view 5. abs. no. 82
for Visits to Physician
Some Effects Source Book
Agenda
for the 1980"S. abs. no. 830
of Quebec Health Insurance. abs. no. 844 of Health Insurance Data, 1979-1980. abs. no. 847
State
Visits With Separate
Charges.
OflTces. Data Pre-
Regulation of Health Services Utilization. Lemons From Michigan. abs. no. 857 Structure of Health Insurance and the Erosion of Competition in the Me_h" ca/Marketplace, abs. no. 864
Child Health. America's Future. abs. no. 84 Children and DentM Care. Charges and Probability of a Visit by lndJ'vidual Characteristics. abs. no. 85 Consumer Attitudes Toward Health Policy and Knowledge About Health
Study of Dental Service Prepayment no. 865 Study of Physician Reimbursement 1. abs. no. 866
Legislation. abs. no. 119 Consumer Expenditure Patterns. Volume I. Food, Household Supplies, Personal and Health Care Products. abs. no. 120 Demand for Medical Care in a Rural Setting. Racial Comparisons. abs. no.
Substitution of Outpatient ence. abs. no. 874
in the Private Under Medicare
Care for Inpatient
Sector. Final ReporL and Medicaid.
Care. Problems
abs.
Volume
and Experi*
Summary of Impact of Alcohoh'sm Treatment on Medical Care Utih'zation and Cost, 1979. abs. no. 875 Survey of Recent Research in Health Economics. abs. no. 882 Survey Results, July 1980. HMO Enrollment and Utilization in the U.S. abs. no. 883 Taxation and Its Effect Upon Public and Pn'vate Health Insurance and Medical Demand. abs. no. 890 Ten Years of Medicare. Impact on the Covered Population. abs. no. 894 Ten Years of Medicare. Impact on the Covered Population. abs. no. 894 Ten Years of Short-Stay Hospital Utih'zation and Costs Under Mcch'care (1967-1976). abs. no. 895 Theoretical Analysis of the Impact of National Health Insurance on Consumer Behavior in the Health Care Market. abs. no. 898 Theory and Practice in Minneapoh's-St. Paul. abs. no. 899 Third-Party Payments for New Health Professionals. An Alternative to Fractional Reimbursement in Outpatient Care. abs. no. 902 Thirty-To-One Paradox. Health Needs of the Aged and Medical Solutions. abs. no. 903
187 Dental Insurance.
abs. no. 194
Determinants of Pediatric Care Utib'zation. abs. no. 201 Differences by Age Groups in Health Care Spending. abs. no. 207 Disabib'ty. From Social Problem to Federal Program. abs. no. 211 Disabih'ty, Health Status, and Utih'zation of Health Services. abs. no. 212 Episodes of Illness and Access to Care in the Inner City. A Comparison of HMO and NOn-HMO Populations. abs. no. 269 Equity in Health Services. Empincal Analyses in Social Policy. abs. no. 271 Expanding Health Benefits for the Elderly. Volume 1. Long- Term Care. abs. no. 289 Fact Book on Aging. A Profile of America's Older Population. abs. no. 295 Family Health in an Era of Strcss. abs. no. 301 Graying of Americ& abs. no. 339 Health and Health Insurance. The Public's View. abs. no. 350 Health and Retirement. Policy and Research Issues. abs. no. 35;2 Health and the War on Poverty. A Ten- Year Appraisal. abs. no. 354 Health Care Poh'cy in a Changing Environment. abs. no. 376 Health in the United States. Charthook. abs. no. 388 Health Insurance Coverage of Veterans. Data Preview 4. abs. no. 393
VII- 11
Health Interview Survey and Minority Health. abs. no. 400 Health Statusand Use of Medical Services. Evidence on the Poor, the Black, and the Rural Elderly. abs. no. 422 Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliography of Empirical Studies. Volume Z abs. no. 424 Health Status, Socioeconomic" Status, and Utilization of Outpatient Services for Members of a Prepaid Group Practice. abs. no. 427 Health, United States, 1980. abs. no. 428
Dental Prepayment Plans. abs. no. 196 Extending Canadian Health Insurance. Options for Pharmacar¢ and Denticare, abs. no. 294 Factors Which Affect the Utilization of Dental Sez_iccs. A Review and Analysis of the Literature. abs. no. 299 Financial Projection in Prepaid Dental Care Plans. abs. no. 313 Forward Plan for Health FY _978-82. abs. no. 320 Fundamental Issues in the Practice of Dental Public Health. abs. no. 327
Household Health Interviews abs. no. 461
Group BeneEt Survey. Plans Cbvering era, 1980. abs. no. 340
and Minority
Health.
The NCHS
Perspective.
Salaried
Employees
of L'_S. Employ-
Impact of Social and Economic Changes on Financial SecuHty Systems. abs. no. 486 Improving Health in America. U.S. Public Health Service Highlights of 1977-80. abs. no. 495 Medicaid, Medicare, and Private Health Insurance Coverage in Five Urban, Low-Income Areas. abs. no. 549 National Health Insurance Issues. The Un'protected Population. abs. no. 624
Group Dental Expense Insurance Experience. abs. no. 341 History and Organization of Pretreatment Review, a Dental &'tilizauon Review System. abs. no. 433 Impact of Comprehensive National Health Insurance on Demand for Health Manpower. abs. no. 477 Influencing Federal, State, and Local Oral Health Policies. abs. no. 506 Insurance BeneEts, Out-of-Pocket Payments, and the Demand for Medical
National Ilealth Insurance, Psychotherapy, and the Poor. abs. no. 627 National Ifealth Program for Infants, Children and Youth. abs. no. 633 Nation's Use of Health Resources, 1979. abs. no. 638 Pediatric Care. Charges, Payments and the Medical Setting. abs. no. 674 Policy Analysis with Social Security Research Files. abs. no. 701 Policy. Politics, and Child Health. Four Decades of Federal Initiative and State Response. abs. no. 704 Poverty and Health. Economic Causes and Consequences of Health ProbIctus. abs. no. 712
Care. A Revtew of the I.a'terature. abs. no. 509 International Dental Care Delivery Systems. Issues in Dental Health Pohcies. abs. no. 518 Issues in Dental Health Polictes. abs. no. 519 Issues in Regulating Quality of Care and Containing Costs Within Private Sector Policy. abs. no. 52 '_. Justice for the Patient and the Dentist. Quality Assurance Activities of the W.K. Kellogg Foundation and the Amen'can Fund for Dental Health. abs. no. 525
Rethinking Health Policy for the Elderly. A Six-Point Program. abs. no. 809 Social StrL,cturc and the Diffusion of Medical Innovations in the United States. Great Britain. Sweden and France. abs. no. 838 Status of Children, Youth and Families, 1979. abs. no. 858 Survey of Recent Research in Health Economics. abs. no. 882
Licensing Rest_edons and the Cost of Dental Care. abs. no. 531 Measurement of Expenditure.,; for Outpatient Physician and Dental Setvices. Methodological FindJngs from the Health Insurance Study. abs. no. 544 Medicaid and Cash Welfare 2f'ecipients. An EmpiriCal Study. abs. no. 546
7hz_-t,v-To-One Paradox. Health Needs of the Aged and Medical Solutions. abs. nc,. 903 T_ o Dcca,lcs of Health Services. Social Survey Trends in Use and Expendi. lure. abs. no. 913
Participation of Pn'vate PracUce Dentists in Medicaid. abs. no. 668 Regulation and the Quality oFDental Care. abs. no. 785 Study of Dental Service Prepayment in the Private Sector. Final Report. no. 865
Welfare Status, Illness and Subjective Health DeEnition. Who Are Ihe bninsured. Data Preview 1. abs. no. 937
Variations in Utilization
abs. no. 934
Who Pays for Pediatric Care. Out of Pocket and Third-Party Party Paymenta for Physician Visits. abs. no. 940 Why New Enrollees Choose to Join Group Health Plan, Inc. abs. no. 942 Dental services Alternative Oral Health Service Delivery Systems. abs. no. 18 Assessing Quality of Care and Oral Health in a PopulaNon With Dental Insurance. abs. no. 42 Changing Patterns and Implications for Cost and Quality of Dental Care. abs. no. 79 Charges apd Sources of Payment Data ['review 2. abs. no. 81
for Dental
Visits
With Separate
Charges.
of a h4"ulti-State Company
abs.
Dental Plan. abs. no. 927
Diagnostic services Achieving Optimum Utilization of Ancillary Services. An Annotated Bibliography, abs. no. 6 Ancillary SeraPes Review and PSROs. What Can the Demonstration Programs Tell Us. abs. no. 4(3 Changes in the Costs of Treatment of Selected Illnesses. 1951-1964-1971. abs. no. 76 CHnical EflTcacy Assessment Program. abs. no. 8006 Comparing the Medical Utilization and Expenok'tures of Low Income Health Plan Enrollees Witl_ Medicaid Recipients and With Low Income Enrollees Having Medicatd EligibiEty. abs. no. 95 CompatT_on of Group Medical Care Insurance Benefits to Charges.
abs. no.
Children and Dental Care. Charges and Probability of a Visit by Individual Charactert_tics. abs. no. 85 Comparing Dental Care Systems in California. abs. no. 94 Comparison of Group Medical Care Insurance Benefits to Charges. abs. no. 96
96 Copayments and Demand for Medical Care. The Califorma Medicaid perience, abs. no. 144 Cost and Regulation of Medical Technology. Future Policy Directions. no. 146
Consumer h)fluence on the Quah'ty of Dental Care. abs. no. 121 Controlling the Cost of Dental Care. abs. no. 140 Dental and Vision Care Benefits in Health Insurance Plans. abs. no. 189 Dental Ca"c and the Health Mm)_tenance Organizatton Concept. abs. no. 1qO Dental Caz e Demand. Point Estimates and Implications for National Health Insurance abs. no. 191
Evaluation of the CA T Scanne," and Other Diagnostic Technologies. abs. no. 285 How Business Can Use Specit_e Techniques to Control Health Care Costs. abs. no. 465 Medical Technology. The CuJprit Behind Health Care Costs. abs. no. 568 Physician Responsibility for the Cost of Unnecessary Medical Services. abs. no. 692
Dental Dcntal Dental Dental
Physicians'Knowledge of Cost. The Case of Diagnostic Tests. abs. no. 697 Relationship Between Diagno:_tie Information Available at Admission and Discharge for Patients in One PSRO Setting. abs. no. 796 Role of Physician Education J')_Cost Containment. abs. no. 818
VII-12
Care tbr Everyone. Problems and Proposals. abs. no. 192 Care for Handicapped People. Special Report. abs. no. 193 losurance, abs. no. 194 h)_urance Plans. abs. no. 195
Health
Care
Progt'ams
Exabs.
Who Pays for Pedaatnc meats for Physician
Care. Out of Pocket Visits. aim. no. 940
and
Third-Party
Party Pay-
Impact of Proposition 484 Impact
Economic/commerdal Access to Me_'cal no. 2
Influences Care for the Elderly.
Do Non-Price
Barriers Matter.
aim.
13 on _lental
of the 1974 Health
Health
Care Amendments
Bargaining in the Health Care Industry. Implementing the End-Stage Renal Disease 492
Services
in CahTornia.
to the NLRA
abs. no.
on Collective
abs. no. 490 Program of Medicare.
abs. no.
American Health Care System. Issues and Problems. aim. no. 27 Annotated Bibh'ography of Health Economics. aim. no. 41 Competition in the Health Care Sector. Past, Present and Future. aim. no. 105 Comprehensive Market and Regulatory Strategies for Me_'cal Care. abs. no. 109 Constitutionality of Medical Malpractice Reform Legislation. A Supple-
Industry's Voice in Health Policy. aim. no. 502 Issues in Health Care Regulation. abs. no. 520 Legislative Response to the MedicM Malpractice Ca'sis: Constituttonal plications, abs. no. 530 MMpractice. Funding Emerges as a Critical Issue. abs. n,. 538 The Malpractidoners. aim. no. 539 Medical Benefit Cost Containment in the U.S.A. abs. no. 552
mental Report. aim. no. 117 Council on Wage and Price Stability abs. no. 172 Crisis in Health Care. aim. no. 173
Medical Malpractice Insurance. A Legislator's View. abs. no. 557 Medical Malpractice Law. 2nd Edition. abs. no. 558 Meddcal Malpractice Litigation Under National Health Insurance. Essential or Expendable. abs. no. 559
Demand Elasticities for Health Pocket Price. aim. no. 185
C_re
Report
on Rising Health
With Special
Care Costs.
Emphasis
on Out-of-
Medical Malpractice aim. no. 560
Pre- Trial Screening
Panels. A Review
1m-
of the J_vidence.
Demand for Me_'cM Care in a Rural Setting. Racial Comparisons. abs. no. 187 Design of Failure. Health Policy and the Structure of Federalism. aim. no. 200 Determining Present and Future Health Claim Costs. aim. no. 204 Doctors, Damages and Deterrence. An Economic View of Mccb'cal Mal-
Medical Malpractice Sm'ts. aim. no. 561 Mecb'cal Malpractice. The Response of Physicians to Premium Increases in CahTorma. abs. no. 562 Medicare Assignment Rates of Physicians. Their Responses to C,_anges in Reimbursement Policy. aim. no. 574 National Health Insurance. aim. no. 607
practice, abs. no. 221 Dollars and Sense of Hospital Malpractice Insurance. Economic Cost of niness Revisited. aim. no. 230
National Health Insurance abs. no. 614 National Health Insurance.
Economic Economics
Foundations of National Health PoKey. of Cost Containment. aim. no. 236
aim. no. 224
aim. no. 231
Eaonorm'cs of Medical Malpractice. aim. no. 239 Effects of Advertising Lessons From Optometry. aim. no. 249 Employment Related Health Benefits in Private Nonfa_;n Business
Opening 663
Estab-
as an Agent
Can We Learn From
Up the Health System.
Pain and Profit. Payer, Provider, 670
for Containing
Health-Care
Canada.
Public and Private Sector
Costs.
abs. no. 617 Friction.
abs. no.
The Politics of Malpractice. aim. no. 667 Consumer. Industry Confronts Health Care Cost,,;. abs. no.
lishmunts in the United States. Volume I. Deterndnants of the Decision by Establishments to Offer a Group Health Plan. aim. no. 263 Epidemiologic Revolution, National Health Insurance and the Role of Health Departments. aim. no. 268 Erosion of the Medical Marketplace. aim. no. 272 Financing Health Care. aim. no. 315 Financing of Health Care. aim. no. 317 Framework for Capital Controls in Health Care. aim. no. 323 From Charitable Immunity to Public Accountability. A Review of Selected Solutions to the Malpractice Problem. abs. no. 324 From Reform to Recidivism. A History of Economists and Health Care, aim. no. 325
PoKey Analysis with Social Secu_ty Research Files. aim. no. 701 PoKey Options and the Impact of National Health Insurance Revisited. abs. no. 703 Pricing, Demanders, and the Supply of Health Care. abs. no. 723 Pro/Yts in Medicine. A Context and an Accounting. aim. no. 741 Proposals for National Health Insurance in the USA. Origins and Evolution, and some Perceptions for the Future. abs. no. 745 Prospects and Problems in Health Services Research. abs. no. 755 Prospects for Health Services in the United States. abs. no. 756 Research in Health Economics, A Survey. abs. no. 803 ResponsibiKty of the Individual. aim. no. 806 Review of the Medical Malpractice Problem in the United States. aim. no.
Health Health Health
and Labor Power. A Theore_cal Investigation. Care. An American Crisis. abs. no. 355 Care Cost Increases. aim. no. 361
811 RJsin 8 Cost of Catastroptu'c IBness. aim. no. 812 Role of State and Local Governments in Relation
Health Health
Care in the American Economy. Number 3. abs. no. 370 Care System in the United States. aim. no. 379
abs. no. 351
vices, aim. no. 819 Selected Stucb'es in Medical
Care and Mech'cal Economics.
Health Cost Problem. Is Regulation Our Only Hope. aim. no. 383 Health Insurance Industry. Structural and Strategic Issues in an Unccrt_u'n Environment. aim. no. 396
1975. aim. no. 827 Services Shared by Health Care Organizations. aim. no. 829
Health Planning as a Regulatory Strategy. A Discussion of its History Current Uses. aim. no. 415 Health Planning in the United States. Issues in Guideline Development. no. 416 Health Reform. The Outlook for the 1980s. abs. no. 418
Societal Responsibility for Strategies for ControlKng abs. no. 861 Study of Physicians" Fees. Variations in Utilization of
Health Services, no. 420
Power
Centers,
and Decision-Making
Mechanisms.
and aim.
aim.
Health Status, Socioeconomic Status, and Utlh'zation of Outpatient Services for Members of a Prepaid Group Practice. abs. no. 427 Hospital Cost Containment Progrums. A Policy Analysis. aim. no. 448 Hospital lnlYation. A Diagnosis and Prescription. aim. no. 452 Hospital-Based Versus Free-Stanab'ng Primary Care Costs. aim. no. 459
to Personal
Annual
An Annotated
Malpractice. abs. no. 841 the Cost of State Medical Assistance abs. no. 868 a Multi-State Company
Voluntary Hospitals Suffer From Fiscal Threatened. _'ty Could Lose 5,200
Health
Ser-
Report,
Bibliography.
Programs.
Dental Plan. abs. no. 927
Erosion. Their E_istenc_ _.is Being Beds, 20,000 Jobs. abs. no. 931
Economics of th/rd-party payors Can Health Be Planned. Or, Why Doctors Should Do Less and Patients Should Do More. Forecasting the Future of Health System Agencies. aim. no. 58
VII-13
Choice Between abs. no. 87
Family
and Individual
Deductibles
in Health
Complex Puzzle of Rising Health Care Costs. Can the Private Together. abs. no. 107 Conference and Unresolved Problems. abs. no. 1 t2
Insurance. Sector Fit it
Assessment of.tclemberSatist,_ction m an HMO. Understanding tion of Variables and Th_.ir Implications. abs. no. 44 Better Services at Reduced Costs Through an Improved Program Recommended for Veterans. abs. no. 50 Blue Cross. What Went Wrong. abs. no. 52
Consumer-Choice Health Plan. Inflation and Inequity in Health Care Today. Alternatives for Cost Control and an Analysis of Proposals for Naoonal Health Insurance. abs. no. 128
Changing Health Care. Perspectives From a New no. 77 Chip Commission. Final Report. abs. no. 86
Dollars and Sense of Hospital Malpractice Economics in Health Care. abs. no. 235
Coinsurance no. 89
Insurance.
abs. no. 224
and the Demand
"Person_[
Medical
for PhysiCian Services.
the ltltcrac•'ate'"
Care Setting.
Four
abs.
Years" Later. abs.
Estimating the Cost of Health Insurance Programs. abs. no. 277 Financial Management Under Third Party Reimbursement. abs. no. 312 Health. A Victim or Cause of Inflation. abs. no. 348
Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Volume VIII, Overview. abs. no. 110 Consumer Responsibility in a Prepaid Group Health Plan. abs. no. 123
Health Plan. The Only Practical Care. abs. no. 412
Solution
Controlling Health abs. no. 135
Health Planning as a Regulatory Current Uses. abs. no. 415
Strategy.
to the Soaring A Discussion
Cost of Medical of its History
Health, United States, 1980. abs. no. 428 Malpractwe. Funding Emerges as a Critical Issue. abs. no. 538 Pain and Prol_t. The Politics of Malpractice. abs. no. 667 Political Economy of Federal Health Programs in the United States. Historical Review. abs. no. 705
and
An
Cost,Financed Costs, Risks,
Care Coats. Strengthening
the Private
Sector's
Hand.
Mental Healt_$ Facility. abs. no. 168 and Benetits oI Surgery. abs. no. 171
Economic Viability of Community-Operated Prepaid Health Plans. abs. no. 233 Effectiveness of CertilTcate of Need Programs. abs. no. 8012 Efforts to Restructure a Mecffcal Delivery System. The British ,National Health Ser_qee. abs. no. )56
Private Cost Containment. abs. no. 727 Research in Health Economics. A Survey. abs. no. 803 R_sing Health Costs. Public and Private Responses. abs. no. 813 Role of Fee Schedules in Physician Reimbursement. abs. no. 8038 Role of Health Insurance in the Health Se_ces Sector. abs. no. 816
Financing Health Care. abs. :no. 315 Foundations for Medical Car*.. An Empirical Investigation of the Delivery of Health Services to a Medicaid Population. abs. no. 322 Guidelines for Planning Health Services. An Annotated Bibliography. abs. no. 347
US.
Health Health
Health
Insurance
Industry.
An Alternative
View. abs. no. 91"7
Eligibility requirements Comparative Experiences in Controlling Expench'tures for Pres'aription Drug._ in State Medicaid Progrnms. ahs. no. 92 Design of Failure. Health Policy and the Structure of Federalism. abs, no. 200 Diagnosis and the Dole. The Function Politics. abs. no. 206
of Illness in American
Distributive
Dtsabihty Policies and Government Programs. abs. no. 215 Effect of Unemployment Insurance Payments on the Health Insurance erage of the Unemployed. abs. no. 246
and the War on Poverty. A Ten-Year Appraisal. abs. no. 354 Insurance. Public Programs. 1978-June, 1980 (A Bibliography With
Abstracts). abs. no. 398 Health Status, Meals'cat Care Utilization, and Outcome. An Annotated Bibliography of Empirical Stuak'_s, Volume 4, abs. no. 426 Hospital.Sponsored Primary Care Group Practices. A Developing Modah'ty of Care. abs. no. 460 Impact of a Change abs. no. 475
in Regulagons
on Costs in an ExperimentM
Program.
Coy-
Impact of Alcohol, Drug Abg's¢ and Mental Health Treatment on Medical Care Utilizan'on. A Review of the Research Literature. abs. no. 476 Impact of the Rhode Island C_tastrophic Health Insurance Plan. abs. no.
Employer Provided Group Health Plans and the Unemployed. abs. no. 262 Employment, Unemployment, and Health Insurance. Behavioral and Descriptive Analysis of Health Insurance Loss Due to Unemployment. abs. no. 265 Health Care Financing Options for Colorado. abs. no. 368 Issues Involved in the Development of a Prepaid Capitation Plan for LongTerm Care Services. abs. no. 522 Med_Z'ald. Current lssues and Potential Reforms. abs. no. 547
489 Implementing the End-Stage Renal Disease Program of Medicare. abs. no. 492 " Improving Access to Health Care Among the Poor. The Neighborhood Health Center EXl_rience. abs. no. 493 Medicare After 15 Years. H&_ It Become a Broken Promise to the Elderly. abs. no. 57t New Health Professionals. Nurse Practitioners and Physician 'S Assistants.
Medicaid Experience. abs. no. 548 Medicare Reimbursement. abs. no. 579 Modifying Aledicaid Eligibility and BenelTts, abs. no. 595 National Health Insurance and Corporate Benel_t Plans. abs. no. 609 State Policies and Federal Programs. Priorities and Constraints. abs. no. 856 Ten Years of Medicare. Impact on the Covered Population. abs. no. 894 Trends in State Administration of Medicaid Programs. abs. no. 912 Unemployment, Eligibility Rules and the Loss of Health Insurance Benetlts. abs. no. 915 Urban Fiscal Crisis in the United States, National Health Insurance, and Municipal Hospitals. abs. no. 916 Variations in State Medicaid Programs. abs. no. 926 Women, Work, and Health. Challenges to Corporate Policy. abs. no. 943
abs. no. 645 New Jersey Diagnosis Related Group (DRG) Evaluation. abs. no. 8030 On Paying the Fiddler to Change the Tune. Further Evidence From Ontario Regarding the Impact of Universal Health Insurance on the Orgamzation and Patterns of Medical Practice. sbs. no. 660 Paths to Alternative Service Modah'ties and Differential Impact of Three Modalities on Familiar 6:roups of Vulnerable Elderly. abs. no. 8032 Prepaid HeMth Plans and HeMth Maintenance Organizations. abs. no. 7 t 7 Prospective Rate Reimbursement and Cost Containment. Formula Reim. bursement in New York. abs. no. 750 Prospective Rate Setting. abs. no. 751 Public Choice in Health. Problems, Politics and Perspectives on Formulating National Health Policy. abs. no. 76 l Quality Assurance in Health Care. abs. no. 768
Ewluations/outcome of health care programs Alcohohs'm Within PrepaM Group Practice Ancillary Services Review and PaROs. grams Tell Us. abs. no. 40
VII-14
What
HMOs.
Recent Report
abs. no. 15
Can the Demonstration
Pro-
Alternative Delivery System Development to the President From the President's
in Denver. Commission
Health. Volume I. abs. no. 801 Responses of Canadian Physicians to the Introduction
abs. no. 777 on :_dental
of Universal
Medical
Health Care Programs
Care Insurance. The First Five Years in Quebec. abs. no. 804 Selected Studies in Medical Care and Medical Economics. Annual Report,
Health Health
1975. abs. no. 827 Effects of Quebec Health Insurance. a_. no. 844 Issues in Limiting Hospital Cost Reimbursement. A Maryland ence. abs. no. 845 Study of the Responses of Canadian Physicians to the Introduction
Health Economics and Health Care. Irreconcilable Gap. abs. no. 385 Health Planning and Regulation. A Manual for State Legislators. abs. no. 413 Health Status, Medical Care Lrtilization, and Outcome. An Annotated Bibliography of Empirical Stu_O'es. Volume 4. abs. no. 426
Some Some
versal Medical 872 Trends
Care Insurance.
in Multihospital
Systems.
The First Five A Multiyear
Experiof Uni-
Years in Quebec.
Compz_son.
abs. no.
abs. no. 911
Exclusions h'om coverage Alcohol and Health. abs. no. 12 Benetlt Rights and Privacy. abs. no. 48
Care Dilemma and Corporate Debt Care Systems in World Perspective.
Hospice. Creating New Models of Care for the Terminally Mech'cald Participation and Medical Care. abs. no. 55 t Medical Malpractice Law. 2rid Edition. abs. no. 558 Medicare, Medical Practice, and the Medical Profession. National Health Insurance ence. abs. no. 610
The Insurance
System
and Fertility
Control.
Capacity. abs. no. 366 abs. no. 380
Nation's Primary
and Health
Resources.
Ill. abs. no. 440
abs. no. 578
The European
Experi-
Use of Health Resources, 1979. abs. no. 638 Care in Durham County. Who Gives Care to Whom. abs. no. 724
Considerations in the Design of Mental Health Benetlts Under National Health Insurance. abs. no. 116 Controlling Health Care Costs. Strengthening the Private Sector's Hand.
Prol_ts in Medicine. A Context and an Accounting. abs. no. 741 Selected Stuak'es in Medical Care and Medical Economics. Annual 1975. abs. no. 827
abs. no. 135 Cost of Catastrophic
Services Shared by Health abs. no. 829
Illness.
Expanding Health Benelits abs. no. 290 Hospice Movement in the How Cheap is a Life. abs. Insurance Cost Savings Due no. 510
abs. no. 159 for the Elderly.
United States. no. 467 to an Adequate
Volume
If. Prescription
abs. no. 441 Alcohoh'sm
lnsunng Intensive Psychotherapy. abs. no. 513 Medicare Coverage for the Treatment of Alcohoh'sm. Medicare Reimbursement. abs. no. 579
Health
and Disease
Private Health Insurance to Supplement Women, Work, and Health. Challenges Working Facilities
With the Insurer.
providing
health
Banet_t. abs.
Prevention
for the Elder-
in the United
Medicare. Volume I. abs. no. 730 to Corporate Policy. abs. no. 943
abs. no. 948
Bibhography.
Spy in the House of Me_'cine. abs. no. 850 Structure of Health Insurance and the Erosion of Competition in _he Medical Marketplace. abs. no. 864 Systems Development. Trends, Issues and Implications. abs. no. 886 Taxation and Its Effect Upon Public and PtT"vate Health Insurance and Medical Demand. abs. no. 890
U.S. Hospice Movement. Vertically Linked Health
Issues in Development. abs. no. 918 Organizations. abs. no. 929
Funding/financing of health care programs Alcohol and Health. abs. no. 12 American Biomedical Network. and Future. abs. no. 26
Health
Care Systems
in America
Present
Annotated Bibliography of Health Economics. abs. no. 4 l Blue Cross. What Went Wro_g. abs. no. 52 Comparative National Policies on Health Care. abs. no. 93
care
Achieving Optimum Utilization of Ancillary Service& An Annotated ography, abs. no. 6 Comparative National Poh'cies on Hea/th Care. abs. no. 93
An Annotated
Terminal Care. Issues and Alternatives. abs. no. 896 Two Decades of Health Services. Social Survey Trends in Use and Expenditure. abs. no. 913
abs. no. 575
Medlgap. States Response to Problems with Health Insurance ly. abs. no. 583 Modifying Medicaid Eligibility and Benetits. abs. no. 595 Perspectives on Health Promotion States. abs. no. 680
Drugs.
Care Organizations.
Report,
Bibli-
Comprehensive no. 109 Conceptualization
Market
and Regulatory
and Measurement
Strategies of Health
for Medical for Adults
(?are. abs.
in the Health
Comp_son of Organizational Sponsorslffp and Service Arrangement Vnriables Among Prepaid Medical Group Practices in the United States. abs. no. 97 Cost Containment in the Health Care Industry. abs. no. 151 Cost of Terminal Care. Home Hospice vs Hospital. abs. no. 162 Day Hospitalization as a Cost-Effective Alternative to Inpatient Care. A Pilot Study. abs. no. 179 Delivery of Health Care in America. abs. no. 182 Determining Health Needs. abs. no. 203 Dollars and Sense of Hospital Malpractice Insurance. abs. no. 224 Employee Health Benel_ts. HMOs and Mandatory Dual Choice. abs. no. 260 Employer Acquisition of Health Care Facilities. A Possible Outcome of Escalating Premiums. abs. no. 261 Financial Management of Health C_sre Organizations. A Referenced Outline and Annotated Bib_ography. abs. no. 311
Insurance Study. Volume VIII, Overview. abs. no. 110 Consumer-Choice Health Plan. A National-Health-Insurance Proposal Based on Regulated Competition in the Private Sector. abs. no. 127 Controlling the Use and Cost of Me_h'cal Services. The New Mexico Experv'mental Mech'cal Care Review Organization. A Four-Year Case Study. abs. no. 143 Cost of Benet_ts for Alcohoh'sm in a National Health Insurance .Program. abs. no. 158 Cost of Catastrophic Illness. abs. no. 159 Costs, Financing, and Distributional Effects of a Catastrophic Supplement to Medicare. abs. no. 170 Delivery of Health Care in Urban Underserved Areas. abs. no. 183 Dental Care for Everyone. Problems and Proposals. abs. no. 192 Determining Health Needs. abs. no. 203 Doing Better and Feeling Worse. The Political Pathology of Health Policy. abs. no. 223
Financial Management Under Third Party Reimbursement. abs. no. 312 Financing Health Care. abs. no. 315 Forecasting. A Cost Control Tool for Health C_re Managers. abs. no. 319 Forward Plan for Health FY 1978-82. abs. no. 320 Future Health Care Organization. abs. no. 330 Guidelines for Planning Health Services. An Annotated Bibliography. abs. no. 347
Economics and the Chronic .Mental Patient. abs. no. 234 Employee Health Benelits. liMOs and Mandatory Dual Choice. abs. no. 260 Employer Acquisiffon of Health Care Facilities. A Possible Outcome of Escalating Premiums. abs. no. 261 Estimates of HMO Growth and Related Cost Savings 2978-90. abs. no. 275 Expanded Health Care Coverage Alternatives. abs. no. 8015
VII-15
Expanding Health abs. no 290
BenetTL_ for the Elderly.
Feasibility and Cost-Effectiveness abs. no. 302
Volume
of Alternative
IL Prescription
Drugs.
Long- Term Care Settings.
Task Force Reports
National Health Expenditures..$hortlions, abs. no. 603
Term Outlook
Re_calch
Agenda.
and Long- 7ctm Prob,'c-
Federal HeMth Dollar, 1969-1976. A Chartbook Analysis of Activities Supported and Strategies Pursued in Federal Expenditures for Health. abs. no. 305 Financial Management of Heslth Care Organizations. A Referenced Outline and Annotated Bibliography. abs. no. 311 Financial Status of Social Sectu4ty Program After the Social Security Amendments of197Z abs. no. 314 Financing Health Care. abs. no. 315 Financing of Health Care. abs. no. 316 Financing of Health Care. abs. no. 317 From Charitable Immunity to Public Accountability. A Review of Selected Solutions to the Malpractice Problem. abs. no. 324 Functional Value Analysis. A Technique For Reducing Hospital Overhead Costs. abs. no. 326
National Health Expenditures, 1979. abs. no. 604 National Health Insurance. abs. no. 607 National Health Insurance and Corporate Benefit Plans. abs. no. 609 National Health Insurance and Income Distribution. abs. no. 611 National Health Insurance in Canada. abs. no. 620 National Health Insurance in the Federal Republic of Germany and its Imphcations for U.S. Consumers. abs. no. 621 National Health Insurance lssL,es. The Cost era National Prescription Program. abs. no. 623 On Paying the Fiddler to Change the Tune. Further Evidence From Ontat4o Regarding the Impact of Universal Health Insurance on the Organizeties and Patterns of Med_:al Practice. abs. no. 660 Opening Up the Health Syster_,. Public and Private Sector Friction. abs. no. 663
Government Health and Welfare Germany. abs. no. 337
Overview 665
Programs
in the United
States and
Guide to Medicaid Data Sources. Volume One. abs. no. 345 Health Care. An American Crisis. abs. no. 355 Health Ca;e Business. International Evidence on Private Versus Health Care Systems. abs. no. 356 Health Care Dilemma and Corporate Debt Capacity. abs. no. 366 Health Caze Financing Options for Colorado. abs. no. 368 Health Care in Transition, abs. no. 372 Health Care Reimbursement abs. no. 378 Health
Economics
and Health
Is Federal
Taxation
of Tax-Exempt
Care. Irreconcilable
Health Economics and Health Care. Irreconcilable Health Insurance Industry. Structural and Strategic Environment. abs. no. 396
West
Public
Providers.
of Group Practice
HMOs.
Survey
Results,
,_4arch 1979. abs. no.
Overview of Health Insurance Study Publications. abs. no. 666 Paying for Primary Care. Time for a Change. abs. no. 672 Payment for Hospital Service_:. Objectives and Alternatives. abs. no. 673 Policies for the Containment of Health Care Costs and Expenditures. abs. no. 700 Polities of Health Care Delivery. abs. no. 708 Polls. Health Insurance. abs. rLo. 709 Preliminary Results From ties. abs. no. 715 of the 28th
a Risk-Shanng
Annnal
Group
Health Health
Maintenance
Institute,
New
Orgamza-
Gap. abs. no. 385
Proceedings
Gap. abs. no. 385 Issues in an Uncertain
York, June 18-21, 1978. abs. no. 735 Protits in Medicine. A Context and an Accounting. abs. no. 741 Proposals to Restructure the Financing of Private Health Insurance.
York, New
abs. no.
Health lns,lranee Study. abs. no. 8020 Health Maintenance Organization Act Amendments of 1978. abs. no. 401 Health Maintenance Organizations. A Gtdde to Planning and Developmeat. abs. no. 403 Health Maintenance Organizations. Federal Financing is Adequate But HEW _gIust Continue Improving Program Management. abs. no. 407
747 Provision of Long-Term Care Services by Community Hospitals in Virgima. abs. no. 758 Reform and Regulation in Lo_Tg-Term Care. abs. no. 779 Regionalizatlon and Health Policy. abs. no. 780 Regulating Hospital Labor Co_ts. A Case Study in the Politics of State Rate
Health Pla.qning and Regulation. A Manual for State Legislators. abs. no. 413 Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliograp)_y of Empirical Studies. Volume 1. abs. no. 423 High Cost of Hospitals and What to Do About It. abs. no. 431
Commissions. abs. no. 785l Regulation of Health Care Delivery. abs. no. 786 Report to the President From the President's Commission on Mental Health. Volume L abs. no 801 Research and Demonstrations in Health Care Financing, 1978-1979. abs.
Hospice. PresctTption for Terminal Care. abs. no. 442 Hospital Cost Control in Maryland. abs. no. 450 Hospital h¢latinn. A Diagnosis and Prescription. abs. no. 452 Impact of Proposition 13 on ,_Iental Health Services in California. abs. no. 484 Incentive Tax for Medicare, Medicaid and National Health Insurance. abs. no. 49ti
no. 802 Research in Health Economics. A Survey. abs. no. 803 Responsibility of Families for Their Severely Disabled Elders. abs. no. 805 Restructuring Federal Medicaid Controls and Incentives. abs. no. 807 Setting National Priorities. A_enda for the 1980"s. abs. no. 830 Social Surveys and Health Po,_icy, Implications for National Health Insurance. abs. no. 839
lndustry's Voice in Health Policy. abs. no. 502 IntTucnce of Competition by PrepaM Group Practice on the Development of an Individual Practice Association. Health Maintenance Organizeties. abs. no. 505 Interfacing National Health Insurance and Income Maintenance. Why Health and Welfare Reform Go Together. abs. no. 516 Kaiser's Financial Strategies and Some Cues for Other HMOs. abs. no. 526 ,gIajor Issues in the Financing and Management of Health Care. abs. no. 536 Malpractice. Funding Emerges as a Critical Issue. abs. no. 538 Management and Policy Issues in HMO Development, 1979. abs. no. 540 _ledically Indigent. A State Perspective on a National Problem. abs. no. 570
Source Book of Health Insurance Data, 1979-1980. abs. no. 847 Spy in the House of Medicine. abs. no. 850 State Policies and Federal Prn_,rams. Priorities and Constraints. abs. no. 856 Strategies for Controlling the Cost of State Medical Assistance Programs. abs. no. 861 Supplementary Health Insurance and Cost-Consciousness Strategy. abs. no. 877 Textbook for Employee Beneat Plan Trustees, Administrators and Advisors. abs. no. 897 Voluntary Hospitals Suffer From Fiscal Erosion. Their Existence is Being Threatened. City Could Lose 5,200 Beds, 20,000 Jobs. abs. no. 93 !
_Ietropolitan Comprehensive Care Program. ties Demonstration. abs. no. 590
Wasted
National
VII-
Commission Recommendations abs. no. 599
10
Commission
on the Cost of Medical
A Health
Systems
Care. 1976-1977.
OrganizeVolume
L
Government
Health
Dollars.
employee
abs. r:o. 932
01ans
Health
Care
Programs
Checkbook's Disoqet
Guide to Health Insurance Plans for FederM Employees. For of Columbia, Maryland, and Virginia (Also covers D. C Guy-
Financial Financing
Projection of Health
in Prepaid Dental Care Plans. abe. no. 3 ! 3 Care. abs. no. 316
ernmant Employees). abs. no. 83 Hospitalization as a Cost-Effective Alternative to Inpatient Care. A Pilot Study. aim. no. 179 EvMuation of Market Mechanisms of Cost Control. aim. no. 283 Health Costs Can Be Reduced by Mllh'ons of Dollars if Federal Agencies
Forecasting Federal Long-Term Care Expenditures. abs. no. 80t 6 Forward Plan for Health FY 1978-82. abs. no. 320 Health Care Business. lnternatlunal Evidence on Private Versus Health Care Systems. aim. no. 356 Health Care Cost Increases. abs. no. 361
Fully Carry Out GAO Recommendations. Health Insurance Coverage for Alcohol/Drug
for Vir-
Health Care Costs. An Analysis Utih'zation. aim. no. 363
Health
Health Health Health
Day
abs. no. 384 Ad_'ctlnn Treatment
glnia State Employees. A Feasibih'ty Evaluation. abs. no. 391 Health Insurance in the Medicare Years. aM. no. 394 HistoriCal Development of the CahTornia l_'lot Program to Provide Insurance Coverage for Alcoholism. aM. no. 432 National Health Insurance and the Market for Pn'vate PsychiatJqc
Services.
abs. no. 613 Office of Personnel Management Should Promote Mexhcal Necessity Programs for Federal Employees" Health Insurance. aim. no. 656 Office of Personnel Managemant's Comprehensive Me_'cal Plans Network Experiment. aim. no. 657 Simultaneous Logit of Plan Memberalu'p in the Federal Employees Health State
BeheSts Program. ab6. no. 832 Employee Health Insurance Plans. Financing. abs. no. 852
Stronger Management Needed Plans' Payment Practices. Utilization Health
to Improve Employee aim. no. 863
of Coverage,
An Economic
Benefi_
Organization
and Cost of Mental Illness Coverage in the Federal Benefits Program, 1973. aim. no. 924
Veterans Administration Hospitals. Enterprise. aim. no. 930 Health
A Survey
Analysis
Health
Employees
of Government
care cost trends/projections
of Current
Trends
in Health
Public
Costs and
Care in the American Economy. Number 3. abs. no. 370 Care Policy in a Changing Environment. aim. no. 376 Care System in the United States. aim. no. 379
Health Care Trends. 381
Minneapolis/St.
Health in the United
States,
Paul. Summary
Chartbook.
Htgblight_.
abs. no.
abs. no. 388
Health Maintenance Organization Planning Model to Evaluate an Alternative Health Care Delivery System for the State of Georgia. abs. no. 402 Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliography of Empirical Studies. Volume 1. abs. no. 423 Health, United States, 1980. aim. no. 428 Hospital Cost Containment. Selected Notes for Future Poh_ T. abs. no. 449 How Much Will U.S Medicine Change in the Decade Ahead. abs. no. 470 Impact of National Health Insurance on New York. abs. no. 482 Impact of National Health Insurance Correction Services. aim. no. 483
on the Use and Spending;
Impacts of Health Maintenance Organizatlbn Hea/th Care Costs. abs. no. 491
Growth
on
lot Sight
Community
Inflation in Hospital Costs and Charges in Maryland. abs. no. '_03 Intlao'on, Unemployment and the Medicaid Program. abs. no. _i04 Insurance, Regulation, and Hospital Costs. abs. no. 512 Interim Report to Congress on Occupational Diseases. abs. no. 517
Alternatives to Institutional Care. An Analysis of State Initiatives. aim. no. 8001 Attempts to Control Health Care Costs. The United States Experience. aim. no. 45 Canada's Thirty Years of Health Care Through Government. Where to From Here. aim. no. 61
Japan's High-Cost Illness Insurance Program. A Study of Its First Three Years, 1974-76. aim. no, 523 Medical Benefit Cost Containment in the U.S.A. abs. no. 552 Medicare Assignment Rates of Physicians. Their Responses to Changes _n Reimbursement Policy. aim. no. 574 Meda_tre. Health Insurance for the Aged and Disabled, 1977. Section 1.
Changes in the Costs of Treatment of Selected Illnesses. 1951-1964-1971. abs. no. 76 Complex Puzzle of Rising Health Care Costs. Can the Private Sector Fit k
Reimbursement by State National Health Expenditures. tions, aim. no. 603
Together. Consequences
National National
abs. no. 107 of Increased Third-Party
Payments
for Health
Care Service_
Health Health
and County. abs. no. 577 Short- Term Outlook and Long- Term Projec-
Expen_'tures, 1979. abs. no. 604 Insurance. aim. no. 607
aim. no. 115 Cost of Catastrophic Illness. aim. no. 159 Cost of Disease and Illness in the United States in the Year 2000. aim. no. 160
National Health Insurance Issues. The Cost of a National Prescr/ptmn Program. aim. no. 623 National Health Insurance. What Now, What Later, What Neve, r. abs. no. 629
Cost of National Health Insurance. The Province of Quebec. aim. no. 161 Crisis in Health Care. abs. no. 173 Description of the Health Financing Model. A Tool for Cost Estimation. abs. no. 198 Determining Present and Future Health Churn Costs. aim. no. 204
NHI Won't Control Costs, Quality, or Access. abs. no. 648 Nursing Home Cost Studdes and Reimbursement Issues. abs. no. 652 On the Cost of National Health Insurance in Quebec. abs. no. 661 PoKtical Economy of Federal Health Programs in the United States. Historical Review. abs. no. 705
Differences by Age Groups in Health Care Spending. aim. no. 207 Does America Spend Too Much on Health Care. aim. no. 222 Dollars and Sense of Hospital Malpractice Insurance. abs. no. 224 Economics in Health Care. aim. no. 235
Promoting Competition in the Health Industry. The Role of Health Plannlng. alto. no. 743 Proposals for the Regulation of Hospital COsts. abs. no. 746 Proposed Framework for Health and Health Care Policies. abs. no. 748
Estimates of HMO Growth and Related Cost Savings 1978-90. aim. no. 275 Estimating the Cost of Health Insurance Prograrns. aim. no. 277
Regulating the Cost of Health no. 784
Expenditures 291 Expenditures
Regulatory Environment for Physician Compensation. abs. no. 789 Review of the Medical Malpractice Problem in the United State, s. abs. no. 811
for Health Care. Federal for Health
Programs
Care of Children
and
and Their Effects. abs. no. Youth in the United States.
aim. no. 292 Family Health in an Era of Stress. aim. no. 301 Federal Health Dollar, 1969-1976. A Chartbook Analysis of Activities Supp_Jrzc'd _nd Strategies Pursued in Federal Expenditures for Health. aim. no. 305
Rasing Cost of Catastrophic
Care.
Illness.
Can We Learn
of Impact
of Alcoholism
Expcl_ence.
abs.
abs. no. 812
Social Welfare Expenditures Under Public Programs, no. 840 Source Book of Health Insurance Data, 1979-1980. Summary
from
An
Treatment
Fiscal
Year 1977. abs.
abs. no. 847
on Medical
Care lJ?ilizadon
VII-17
and Cost,
1979. abs. no. 875
of Cause and Control.
Ten
Years of Short-Stay Hospital UoTization (1967-1976). abs. no. 895 Toward a Physician Payment Policy. Evidence zarion Program. abs. no. 908
and
Costs
Under Medicare
From the Economic
Stabili-
abs. no. 362
Health Care. Regulation, Economics, Ethics, Practlt'e. abs. no. 377 Health Cost Problem. Is Regulation Our Only Hope. abs. no. 383 Health Economics and Health Care. IrreconclTable Gap. abs. no. 385 Health _n the United States. Chartbook. abs. no. 388
Trends in Medical Care Costs. Do HMOs Lower the Rate of Growth. abs. no. 910 Two Decade's of Health Services. Social Survey Trends in Use and Expenditore. abs. no. 913
Health Insurance Coverage forAlcohol/Drug Addiction Treatment for _"irginia State Employees. A Feasibtlity Evaluation. abs. no. 391 Health Insurance Industry. Structural and Strategic Issues in an U'nccrtain Environment. abs. no. 396
Veterans Administration Hospitals. Enterprise. abs. no. 930 Workers' Compensation Insurance. no, 946
Health Insurance Study. abs. no. 8020 Health Maintenance Organizations Can Help Control Health Care Costs. abs. no. 406 Hospital Care in America. abs. no. 445 Hospital Cost Containment Ac,: of 1979, abs. no. 447 Hospital-Based Physicians. Current Issues and Descn)gtive Evl_lence, abs no. 458
Health care costs Can Health Be Planned
An Economic Recent
Analysis
Trends
Or, Why Doctors
of Government
in Employer
Should
Costs. abs.
Do Less and Patients
Should Do More. Forecasting the Future of Health System Agencies. abs. no. 58 Case-Mix Difference Between Nonprotit and For-Profit Hospitals. abs. no. 70 Catastrophic Illness Expense. Implications for National Health Policy in the United States, abs. no. 73 Catastrophic Illness in an HMO. abs. no. 74
Impact of HMOs. Evidence and Research Issues. abs. no. 480 Impact of Membership in an Enrolled, Prepaid Population on Utilization of Health Services in a Group Practice. abs. no. 481 Issues Involved in the Development of a Prepaid Capitation Plan for LongTerm Care Services. abs. no. 522 Measurement of Expenditures for Outpatient Physician and Dental Setvices. Methodological Findings from the Health Insurance Study. abs.
Charges and Sources of Payment for Dental Data Prevl_'w 2. abs. no. 81
no. 544 Medicaid Experience.
Visits With Separate
Charges.
abs. no. 548
Charges and Sources of Payment for Visits to Physician Ol_iTees. Data Previe_ 5. abs. no. 82 Children and Dental Care. Charges and Probability of a Visit by Individual Characteristics. abs. no. 85 Chip Comtm3sibn. Fl)tal Report. abs. no. 86
Mech'cal Care Plans. How to Control the Costs. abs. no. 553 MedJ'cal Care Use by a Group of Fully Insured Aged. A Case Study. abs. no. 555 Medical Malpractice. The Response of Physicians to Premium Increases in California. abs. no. 562
Comparati_ Absence Experience Among Employees Covered by a Prepaid or a Blue Cross/Blue Shield Health Insurance Program. abs. no. 91 Comparative E_periences in Controlling Expench'tures for Prescrip_on Drugs 1_ State Medicaid Programs. abs. no. 92 Comparison of Group Medical Care Insurance Benefits to Charges. abs. no. 96 Compensation Arrangements Between Hospitals and Physicians. abs. no. 101
Mental Health Services. UtilizaNon by Low Income Enrollees in a Prepaid Group Practice Plan and in an Independent Practice Plan. abs. no. 586 Methods for Setting Priorities h7 Areawide Health Care Planning. AN Annotated Bibliography. abs. rLo. 589 National Commission on the Cost of Medical Care. 1976-1977. Volume Z Collected Papers. abs. no. 600 National Commission on the Cost of Medical Care. 1976-197Z Volume 3. Literature Reviews Data Bases. abs. no. 601
Competition in the Health Care Sector. Past, Present and Future. abs. no. 105 Conceptualization and _iteasurement of Health for Adults in the Health Insurance Study. Volume VIII, Overview. abs. no. 110 Conditions/'or Change in the Health Care System. abs. no. 111 Conference and Unresolved Problems. abs. no. 112
National Health Care Expenditure Survey. abs. no. 8027 National Health Expenditures, 1979. abs. no. 604 New Group Health Insurance. abs. no. 644 Payment for Hospital Services. ObjecNves and Alternatives. abs. no. 673 Physician Responsibility for the Cost of Unnecessary Meak'cal Services. abs. no. 692
Consumer E_penditure Patterns. Volume [ Food, Household sonal and Health Care Products. abs. no. 120
Physicians" Knowledge of Cost. The Case of Diagnostic Politics of Health Care. abs. no. 707
Controlling 134
Health
Care Costs. A National
Councd on _ _ge and Price Stability abe..o. 172
Leadership
Report
Supplies,
Conference.
ON Rising
Health
Per-
abs, no.
Care Costs.
Dcil_et y of Health Care in America. abs. no. 182 Dcvelopment of Health Insurance. abs. no. 205 Econotm2" COst of Illness Revisited. abs. no. 230 Eeonolmc Economt_s
Foundations of Medical
of National Health Policy. Care. A Policy Perspective.
Preliminary Analysis of the Costs of Maintaining tTts in Selected Plans. abs. rLo. 714 Preventive Medicine USA. Health Promotion Non. abs. no. 721
Pension
ProfessionalStandards no. 738
Review
Orgam'zation
and Health Bene-
and Consumer
Pricing, Demanders, and the Supply of Health Proceedings of the 281h Annual Group Health York, June 18-21, 1978. ab,.;, no. 735 abs. no. 231 abs. no. 238
Tests. abs. no. 697
Health Educa-
Care. abs. no. 723 Institute, New York, New
1979Progratm
Evaluation.
abs.
Employee Health Benefits. HMOs and Mandatory Dual Choice. abs. no. 260 _t Expanding Health Benefits for the Elderly. Volume I. Long-Term Care. abs. no. 289
Profits in Medicine. A Context and an Accounting. abs. no. 741 Reimbursement for Durable Mech_al Equipment. abs. no. 791 Repeated Hospitalization for the Same Disease. A Multiplier of National Health Costs. abs. no. 798
Fact Book on Aging. A Profile of America's Older Population. abs. no, 295 Financing Health Care. abs. no. 315 Finauc#lg of Health Care. abs. no. 317 Health arm the _r on Poverty, A Ten-Year Appraisal. abs. no. 354
Research in Health Economics. A Survey. abs. no. 803 Setting National Priorities. Agenda for the 1980's. abs. no. 830 Short-Run Hospital Responses ,_oReimbursement Rate Changes_ 831
Health Health
Spy in the House of Medicine. abs. no. 850 State Regulation of Health Services Utilization.
V11-18
Care Cost Increases. abs. no. 361 Care Cost lnlIation in the United States.
Toward
a Unlined Theory
Lessons
Health
From
Care
abs. no.
_dicbigan,
Programs
abs. no. 857 Strategies for Controlling abs. no. 861
the Cost of State
Mech'cal Assistance
Programs.
Health Care Costs, An Anadysis of Current Utilization. abs. no. 363 Health Care in Transition. abs. no. 372
Trends
in Health
Costs and
Strategies for Financing National Health Insurance. Who Wins and Who Loses. abs. no. 862 Study of Physicians" Fees. abs. no. 868 Survey of Hospital Semi-Private Room Charges as of danuary 1981. abs. no.
HeMth Health Health Health
880 Systems Development. Trends, Issues and Implications. abs. no. 886 Toward a National Health Poh'cy. Public Policy and the Control of Health-
Health Maintenance Organizations. A Guide to Planning and Developmeat. abs. no. 403 Health Status, Medical Care Utilization, and Outcome. An Annotated Bibli-
Care Costs. abs. no. 907 Trends _n Multihospital Systems. A Multiyear CompariSon. abs. no. 911 Use and Expenditures Analyses From the National Meda'cal Care Expenditure Survey. abs. no. 919
ography of Empirical Studies. Volume 4. abs. no. 426 Impact of Membership in an Enrolled, Prepaid Population on Utilization Health Ser_7"ces in a Group Practice. abs. no. 481 The Malpractitioners. abs. no. 539
Working Papers on Major Budget Programs. abs. no. 947
Medicaid Experience. abs. rto. 548 Medical Care Use by a Group of Fully no. 555
and Program
Issues in Selected
Health
Health care/services Ambulatory Care Systems. Volume IV. Designing Medical Services Health Maintenance Organizations. abs. no. 23 American Health Care System. Issues and Problems. abs. no. 27 Analysis of Workers" Compensation Laws. abs. no. 39
for
Care. Regulation, Economics, Ethl_s, Practice. abs. no. 377 Care Systems in World Perspective. abs. no. 380 Economics and Health Care. Irreconcilable Gap. abs. no. 385 in the Future. In the Pink or in the Red. abs. no. 387
Insured
Aged.
A Case Study.
a(
abs.
Medical Malpractice Insurance. A Legislator's View. abs. no. 557 Medical Malpractice Law. 2rid Edi'tion. abs, no. 558 Medical Malpractice. The Response of Physicians to Premium Increases California. abs. no. 562 Mech'eare Reimbursement. abs. no. 579
in
Assessing the Utilization and Productivity of Nurse P_ct_'oners and Physi. cian's Assistants, Methodology and Findings on Productivity. abs. no. 43
Metropolitan Comprehensive Care Program. A Health Systems tion Demonstration. abs. no. 590 National Commission on the Cost o£ MechCal Care. 1976-1977.
Benetlts in Medical Care programs, abs. no. 49 Catastrophic Health Insurance. abs. no. 72 Characteristics of Group Heaith Plans, abs. no, 8005 Checkbook 's Guide to Health Insurance Plans for Federal Employees. For District of Columbia, Maryland, and Virginia (Also covers D.C Guyerament Employees). abs. no. 83 Comparisons of Prepaid Health Care Plans in a Competitive Market. The Seattle Prepaid Health Care Project. abs. no. 100
IJt_ratur¢ Reviews Data Bases. abs. no. 601 National Health Care 2_xpendt'ture Survey. abs. no. 8027 ,_rational Health P_xpendt'tures, 1979, abs. no. 604 National Health Insurance and Corporate Bane[it Plans. abs. no. 609 National Health Insurance and Health Resources. The European t_xperienee. abs. no. 610 National Health Insurance and Income Distn'hution. abs. no. 611 Nattbnai Health Insurance in Canada. abs. no. 620
Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Volume VIII, Over_ew. abs. no. 110 Controlling the Costs of Retirement Income and Me_'eal Care Plans. abs. no. 142
National Health Insurance Issues. The Adequacy of Coverage. abs. no. 622 National Health Insurance. 96th Congress second session, Volume 2. abs. no. 631 Nation's Use of Health Resources, 1979. abs. no. 638
Controlh'ng the Use and Cost of Medical Services. The New Mexico Experimental Medical Care Review Organization. A Four-Year Case Stud_ abs. no. 143
New Group Health Insurance. abs. no. 644 New Health Professionals. Nurse Practitioners abs. no. 645
Delivery of Health Care in America. abs. no. 182 Demand Elasticities for Health Care With Special Emphasis on Out-o£Pocket Price. abs. no. 185 Determining Health Needs. abs. no. 203 Development of Health Insurance. abs. no. 205 Digest of Selected Health and Insurance Plans. Volume I. Health Bunetlts. 1977-79 Edition. abs. no, 209
Planning for Posthospitai Care. A Pollowup Study. abs. no. 698 Poh'tics of Health Care. abs. no. 707 Preh'minary Analysis of the Costs of Maintaining Pension and HeMth Bene[its in Selected Plans. abs. no. 714 Pressures and Problems For Organized Ambulatory Services in the Next Decade. abs. no, 718 Preventive Health Care in the HMO, Cost Bane[it Issues, abs, no. 720
Disability, Employee 260
l_7"mary Care in Durham County. PtT"vate Industry Health Insurance erin 1974. abs. no. 731
Health Health
Status, and Utilization of Health BenetYts. HMOs and Mandatory
Services. abs. no. 212 Dual Choice. abs. no.
and Physician
Proceedings of the 28th Annual Group Health Institute, York, June 18-21, 1978. abs. no. 735 Regionalization and Health Policy. abs. no. 780 Research in Health Economics. A Survey. abs. no. 803
Health Departments. abs. no. 268 Equal Treatment and Unequal Bane[its. A Re-examination Medicare Services by Race, 1967-1976. abs. no. 270
Role of Payment Source in Differentiating Nursing vices, and Payments. abs. no. 817 Role of Physician Education in Cost Containment.
Pact Book on Aging. A ProHle of Ame_ca's Financing Health Care. abs. no. 315
Older
Population.
of the Use of abs, no. 295
Forecasting. A Cost Control Tool for Health Care Managers. abs. no. 319 Group Benelit Survey. Plans Covering Salaried Employees of U.S, Employ. ers, 1980. abs. no. 340 Guidelines for Planning Health Services. An Annotated Bibliography, abs. no. 347 Health and Health Insurance. The Pubh'c's View. abs. no. 350
Selected Studies in Medical 1975. abs. no. 827
Care and Medical
Home
Vcdume 3.
"s A:¢sistants.
Who Gives Care to Whom. Plans. Type of Administration
Employment Related Health Benetits in Private Nonfarm Business Estab. lishments in the United States. Volume II. Description of Salectc_t Data. abs. no. 264 Epidemiolngic Revolution, National Health Insurance and the Role of
Organiza-
New
abs. no. 724 and InsurYork, New
Residents,
Set-
abs. no. 818
Economics.
Annual
Report,
Source Book of Health Insurance Data, 1979-1980. abs. no. 847 Spy in the House of Medicine. abs. no. 850 State Employee Health Insurance Plans. A Survey of Coverage, Benefits, Financing. abs. no. 852 State Regulation of Health Services Utilization. Lessons From Michigan. abs. no. 857
VII-19
5tcF._ t_ .__v_,tr_; l,;.ziat_u:_ a .¢lea_lh Care Costs. abe. no. 860 S_iat_,_ _ for C_mrroJLing .the Cost _f Sta*.e ?¢Iedical Assistance abs lo. 861 Vertically L1)2keo' Health OrganizaOons. Women_ Work, and Health. Challenges Health information/data Alcohohsm Program ._ed Information abs. no. 13
systems Management System.
abs. no. 929 to Corporate Policy.
Through
1. Actuarial
the Operation Data
to Health
Policy
Decisions.
abs. no. 943
of a Computer-
on Utiliza_on
Ambulatory C_ae ,_ystems. Volume 1K Designing Meddcal HeaL'h Maintenance Organizations. abs. no. 23 _a,,,adla:. App*oaches _nce. abs no. 62
Programs.
National
of Services. Services Health
h_r
Insur-
_hdeasulet_:citt of Eapendztm'es lot Outpatient Ph)'$lclan and DcntM Scrvices. ?¢I¢_hodological Fndings from the Health Insurance Stud)'. abs. no, 544 Measuring Olsabih'ty and U,!ff_zation. Two Medicaid Experience. abs. no. 548 Medicare. Health Insurance for the Aged Reimbursement by State and County. Modelling the Effects of NationM Health abs. no. 594 National Commission
Health
Surveys.
abs. no. 545
and Disabled, 197Z Section 1. abs. no, 577 Insurance in the Urn'ted States.
on the Cost of _gledical Care. 1976-197Z
Volume
3.
Literature Reviews Data Bases. abs. no. 601 National Health Care Expe*tditure Survey. abs. no. 8027 Nanonal Health Insurance gram. abs. no. 623
I_suea. The Cost of a National
Prescription
Pro-
Catalog ,_f PaDh_" L'_c Data Tapes from the National Center for Health SratL, tlcs. abs. no. 71 Cha.qge* ,n the Costs of Frcntment of Selected Illnesses. 1951-1964-197l. abs. no 76
Pohcy Analysis with SocJM _ecurity Research FlTes. abs. no. 701 Poverty and Health. Economic Causes and Consequences of Health ProbIrma. abs. no. 712 Prospective Reimbursement in Rhode Island. Additional Perspectives. abs.
6bt,c'epwalizanbn and Measurement of Health for Adults in the Health Insurance Study. vblame VIII, Overview. abs. no. 110 _bnditio3s [o; Change in the Health Care System. abs. no. 111 Cbst C_,_,ta&ment ThrougP. Risk-Sharing by Pt4mary Care Physicians..4 History of the Development of United Healtheare. abs. no. 155 Description of the Health Financing Model. A Tool for Cost Estimation. abs. no. 198
no. 752 Providing More Information on Work Injury and Illness. abs. no. 757 Quality Assurance in a Prepaid Group Practice. abs. no. 767 Relationship Between Diagnostic lnforma_on Available at Admission and Discharge for PaNents izt One PSRO Setting. abs. no. 796 Report on Coalitions to Co_tain Mech'cal Care Costs. abs. no. 800 Resurvey of Private Practice Physicians, 1979. abs. no. 8037
De_@q _br a Corporate Health Care _lonitoring System. Diagn3sD Related Group (DR G) Management Information _bs _o. 8009
Re_Tew of the _ledical Malpractice 811 Selected Topics in Federal Health
abs. no. 199 System Stuck'ca.
Direction, s tbr the '80s. Final Report of the Panel to Evaluate the CooperaNve t tea/th StatisnL's System. abs. no. 210 _TK_ct., v, "Financial Incentives on Physicians' Specialty and Location Deci.,.'.'on. abs. no 250
Services abs. System Systems
Problem
_)7 the United
Statistics.
abs. no. 828
States.
abs. no.
Shared by Health Care Organizations. An Annotated Bibliography. no. 829 of Hospital UmTorm Reporting (SHUR). abs. no. 884 Approach to Health Insurance Policy InformaNon. A Preliminary
_mp/oyc_: Benct_ts 1979. at_s. no. 259 Est_mat_g the Cost of Health Insurance Programs. abs. no. 277 Evaluation oi the Max&hum Allowable Cost (MAC) for Drugs Program. Phas¢. I R epo_t. [ )nal Design Report and Report of Pilot Study Analym]_. :bs t o. 287
Taxonomy of Health Insurance Issues, Program Options, Problems and Solutions. abs. no. 885 Type, Length, and Cost of _'_e for Home Health Paoents. A Report of the Discharge Summary Fea_ibdJty Study. abs. no. 914 Use and Expenditures AnMyaes From the National _[edical Care Expendi-
_c_
lure Survey. abs, no. 919 Variations in State Medical_ Programs. Wasted Health Dollars. abs. no. 932 Who Are the Uninsured. Data Preview
A._ Y_,ur gSage_cips A Ciuide to Sources of Statistical Intbrmation on _vla)o.- klealzh Topics. Fourth Edition. abs. no. 300 FOrccastL_g. A _)st ConL-ol Tool for Health Care Managers. abs. no. 319 Gm_te to Med_:.'aM Data Sources. Volume One. abs. no. 345 Heal;_+ Ctrc Data Initiatives. abs. no. 8019
abs. no. 926 1. abs. no. 937
Health Care Z)ilemma. Problems of Technology in HeMth Care Deh'verj: abs. no. 367 Health E,'ouo.,mc_ a_'_d Health Care. hreconcilable Gap. abs. no. 385 Hca/tl_ Insurance Publk" Programs. 1978-June, 1980 (A Bibliography With At,_;r_c';_. abs. no. 398 Health h_tc.zvie_ Survey and 34_nority Health. abs. no. 400 Hcatth Mninrenance Organization Planning Model to Evaluate an .Alterna_.'_e _cMth C_re Dehve_y System for the State of Georgia. abs. no. 402 Health *tams, Mcdica! C_¢e Uti.Ozatiun, and Outcome. An Annotated Bibh: ,gtap_y of £_,_p_rical S_udies. Volume 1. abs. no. 423 Health S¢:tgus, _cd_Z'al Care Utilization, and Outcome. An Annotated Bibh: ,-g_a?.Ty of Empirical Studies. Volume 2, abs. no. 424 Health Status, Medical Care Utihzation, and Outcome. An AnnotatedBibll ograp _y of Emp_Hc'al Studies. Volume 3. abs. no. 425 Health St*,tus, Medical Care Utilizat_bn, and Outcome. An Annotated Bibh: ograpny of Empirical Studaes. Volume 4. abs. no. 426
Health insurance hadustry Adding a Dose of Compeftign to the Health Care Industry. abs. no. 7 Adequacy of Private Health Insurance Coverage. abs. no. 8 Blue Cross. What Went Wrong. abs. no. 52 Cancer Insurance, A Review of Pubh'cly Available DocumentS. abs. no. 8003 Cancer Insurm_ce. Exploiting Fear for Profit. An Examination of Dread Disease Insurance. abs. no. 64 Comparison of Group _4edic_d Care Insurance Benefits to Charges. abs. no. 96 Controlling Health Care Costs. Strengthening the Private Sector's Hand. abs, no. 135 Development of Health Ins_'ance. abs. no, 205 Effect of Physician-Controlled Health Insurance. abs. no. 243 Going Bare. Continuance and Conversion Provisions in Health Insurance. abs. no. 336
Household Health Interviews and Minority Health. The NCHS Perspective.. abe. n _. 461 Impacts of Health Maintenance Orgamzation Growth on Community Health Care Costs. abs. no. 491 lntb_ _,*am )n Needs oY National Health Insurance. A Discussion of Prince-
Health Insurance in the Meaieare Years. abs. no. 394 Health Insurance Industry. Structural and Strategic Issues in an Uncertain Environment. abs. no. 396 Health Services and Health Hazards. The Employee's Need to Know. abs. no. 419
pies. lssuc3, and Legislative Recommendations. abs. no. 507 lnsuzance. Re_alat_bn, and itosp_lal Costs. abs. no. 512
Health, United States, 1980. abs. no. 428 How Interested Groups Have Responded to a Proposal for Economic
VII-20
Corn-
Health Care Programs
petition
in Health
Services.
abs. no. 468
Controlling
MedJbald
Utilization
Patterns.
Copayments peHence,
National Health Insurance as an Issue in Political Economy. The Implications of the Kennedy Health Secua'ty Act for Developing a Strategy to Effect Major Reorganization of Health Care Delivery in America. abs. no. 615 New Group Health Insurance. abs. no. 644 Policy Analysis _qth Social Security Research Files. abs. no. 701
Cost Effective Acute Care Facilities Planning in Michigan. ab:s. no. 157 Diagnosis Reined Group (DRG) Management Information System Studies. abs. no. 8009 Digest of Hospital Cost Containment Projects, Third Edition. abs. no. 208 Discounting and Differential Pricing Practices in the Health Care Field. abs. no. 216
Proceedings. 27th Annual Group Health June 19-22, 1977, ads. no. 736
Economics Evaluating
U.S. Health
Insurance
Industry.
Institute,
An Alternative
Los Angeles,
California,
View. abs. no. 917
Home health services Better Services at Reduced Costs Through an Improved Program Recommended for Veterans, abs. no. 50 Child Health. America's Future. abs. no. 84 Cost of Terminal Care. Home Hospice' vs Hospital, Delivery Prospers in Diversity. abs. no. 184
"'Personal
abs. no. 162
Care. The Califorma
of Mech'cal Care. A Policy Perspective. Hospital Productivity. abs. no. 279
Expenditures 291 Care"
and Demand for Medlbal abs. no. 144
abs, no. 138
Malpractice CHsis. What Was It All About. abs. no. 537 Medical Care Plans. How to Control the Costs. abs. no. 553
for Health
Care. Federal
Medicaid
E._-
abs. no. 238
Programs and Their Effects.
abs. no.
Health Care Market. Can .Hospitals Survive. abs. no. 374 Health Care Reimbursement Is Federal Taxation of Tax-Exempt Providers. abs. no. 378 High Cost of Hospitals and What to Do About It. abs. no. 431 Hospice. Hospital
Creating New Models of Care for the Terminally Care in America. abs. no. 445
111.;Lbs. no. 440
Effects and Costs of Day-Care Services for the Chronically Ill. A Rsndomized Experiment. abs. no, 248 Expanding Health Benefits for the Elderly. Volume L Long-Term Care. abs. no. 289
Hospital Cost Containment Act of 1979. abs. no. 447 Hospital Cost Control in Maryland. abs. no. 450 Hospital Cost Inflation and Health Insurance. A Complex abs. no. 451
Home Health Care Services. Tighter Fiscal Controls Needed. abs. no. 437 Home Health. The Need for a National Policy to Better Provide for the Elderly. abs. no. 438
Hospital Reimbursement by Diagnosis Related Groups. Preliminary ography, abs. no. 456 Medicare. The Politics of Federal Hospital Insurance. abs. no. 582
Homemaker Services. Essential Option for the Elderly. abs. no. 439 Hospice. Creating New Models of Care for the Terminally Ill. abs. no. 440 Hospice Movement in the Urn'ted States. abs. no. 441
Metropoh'tan Comprehensive Care Demonstration Proposal. abs. no. 8025 Minimal Care Units. Mechanisms for Hospital Cost Containment. abs. no. 591
Hospital Backlog. Patients With No Place How Business Can Use Specific Techniques
Mode of Payment and Length PSRO_ abs. no. 592
To Go. abs. no. 443 to Control Health Care Costs.
of Stay in the Hospital.
Market
More
Model. Bibli-
Work
for
abs. no. 465 Impact of Long-Term Care on Functionally Disabled Adults. abs. no. 8022 Maintaining the Elderly in the Community. abs. no. 8024 New York State Long Term Health Care Program. abs. no. 647 Patient Outcomes in Three Alternative Long-Term Care Settings. abs. no. 669 Reimbursement Alternatives for Home Health Care. abs. no. 790 Responsibility of Families for Their Severely Disabled Elders. abs. no. 805 Terminal Care, Issues and Alternatives. abs. no. 896 Thirty. To-One Paradox. Health Needs of the Aged and Medic M Solutions.
National HMO Census Survey, 197Z Summary. abs. no. 634 Nego_'_ting Reimbursement Contracts. The Miclu'gan Experience, abs. no. 640 Net Claim Costs and Reserves for Accident-Only and Intensive-Care-Only Hospital Coverages. abs. no. 642 New Jersey Diagnosis Related Group (DRG) Evaluation. abs. no. 8030 New Jersey Hospital Reimbursement Under S-446. Elements _md Effects, 1980. abs. no. 646 New York Case Mix Study. abs. no. 8031 Overview of Health Insurance Study Publications. abs. no. 666
abs. no. 903 Type, Length, and Cost of Care for Home
Patient Outcomes 669
Discharge L(S. Hospice
Summary Movement.
Health
Patients.
A Report
of the
Feasibility Study. abs. no. 914 Issues in Development. abs. no. 918
Hospital services Achieving Cost-Effective Practice in a PrepaM Plan. abs, no. 5 Alternativos to Prepayment Finance for Hospital Services. abs. no. 22
in Three Alternative
Long-Term
Care Settings.
abs. no.
Payment for Hospital Services. Objectives and Alternatives. abs. no. 673 Physician Reimbursement and Hospital Use in HAlOs. abs. no. 691 Professional Standards Review Organization 1979 Program Evaluation. abs. no. 738 Proposals for the Regulation of Hospital Costs. abs. no. 746 Prospective Rate Reimbursement and Cost Containment. Formula Reim-
Analysis of Case Mix Complexity Using Information Theory and Diagnostic Related Grouping. abs. no. 32 Analysis of Prospective Payment Systems in Upstate New York. abs. no. 35 Case-Atix Difference Between Nonprofit and For-Profit Hospitals. abs. no. 70 Changing Role of the Hospital, Options for the Future. abs. no. 80 Comparing the Mech'cal Utilization and ExpencHtures of Low Income Health Plan Enrollees With Medicaid Recipients and With Low Income Enrollees Having Medicau_t Eh'gibih'ty. abs. no. 95 Comparison of Group Medical Care Insurance Benefits to Charges. abs. no. 96
bursement in New York. abs. no. 750 PSRO, An Evatua_on of the Professional Standards Review Organization Programs, Volume If. A Cost-Benefit Context for PSRO Utilization Control Activities. abs. no. 759 Reimbursement for Hospital Services. abs. no. 792 Relationsltip Between Diagnostic Information Available at Admission and Discharge for Patients in One PSRO Setting. abs. no. 796 Repeated Hospitalization for the Same Disease. A Multiplier of National Health Costs, abs. no, 798 Research and Demonstrations in Health Care Financing, 1978-1979. abs. no. 802
Comparison of the Hospital Cost Experience of Three Competing HAlOs. abs, no. 98 Comparison of the Quality of Maternity Care Between a Health-Malntenance Organization and Fee-For-Service Practices. abs. no. 99 Containment of Hospital Costs. A Strategic Assessment. abs. no. 131
Rising Hospital Costs Can Be Restrained by Regulating Payments and Improving Management. abs. no. 814 Some Effects of Quebec Health Insurance. abs. no. 844 Summary of Rate Review in Maryland. abs. no. 876 Survey of Hospital Semi-Private Room Charges as of January 1981. abs. no.
VII-21
880 Sarvey R,:sults. July 1 _60. I-i_IO Enrollment no. _$3 Systems 9evelopmcnt.
Trends, Issues
and Utihzation
and Implications.
in the L_S. abs.
Yeazs of Short-Stay Hospital Utilization and Costs Under Merle'care (1967.1976). abs. no. 895 Terminal Care. Issues and Alternatives. abs. no. 896 US. Hospice l_rovement. Issues in Development. abs. no. 918 Use of Hospital Services Under Two Prepaid Plans. abs. no. 920 Veterans Administration Hospitals. An Economic Analysis of Government pFise, abs. no. 930
Pharmaceutical
jeer. _.bs. no. 24 Aspects of Medicare Cha_ges and Sources Data Preview 2. Charges _nd Sources vie_" 5. abs. no. Choice B.:tween abs. no. 87
Evidence
Serw_es
in Colorado.
abs. no. 16
for Merle'care Recipients.
A Pilot Pro-
Family
abs. no. 8002
and Individual
Arrangements
Deductibles
in Health
Insurance.
Among Employees Covered by a Prepaid Health Insurance Program. abs. no. 91
Between
Hospitals
for the United
How Business Can Promote lies. abs. no. 463 How Cheap is a Life.
Insurance.
Good Health
A Complex
for Employees
Market
and
Physicians.
abs. no.
Competing for Acute Care Dollars. The Economies of Risk Reduction, no. 102 Complex Puzzle of Rising Health Care Costs. Can the Private Sector 7bgether. abs. no. 107 ConceptuMization and Measurement of Health for Adults Insurance Study. Volume VIII, Overview. abs. no. 110
abs. Fit it
in the Health
King-
and
Model.
The1? Fami-
abs. no. 467
How Interested Groups Have Responded to a Proposal for Econom2c petition in Health Service, s. abs. no. 468
of Payment for Dental Visits With Separate Charges. abs. no. 81 of Payment for Visits to Physician Oft_ces. Data Pre82
Comparative Absence Experience or a Blue Cross/Blue Shield Compensation 101
on Length-of-Visit.
lmplieaobns
Health Insurance Study. abs. no. 8020 Health Planning and Regulation Effects on Hospital Costs, abs. no. 414 Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliography of Empirical Stadies. Volume 3. abs. no. 425 High Cost of Hospitals and What to Do About It. abs. no. 43 l Hospital Collective Bargaining. Structure and Process. abs. no. 446 Hospital Cost IntTation and tIealth abs. rto. 451
Impact of third-party coverage Allocatlo:7 of Physicians'Services. Ambulatory
Cost Problem. Is Regulation Our Only Hope. abs. no. 383 Insurance Coverage lot Alcoholism, 1975. abs. no. 392
Health Insurance in the Unil'ed States. dom. abs. no. 395
abs. no. 886
Ten
_tc_
Health Health
Corn-
How Things Work in the ReM World of Hospital Finance. abs. no. 471 IIlness Prevention and MedicM Insurance. abs. no. 474 Impact of Family Structure on ChiIdren's Health Care Use. abs. no. 478 Impact of the 1974 Health Care Amendments to the NLRA on Collective Bargaining in the Health Care Industry. abs. no. 490 Insurance, Regulation, and HospitM Costs. abs. no. 512 Medicaid, Medicare, and Private Health Insurance Low-Income Areas. abs. no. 549
Coverage
Mech'cal Malpractice. The Response CaHlbrnia. abs. no. 562
to prema'um Increases
of Physicians
in Five Urban, in
_lethodology Used to Measua'e Health Care Consumption Du_qng the First Year of the Health Insur, mce Experiment. abs. no. 588 Minimal Care Units. Mechanisms for Hospital Cost Containment. abs. no. 591 New
Health Professionals. abs. no. 645
Nurse
Practitioners
and Physician's
Assistants.
Consequences of Increased Third-Party Payments for Health Care Services. abs. no. 115 Consume_" IntTuence on the Quality of Dental Care. abs. no. 121 Controlliz,g the Cost of Dental Care. abs. no. 140 Cost of National Health Insurance. The Province of Quebec. abs. no. 161 Demand for General Practitioner and Internist Services. abs. no. 186
Norms Hypothesis and the Demand for Medical Care. abs. no. 649 On Having Your Cake and _$ating It Too. Econometric Problems in Estimating the Demand for Health Services. abs. no. 659 Paying for Primary Care. Time for a Change. abs. no. 672 Physician Participation in HeMth Insurance Plans. Evidence on Blue Shield. abs. no. 689
Dental C_re Demand. Point Estimates Insurance. abs. no. 191 Dental C:are for Ever>one. Problems
Physicians' Charges Under heedicare. Liability, abs. no. 695 Politics of Health Care. abs. no. 707
and Implications and Proposals.
for NationalHealth abs. no. 192
Disability Insurance. Trends Since World War II. abs. no. 214 Discounting and Differential Pricing Practices in the Health Care Field. abs.
Pressures and Problems for Organized Decade. abs. no. 718
no. 216 Eeonomi¢s of Cost Containment.
Price Setting in the Market ture. abs. no. 722
abs. no. 236
Assignment
Rates
Ambulatory
for Physicians'Services.
and
BenelTciary
Services
in the Next
A Review
of the Litera-
El?act of PhysJcian-Controlied Health Insurance. abs. no. 243 Erosion o( the 34edicM Marketplace. abs. no. 272 Estimate 9f the Impact of Deductibles on the Demand for Medical Care S¢sv&cs. abs. no. 273 Evaluatlo:7 of Alternative Payment Strategies for Hospitals. A Conceptual Apprvach. abs. no. 280
Private Health Insurance to Supplement Medicare_ Volume Labs. no. 730 Private Physicians and Public Programs. abs. no. 732 Program for Elective Surgical Second Opinion. Surgical Experience of Program Participants, 1976-197Z abs. no. 742 Promoting Competition in th,,_ Health Industry. The Role of Health Planning. abs. no. 743
Expcnditt 291
Provision of Long- Term Care 9ervices abs. no. 758
'res toe Health
Care. Federal
Programs
and Their Effects.
abs. no.
by Community
Hospitals
in Virginia.
Fee-t'or-Serv_ce Physician Payment. Analysis of Current Methods and Their Development, abs. no. 308 Financial Management Under Third Party Reimbursement. abs. no. 312 Health au J Taxes. An Assessment of the Medical Deduction. abs. no. 353
Rapid Rise of Hospital Costs. abs. no. 771 Regulation and the Quah'ty of Dental Care. abs. no. 785 Regulation of Health Care in the United States. abs. no. 787 Reimbursement Alternatives for Home Health Care. abs. no. 790
Health C,tre Business. International Evidence on Private Versus Pubh'c Health Care Systems. abs. no. 356 Health C_re Cost Increases. abs. no. 361 Health Care Guidance. Cotnmereial Health Insurance and National Health
Rising Hospital Costs Can proving Management. Role of Fee Schedules in Role of Health Insurance
Polio). abs. no. 369 Health C_re in the 1980s.
Short-Run 831
371
VI|-22
Who Provides.
Who Plans.
Who Pays. abs. no.
Structure
Hospital
Be Restrained by Regulating Payments and Iraabs. no. 814 Physician Reimbursement. abs. no. 8038 in the Health Services Sector. abs. no. 816
Responses
of Health Insurance
to Reimbursement
Rate
Changes.
and the Erosion of Competition
Health
Care
abs. no.
in the Meek'-
Programs
cal Marketplace. Study of Physicians" Third Party Payment
abs. no. 864
Health
Care Costs. Private
Fees• abs. no. 868 for Nonphysician Health
Health Health
Care Dilemma and Corporate Debt Capacity. abs. no. 366 Care Market. Can Hospitals Survive. aim. no. 374
Recommendations. aim. no. 900 Third Party Reimbursement Aspects
Practitioners.
of Physician
Realities
Compensation.
and
abs. no.
901 Third-Party Payments for New Health Professionals. An Alternative Fractional Reimbursement in Outpatient Care. abs. no. 902 U.S. Health Insurance Industry. An Alternative U.S. Hospice Movement. Issues in Development. Who Inpatient
Initiates
Visits to a Physician.
to
View. aim. no. 917 abs. no. 918
Data Preffew
Hospital
Capital
3. abs. no. 939
Expenditures.
Health Care Reimbursement aim. no. 378 Health Economics Health Personnel. no. 411
for Containment.
Is Federal
Taxation
abs. no. 364
of Tax-Ezempt
and Health Care. Irreconcilable Meeting the Explosive Demand
Providers.
Gap. abs. no. 385 for Medical Care. abs.
Health Planning and Regulation Effects on Hospital Health, United States, 1980. abs. no. 428
Costs.
abs. no. 414
HIAA Reviews State Cost Control Regulation. aim. no. 430 High Cost of HospitMs and What to Do About IL aim. no. 431 Hospital Backlog. Patients With No Place To Go. abs. no. 443
facilities
Analysis of Programs to Limit Report. abs. no. 34
Initiatives
Dral_ Final
Hospital Capital Expenditure suits, abs. no. 444
Controls.
Their Desired
and Expected
Re-
Analysis of the Effects of Prospective Reimbursement Programs on Hospital Expenda'tures. abs. no. 37 California Health Facilities Commission. A Case Study of Government
Hospital Hospital Hospital
Care in America. abs. no. 445 Collective Bargaining. Structure and Process. abs. no. 446 Cost Containment Programs. A Policy Analysis. abs. no. 448
Regulation. abs. no. 56 Case-Mix Difference Between NonprotTt and For-ProlTt 70 Changing Role of the Hospital. Options for the Future.
Hospital Hospital Hospital Hospital
Cost ContMnment. Selected Notes for Future Policy• abs. no. 449 Cost Control in Maryland. aim. no. 450 Cost Inflation Study• aim. no. 8021 Production. Can Costs Be Contained. aim. no. 453
Hospitals.
abs. no. 80
Compensation Arrangements Between Hospitals and Physicians. 101 Control of Hospital Costs by Rate-Setting. aim. no. 133 Controlling Controlling
Hospital Hospital
Costs. The ReveMit_ Costs. The Revealing
Care Review
Organization.
Cost Containment Through Employee Cost Control Challenge for Hospitals. Cost Effective
Acute
Cost Rel_nbursement no. 163 Delivery of Health Digest of Hospital Economic Economics
Care Facilities
Foundations of Medical
The New Mexico
Expert-
A Four- Year Case Study.
Incentives Program. abs. no. 156 Planning
and Price Competition Care in America. Cost Containment
aim. no.
Cue of In_'an& aim. no. 136 Case of Indiana. Summary. aim.
no. 137 Controlh'ng Rising Hospital Costs. abs. no. 139 Controlh)_g the Use and Cost of Medical Services. mental Medical aim. no. 143
aim. no.
in Michigan. in the Hospital
Hospital Rate Setting. Ttu's Way to Salvation. abs. no. 454 Hospital Regulation Through State Rate Review. Mandated Interference a Noble Intrusion. aim. no. 455 Hospital-Basod no. 458
Physicians.
Current
Issues
and Descriptive
EvMenee.
or aim.
Hospital-Based Versus Free-Standing Primary Care Costs. aim. no. 459 How Interested Groups Have Responded to a Proposal for Economic Competition in Health Ser_ces. aim. no. 468 How Interested Groups Have Responded to a Proposal petition in Health SerWce& aim. no. 468
for Economic
Corn-
aim. no. 154
How Things Work in the Real World of Hospital Finance. aim. no. 471 Idea Whose Time Has Come. Less Health Insurance. aim. no. 473
aim. no. 157
Impact
Industry.
Impact of Rate Regulation ta/s. aim. no. 485
abs. no. 182 Projects, Third Edition.
aim.
abs. no. 208
of National Health Poh'cy. abs. no. 231 Care. A Policy Perspective. aim. no. 238
of National
Health
Insurance
Impact of State Certificate-of-Need riGa. aim. no. 487 Impact of State Government 488
on New
on the Diffusion
York.
of New
abs. no. 482
Technologies
in Hospi
Laws on Health Care Costs and Utiliza-
Rate Setting on Hospital
Manageme_t.
abs. no.
Effect of PSROs on Health Care Costs. Current Findings and Future E valuations, abs. no. 244 Effects of Hospital Cost Containment on the Development and Use of Medical Technology. aim. no. 251 Evaluating Hospital Productivity. aim. no. 279 Evaluation of Alternative Payment Strategies for Hospitals. A Conceptual Approach. abs. no. 280 Expenditures for Health Care. Federal Programs and Their Effect_ abs. no. 291
Increases in Hospital Expenses, 1976-1979. A Comparison of States With Mandatory Cost Containment Programs and States Without Mandatory Cost Containment Programs. abs. no. 498 Inflation in Hospital Costs and Charges in Maryland. aim. no. 503 Insurance Benefits, Out-of-Pocket Payments, and the Demand for Medical Care. A Review of the La'terature. aim. no. 509 Insurance, Regulation, and Hospital Costs. aim. no. 512 Joint Health Cost Containment Program. Hospital Utilization Report. abs. no. 524
Exploratory Study of the Acceptance of Current Federal Health Care Policy by Hospital Administrators, Trustees, and Physicians. aim. no. 293 Financial Management of Health Care Organizations. A Referenced Outline and Annotated Bibliography. aim. no. 311
Laws of Motion in the For-Profit Health Examples. abs. no. 529 LintNng Physicians, HospitM Management, Medical Care. aim. no. 533
Financing of Health Care. abs. no. 317 Framework for Capital Controls in Health Care. abs. no. 323 From Charitable Immunity to Pubh'c Aeeountabih'ty. A Review o£Selected Solutions to the Malpractice Problem. abs. no. 324 Functional Value Analysis. A Technique for Reducing Hospital Overhead Costs. abs. no. 326 Health. A Victim or Cause of Inflation. abs. no. 348
Malpractice. Funding Emerges as a Critical Issue. aim. no. 538 Medical Malpractice Insurance. A Legislator's View. aim. no. 557 Medical Technology and Hospital Costs. abs. no. 566 Medical Technology. The Culprit Behind Health Care Costs. abs. no. 568 Metropolitan Comprehensive Care Demonstration Proposal. abs. no. 8025 Metropolitan Comprehensive Care Program. A Health Systems Organization Demonstration. aim. no. 590
Health Care Cost Elements tions, abs. no. 360
Minimal 591
Affecting
Health Care Costs. An Analysis Utilization• abs. no. 363
Legislative
of Current
and Planning
Trends
in Health
ConsideraCosts and
Care Units. Mechanisms
Model for Assessing 593
and Effecting
Industry.
Theory
Cost Containment
for Hospital Hospital
A
and
and Better
Cost Containment.
Closure.
Three
Final Report.
abs. no. aim. no.
VII-23
"
._¢ul_ .'=,.'_• C__::: .q _.2rc':a_s A._;_7_ntstratlb_
]nitlati, e in Health
Conmq abs. no. 596 :¥a;i_nal CoJnm_ssic,n on the Cost of Medical
Care. 1976-197Z
Care Cos_ Volume 2.
("ollec_ed Papers. abs. m,. 000 Natio_al Hospital Rate. Sett_t:g Stuay. ,4 Comparative Review of Nine Prospective Rate-Setting Programs. abs. no. 637 NegotDtL_g Re_'?nburscment Contracts. The Michigan Experience. abs. no. 640 NHI
Won't
Conlrol
Costs,
QuMit),
or Access.
abs. no
648
t>, Hosp/tM Services Objec_s and Alternatives. Care. Charges, Pc)meats and the Medical Setting.
Per-Case Physician Planning
Reimbursement for Medical Care. Final Report. abs. no. 675 Glut Will Force Dbspitals to Look Outward. abs. no. 686 tot Posthospital Care. A Followup Study. abs. no. 698 Four Decades
of Federal
abs. no. 673 abs. no. 674
Initiative
abs. no. 916 Analysi3
of Government
care facilities
Coat Effect and Benefits Associated with DomictIiary ate Nursing Care. abs. no 8008 Cost-Benefit Analysis Mandatory Current and Future Development Alentally Retarded. A Survey
and
An Economic
Voluntary Hospitals Suffer From Fiscal Erosion. Their Existence is Being Threatened. City Could Lose 5,200 Beds, 20,000 Jobs. abs. no. 931 Working Papers' on .Major Budget and Program Issues in Selected Health Programs. abs. no. 947 Intermediate
Pa_'r_ent Pedl_:rit-
Poh<_, Pc 'itlcs_ and Child Itealth. S_atc Respon,_c abe. no 704
Mun_c':_al ftospitals,
Veterans Administration Hospitals. Enterprise. abs. no. 930
Expanding Health Benefits no. 289
Care and Intermedi-
Medicare Partim))ation. abs. no. 164 of Intermediate Care Facilities for the of State O#Tcials. abs. no. 174
for the Elderly.
Volume
Politics and Economics of lqospital Cost Containment. abs. no. 706 Prospective RaLe Reimbursement and Cost Containment. Formula Reim-
Feasibility and Cost-Effectivez_ess abs. no. 302
b_Jrsement in New York. abs. no. 750 Prost,ec-t_v:" Rat,," Setting abe. no. 751
Health Personnel. no. 411
Prospccu,e Reimbursement System Based on Patient Case-Mix h_r New Jer_
Health, United States, 1980. _bs. no. 428 Hospice Movement in the United States. abs. no. 441 Hospice. Prescription for Terminal Care. abs. no. 442 Hospital Backlog. Patients Wtth No Place To Go. abs. no. 443 Nationwide Study of Domicil/ary Care. abs. no. 8029 Nursing Home Cost Studies and Reimbursement Issues. abs. no. 652
Public H_:pl_al and _ts Local Ecology in the United States. Some Relation.vh_ps _tetween _he "'Plight oft_he Public Hospital"and the "'Plight of the C;tws'_ abs. no. 763
Role of Payment Source vices, and Payments.
Qaaho
Assura,we
io Health
Re-exmmZ_bg the Rhode _¢-nt. ibs. no. 775 Rc-gulatin_ Regulating
Hospital Hospital
Care. abs. no. 768
lMand Experience
Limitations
with Prospective
Reimburse-
Costs. The Development of PubhZ- Poh'cy. abs. no. 782 Labor Costs. A Case Study in the Politics of State Rate
(bmmisa7ons. abs. no. 783 Regulatk_t, of Health Facilities and Services no. 78 _ RegJator; A?n #oament Repeated .tio_pitalization
for Physician tot the Same
by "CertiBcate
of Need. ". abs.
Compensation abs. no. 789 Disease. A Multiplier of National
,_leeting
of Alternative
I, Long- Term Care. abs.
the Explosive
Long- Term Care Settings.
Demand
in D;fferentiating abs. no. 817
Nursing
for Medical
Home
Care. abs.
Residents,
Ser-
on coverage
Benefit Rights and Privacy. abs. no. 48
7he Insurance
System
Cancer Insurance. Exploiting Fear for ProlTt. An Disease Insurance. abs. nc,. 64 Considerations in the Design of Mental Health Insurance. abs. no. 116
Health
and Fertility Examination
Benefits
of Dread
Under
Controlling the Cost of Dental Care. abs. no. 140 Controlling the Costs of Retire, ment Income and Medical no. 142
Control.
National
Care Plans. abs.
Health Costs. abs. no. 7q8 Sat tngs to CHAAtPUS From Requ_?ement to Use Uniformed Sere'cos Hospitals, abs. no. 822 Short Run Hospital Responses to Reimbursement Rate Changes, abs. no.
Costs, Financing, and Distributional Effects of a Catastrophic Supplement to Medicare. abs. no. 170 Delnstitutionalization and _Iental Health Services. abs. no. 181 Dental and Vision Care Benefits in Health Insurance Plans. abs. no. 189
831 Social Me, licinc. The Advance of Organized Health Services in AmeriCa. abs. m. 834 Some l_sucs in Limiting Itos;ital Cost Reimbursement. A Maryland Expe_ic_c:', abs. no. 845 State Hospital Cc.st Containment Programs. abs. no. 854 Stratc_ze_ ro_ C)_ni:olh)_g ti_e Cost of State Medical Assistance Programs, a_s _a. 86 _ St_botlttt(IOrl of Oatpanent Care lot Inpatient Care. Problems and k:_pe_ic_,:cc. _hs. no. 874 Su,,_,_a 0 _i Rate Rc,_ew in _Vlaryla,nd. abs. no. 876 3),_tem of Ho.sp_tal Uniform Reporu'ng (SHUR). abs. no. 884 Tech;¢olo_ v in Hospttals. _Icd}cal Advances and Their Diffusion. abs. no. 893
Health, United States, 1980. _bs. no. 428 How Cheap is a Life. abs. no. 467 Impact of the 1974 Health C_"e Amendments to the NLRA on Collective Bargaining in the Health Care Industry. abs. no. 490 Medicare Coverage for the Treatment of Alcoholism. abs. no. 575 ._Iedigap. States Response to Problems with Health Insurance for the Elderly. abs. no. 583 Minimal Care Units. Mechanisms for Hospital Cost Contat)_ment. abs. no. 591 On Having Your Cake and Eating It Too. Econometric Problems in Estimating the Demand for Nealth Services. abs. no. 659 Paying lot Pmlnary Care. Time for a Change. abs. no. 672 PHvate Health Insurance BeneOts for Alcoholism, Drug Abuse and Mental Illness. abs. no. 728
7 an Veals of Short-Stay Hospital U_}ization and Costs Under Medicare (1067-1976) abs. no. 895 Textbook 2br Ernplqvee Benefit Plan Trustees, Administrators and Advi-
Report of the HEW Task Force on Implementation of the Report to the President From the President's Commission on Mental Health. abs. no. 799
st,r,_, abs. no 897 7"rcnd._ i_ _raeitit)' L'sc An EvaluatLon
Savtngs to CHA MPUS From Requirement pitals, abs. no. 822
of the Impact
of Adverse
C _>odittbns on ;he Status of the Poor. abs. no. 909 ]'l¢t_d_ 1)1 _lult_hospital S2stems. A Multiyear Comparison. Urba,'_ b_ca!
VII-24
CSt_:s L_, ,'he L_ited
States,
National
Health
Economic
Trends in State Admlnistratio._
to Use Uniformed
of MediCaid
Programs.
Services
Hos-
abs. no. 912
abs. no. 911 Insurance,
and
Long term care facilities
Health
Care
Programs
Altering MedJcaid Provider Reimbursement Methods. abs. no. 17 Alternatives to Nursing Homes. abs. no. 21 Care of the Aged. Old Problems in Need of New Solutions. abe. no. 66 Catastrophic Health Insurance. abs. no. 72 Controlling the Use and Cost of MediCal Services. The New Mexico Experimental Medical Care Review Organization. A Four-Year Case Study. abe. no. 143 Cost Effective Acute Care Facilities Planning in Michigan. abs. no. 157 Cost of Catastrophic Illness. abs. no. 159 Cost-Benefit Analysis Mandatory Medicare Participation. abe. no. 164 Deciphering Deinstitutionaiization. Complexities in Policy and Program
of a Recent Proposal. abs. no. 778 Comprehensive and Catastrophic Health Insurance Programs. An Overview. abs. no. 8041 State Health Legislation Report Vol. 8 No. 3. State Comprehensive and Catastrophic Health Insurance Legislation. abs. no. 853 State of Hawaii Prepaid Health Care Act (Chapter 393, FIRS) and Related Rules and Regulations. abs. no. 855 State
Working
With the Insurer.
Medicaid Aclu'evements
and Problems
abs. no. 948
of Medicaid.
abe. no. 4
Analysis. abs. no. 180 Deh'very Prospers in Diversity. abe. no. 184 Entering a Nursing Home. Costly Implications for Medicaid and the Elderly. abs. no. 267 Evaluation of the National Long-Term Care Channeling Demonstration. abs. no. 8014 Expanding Health Benefits for the Elderly. Volume I. Long-Term Care. abe. no. 289
Altering Mech'caid Provider Reimbursement Methods. abs. no. 17 Aspects of Medicare in Colorado. abe. no. 8002 BenetTt Recovery in Medicaid. An Examination of the Development and Implementation of a Benefit Recovery System in the State of Minnesota, abe. no. 47 Changing Medicaid Population. abs. no. 78 Changing Patterns and Implications for Cost and Quality of Dental Care. abs. no. 79
Feasibility and Cost-Effectiveness abe. no. 302
Children and Dental Care. Charges Characteristics. abe. no. 85
of Alternative
Long-Term
Care Settings.
Forecasting Federal Long-Term Care Expenditures. abe. no. 8016 Health Care in the 1980s. Who Provides. Who Plans. Who Pays. abe. no. 37l Health, United States, 1980. abe. no. 428 Home Health. The Need Elderly. abs. no. 438
for a Nau'onal
Policy
to Better
Provide
for the
and Probability
era
Visit by individual
Comparative Experiences in Controlling Expenditures for Prescription Drugs in State Medicaid Programs. abe. no. 92 Comparing the Medical Utilization and Expenda'tures of Low Income Health Plan Enrollees With Medicaid Recipients and With Low Income gnroll_ Hating Medicaid Eligibility. abe. no. 95 'Contrasts in HMO and Fec-for-Serffc_ Performance. abe. no. 132
Hospice. Prescription for Terminal Care. abe. no. 442 Hospital Backlog. Patients With No Place To Go. abe. no. 443 Impact of Long- Term Care on Functionally Disabled Adults. abe. no. 8022 Impact of National Health Insurance on New York. abe. no. 482
Controlling MedicaM Utilization Patterns. abe. no. 138 Controlling the Use and Cost ofMedical Services. The New Mexico Experimental Medical Care Review Organization. A Four- Year Cz_e Study. abe. no. 143
Issues Involved in the Development of a Prepaid Capitation Plan for LongTerm Care Services. abs. no. 522 Medicare and Meda'caid Amendments of 1980. abe. no. 572 Nationwide Study of DomicllYm'y C_re. abe. no. 8029 Needs of the Elderly. abs. no. 639
Copayments and Demand for Medieal Care. The California Medicaid Experience, abe. no. 144 Cost-Benefit Analysis Mandatory Medicare Particil_tion. abe. no. 164 Cost-Effectiveness of a Restrictive Drug Formulary, Louisiana vs. Texas. abe. no. 166
New York State Long Term Health Care Program. abe. no. 647 Nursing Home Cost Studies and Reimbursement Issues. abe. no. 652 Nursing Home Utilization Patterns. Implications for Policy. abe. no. 653 Paths to Alternative Service Modalities and Differential Impact of Thren Modalities on Familiar Groups of Vulnerable Elderly. abe. no. 8032 Patient Outcomes in Three Alternative Long-Term Care Settings. abs. no. 669 Provision of Long- Term Care Services by Community Hospitals in Virginia. abs. no. 758 Reform and Regulation in Long-Term Care. abe. no. 779 Responsibility of Families for Their Severely Disabled Elders. abe. no. 805 Role of Payment Source in Differentiating Nursing Home Residents, Services, and Payments. abs. no. 817 Thirty- To-One Paradox. Health Needs of the Aged and Medical Solutions. abs. no. 903 Too Old, Too Sick, Too Bad. Nursing Homes in America. abs. no. 905 US. Hospice Movement, Issues in Development. abs. no. 918
Current and Future Development of Intermediate Care Facilities for the Mentally Retarded. A Survey of State Officiais. abe. no. 174 Dental Care for Handicapped People. Special ReporL abs. no. 193 Department of Health, Education, and Welfare, Office of the Inspector General. Annual Report, January 1, 1979 to December 31, 1979. abs. no. 197 Design of Failure. Health Policy and the Structure of Federalism. abs. no. 200 Discounting and Differential Pricing Practices in the Health Care Field. abs. no. 216 Drug Prescription Rates Before and At_er Enrollment of a Medicaid Popuiaties in an HMO. abe. no. 226 Effect of a Mandatory Second Opim'on Program on Medicaid Surgery Rates. An Analysis of the Massachusetts Consultation Program for Elective Surgery. abs. no. 240 Effect of SSI on MecUcaid Caseloads and ExpendJ'tures. abs. no. 245 Effects of Medieare and Medicaid on Access to and Quality of Health Care. abe. no. 253
Mandated benefits Alcohol and Health.
Employmen_ seriptive
abs. no. 12
Unemploymen_ and Health Insurance. Behavioral and DeAnalysis of Health Insurance Loss Due to Unemployment. abe.
Chip Commission. Final Report. abe. no. 86 Health Insurance Coverage for Alcoholism, 1975. abe. no. 392 Impact of the Rhode Island Catastrophic Health Insurance Plan. abe. no. 489
no. 265 Entering a Nursing Home. Costly Implications for Mech'caM and the Elderly. abe. no. 267 Estimated Cost of Implementing the Regulations Limiting Payment Under
Law and Legislative Summaries. States 1979. abe. no. 528 Modifying Medicaid Eligibility and Benefits. abe. no. 595 Private Health Insurance Benefits for Alcoholism, Drug Abuse Illness. abs. no. 728
Federal Health Programs to Maximum Allowable Costs (MAC'S) and Estimated Acquisition Costs (EAC'S). abs. no. 274 Evaluation of the Maximum Allowable Cost (MAC) for Drugs Program. Phase I Report. Final Design Report and Report of l_'lot Study Analysis.
Reducing
Medicaid
Expenditures
Through
Family
Responsibility.
and Mental C_tique
abe. no. 287
VII-25
_-.j,J: = _:,' #J_::_!:,5 .LJ:'e _ .>_'eYagc ,q[te_zativ¢s. abs no. 8015 E,_p_ts_t_Jg ]-i_alih _e_:c_fft__.'or c¢_e_Tdcrly. Volume L Long- Term _re. no. 289 E_.penaitures 29 l Expenaiturea'
fro Health
Care. Federal
Programs
for Health
Care of Children
abs.
States.
Responsibffity of Familws f_r Their Severely Disabled Eldels. abs. no. 805 Restructttring Federal Medicaid Controls and Incentives. abs. no. 807 Rethinking Health Policy for the Elderly. A Six-Point Program. abs. no. 809
abs. r,_. 292 FL-_anc,'_l Status ot Social Security Program After the Soc'i_t Secttrity A:aendmcnts of 197; abs no. 314 F_,_mda _ozJs tb; l_l_dicaJ 'L'ac¢. An Empirical Investigation of the De, very of kfealth Ser_TL-es to a MedJcMd Population. abs. no. 322 G_ographic Variation in Physiciyms" Fees'. Payments to Physicians Under Medicare and Medicaid. abs. no. 335 Guide t_ ,h4edscaia Data Sourees, Volume One. abs. no. 345
Selected Bibliographic Research Guide to the MediCaid Program. abs. no. 826 Short-Run Hospital Re_por,,ses to Reimbursement Rate Changes. abs. no. 831 Some Aspects of Ambulatory Care Under Medicaid in New York City. abs. no. 842 Some State and Federal Pe,_spectives on Medicaid. abs. no. 846 State Guide to Mechcaid C_st Containment. abs. no. 8042
Hc-alth Health the Health
State Policies and Federal Programs. Pt4ot_ties and Constraints. abs. no. 856 Status of Children, Youth and Families, 1979. abs. no. 858 Study of Physician Reimbur:;ement Under Medicare and Medicaid. Volume IL abs_ no. 867
and
and Their EffecL_. abs. no.
Report of the HEW Task ,_orce on Implementation of the Report to the Pres12tent From the Pre:4dent's Commission on _4entai Health. abs. no. 799
Youth in the United
_nd the _r _m Poverty. A Ten- Year Appraisal. abs. no. 354 Care Cost Couta_)Tment E__peziments. Policy, Ino_'vidual Rights, and Law. abs. no. 358 ,T_re Finan_-mg OpNons tot Colorado. abs. no. 368
Health Cos_ Can Be Reduced by Millions of Dollars if Federal Agencies F_l!y Carry Out GA 0 Recommenda_ons. abs. no. 384 Health ,nsurance ,"o ;he Medtcare Years. ahs. no. 394 H_:_lth ,osurance. Public Progra_ns, 1978-June, 1980 (A Bibliography With Abs'ractsk abs, no. 398
Too Old, Too Sick, Too Bad. Nursing Homes in America. abs. no. 905 Trends in State Administration of Medicaid Programs. abs. no. 912 Van'ations _n State Medicaid Programs. abs. no. 926 Wasted Health Dollars. abs no. 932 When a Solution Is Not a Solution. Medicaid and Health Maintenance
Incen t: _ e T_ lot ,_lcd_c_-c, ._ledJcaid and National Health Insurance. no. 496 ln_Tagl_,_:. Uncmplo)ment and the ]_tedicaid Program. abs. no. 504
Organizations, abs. no. 936 Working Papers on Major Budget Programs. abs. no. 947
.hfan_g_).g ,_4cdicaid Drag Expenditures. aches, abs. no. 541 _trdicai.t and Cash Welfare Recipients. _4ed_k-aLZ Current issues and Potential
An Analysts
Par;ic_pnt_on
and Medical
Care.
and Program
Issues
in Selected
Health
Appro-
An EmpitTbai Study. abs. no. 546 Reforms. abs. no. 547
_t4cdicai.1 Experience. abs. no. 548 _IedicaLt, _tedicare, and P:_'vate Health Insurance lo_ .Income Area_, abs. no. 549 _lcd_caLt .&l_lls. Fact or F_cttbn. abs. no. 550 _lcdi_-a_!
of Divergent
abs.
Coverage in Five Urban,
abs. no. 551
Medical technology impacts American Biomedical Netwark. and Future. abs. no. 26
Health
Care Systems
in America
Present
Changes in the Costs of Treatment of Selected Illnesses. 1951-1964-1971, abs. no. 76 Cost and Regulation of Medical Technology. Future Poh'cy Directions. abs. no. 146 Costs, Risks,
and Banel_ts
ae Surgery.
abs. no. 171
_lcdi_'ahy Indigent. A State Perspective on a National Problem. abs, no. 570 __ledicar,: and _{[edicaid Ameodmants of 1980. abs. no. 572 Medicare a,_d ._led_eaid Physician Payment Incentives. abs. no. 573 ,_ledt_'ar, _ As_g_,,mcnt Rates of Physicians. Their Responses to Changes .in R ci_z'bursement Policy. abs. no. 574 _lcntal Health Services for Med_aid Enrollees in a Prepm'd Group Practice
Economic Analysis of Alter_ative Health Care Innovations. abs. no. 228 Effects of Hospital Cost C_mtainment on the Development and Use of Meda'cai Technology. ab_i. no. 251 Erosion of the Medical Marketplace. abs. no. 272 Evaluation of the CA TScanner and Other Diagnostic Technologies. abs. no. 285
Pla;_. abs. no. 585 A4ctropoTtan Comp_-ehcns_ve Care Program. A Health Systems Organizati_m Otto.narration. abs. no. 590 hi,de ol Paytnent and Le,Tgth of Stay in the Hospital. More Work h_r PSR Os. abs. no. 592 _Iodit)_.g _led_-am" El_gibffit¢ and BeatErs. abs. no. 595 Multiple Healrh Insurance Coverage. The Overlap of Dread Disease and E.*z_ c_sh Pobk'Mu _)th Other Types of Coverage. abs. no. 597 Nu)_x)_g _tome L _7_ation Patterns. ImpltZ'ations for Policy. abs. no. 653 Part_k:_pa._n of Przvat¢ Practice Dentists in _Iedicaid abs. no. 668 Puking t_ r P_fs_'_an Services Under Medicare and Medicaid. abs. no. 671
Health Care Dilemma. Prob!ems of Technology in Health Care Delivery. abs. no. 367 Health Care in the Americn_ Economy. Number 3. abs. no. 370 Health Care Policy in a Changing Environment. abs. no. 376 Health Economics and Health Care. Irreconcilable Gap. abs. no. 385 Health in the Future. In the Pink or in the Red. abs. no. 387 Health. What Is It Worth. Measures of Health BaneEts. abs. no. 429 Hospital Cost Containment. Selected Notes for Future Policy. abs. no. 449 Illness Prevemion and Medical Insurance, abs. no. 474 Impact of Rate Regulation or_ the Diffusion of Now Technologies in Hosp_ tais. abs. no. 485
Percept_vns of :_led_al Care, The Impact of Prepayment. Phy._'_c_n Acc_ptancv uf_,_4edicaid Patients. abs. no. 682
Improving Health in America, 1977-80. abs. no. 495
abs. no. 677
U.S. Public
Ph) svk'_n Part_cipat_bn _'n State A4edicaM Programs. abs. no. 690 Prepaid t(ealth Plans and Health ._/laintenance Org_tffzations. abs. no. 717 Private P_yst_ians and Public Programs. abs. no. 732 Proiessional Standards Review Organ_zadon 1979 Program Evaluation. abs. _o. 738
Laws of Motion in the For.Prol_t Examples. abs. no. 529 Medical Technology. A Different Costs. abs. no. 565 MedleM Technology and Hospital
Prol)!c 9: Health,care clove'rage, Reducing Medicaid Eapenditures
Medical Medical
l'he Haves and Have-Nots. abs. no. 740 Through Family Responsibility. CHtique
_f a _!ecent Proposal. abs. no 778 Red_'t_o_ts _)_ Public Health Care Coverage. abs. no. 8036 Ref_rm a,_d Regulat_bn in Long-term Care. abs. no. 779 Regulat_ V Environment for Physician Compensation, abs. no. 789
VII-20
Technology. Technology.
Health
Health Industry.
Service A
Theory
View of the Contentious Costs.
H_ghlights
of
and
Three
Debate
Over
abs. no. 566
Poh_ie.,_ and Problems. abs. no. 567 The CMprit Behind Health Care Costs.
abs. no. 568
Medical Technology. Who's To Say When We've Had Enough. abs. no. 569 Medicare, Medical Practice, and the Mea_'cal Profession. abs. no. 578 National Commission on the Cost of Medical Care. 1976-197Z Volume 1. Comrmssion Recommendations Task Force Reports Research Agenda.
Health Care Programs
abs. no. 599
Care. A Review
National Commission on the Cost of Medical Collected Papers. abs. no. 600 National Commission on the Cost of Medical
Care. 1976-197Z
Volume 2.
Care. 1976-197Z
Volume
3.
of the Literature.
abs. no. 509
Life Cycle Preventive Services Study. abs. no. 8023 Magnitude and Determinants of Phystcian Initiated States. abs. no. 534
Visits in the United
Literature Reviews Data Bases. abs. no. 601 Politics of Health Care. abs. no. 707 Rapid Rise of Hospital Costs. abs. no. 771
Measurement of Expenditures for Outpatient Physician and Dental vices. Methodological Findings from the Health Insurance Study. no. 544
Social Structure and the Diffusion of Medical States, Great Britain, Sweden and France.
Medicare Assignment Rates of Physicians. Reimbursement Policy. abs. no. 574
Innovations in the United abs. no. 838 in the Medi-
Medicare York.
Substitution of Outpatient ence. abs. no. 874
and Experi-
Methodology Used to Measure Health Care Consumption During Year of the Health Insurance Experiment. abs. no. 588
Technology Technology
Care. Problems
and the Quality of Health Care. abs. no. 892 in Hospitals. MedJ'cal Advances and Their Diffusion.
abs. no.
893
National Ambulatory January-December
Opinion
Demonstration
MedicM Care Survey. 197Z abs. no. 598
Project.
to Changes
Structure of Health Insurance and the Erosion of Competition cal Marketplace. abs. no. 864 Care for Inpatient
Second Surgical abs. no. 581
Their Responses
1977 Summary.
Setabs.
Greater
m
New
the First
United States,
National HMO Census Survey, 197Z Summary. abs. no. 634 Paying for Physician Services Under Medicare and Medicaid. abs. no. 671
Medical/surgical services Access to Ambulatory Care and the U.S. Economy. abs. no. 1 Age and Medical Care Utilization Patterns. abs. no. 11 Alternative Physician Payment Methods. Incentives, Efficiency, and National Health Insurance. abs. no. 19 Analysis of Economic Performance in Medical Group Practices. abs. no. 33 BenelTt Rights and Privacy. The Insurance System and Fer_Tity Control. abs. no. 48
Pediatn'c Care. Charges, Payments and the Medical Setting. abs. no. 674 Per-Case Reimbursement for Medical Care. Final Report. abs. no. 675 Physician Responsibility for the Cost of Unnecessary Medical Services. abs. no. 692 Physicians" Charges Under Medicare, Assignment Rates and Benel%'lary Liability. abs. no. 695 Price Setting in the Market for Physicians'Services. A Review of the Literature. abs. no. 722
Can Pn)nary Care Deh'ver. abs. no. 60 Changes in the Costs of Treatment of Selected Illnesses. 1951-1964-1971. abs. no. 76 Charges and Sources of Payment for Visits to Physician Offices. Data Prewew 5. abs. no. 82 Coinsurancc and the Demand for Physician Services. Four Years Later. abs. no. 89 Comparing the Medical Utilization and Expenditures of Low Income
Program for Elective Surgical Second Opimbn. Surgical Experience of Pro#ram Participants, 1976o197Z abs. no. 742 Rates of Surgical Care in Prepaid Group Practices and the Independent Setting. What Are the Reasons for the Differences. abs. no. 773 Reimbursement for Physicians" Services. abs. no. 793 Relationslu'p Between Utih'zation of Mental Health and Somatic Health Services Among Low Income Enrollees in Two Provider Plans. abs. no. 797
Health Plan Enrollees With MedicMd Recipients and With Low Income Enrollees Having MedJ'cald Etigibility. abs. no. 95 Comparison of Group Medical Care Insurance Benefits to Charges. abs. no. 96 Comparison of the Quality of Maternity Care Between a Health-MMntehence Organization and Fee-For-Service Practices. abs. no. 99 Controlling MedicaJ'd Utilization Patterns. abs. no. 138
Responses of Canadian Physicians to the Introduction of Universal _¢edical Care Insurance. The First Five Years in Quebec. abs. no. 804 Role of Fee Schedules in Physician Reimbursement. abs. no. 8038 Role of liSA "sin Development of Ambulatory Care Services. abs. no. 8039 Second Surgical Opim'ons. What Have We Learned. abs. no. 823 Some Aspects of Ambulatory Care Under Medicaid in New York City. abs. no. 842
Copayments and Demand for Medical Care. The California MedJcald Expcncnce, abs. no. 144 Cost Containment by a Third Party Payer. Negotiations of Surgical Fees.
Some Effects of Quebec Health Insurance. abs. no. 844 Study of Physicians' Fees. abs. no. 868 Study of the Responses of Canadian Physicians to the Introduction
abs. no. 149 Costs, Risks, and Benefits of Surgery. abs. no. 171 Demand for General Practitioner and Internist Serffces. Determinants of Pediatric Care Utilization. abs. no. 201
versM MedicM Care Insurance. The First Five Years in Quebec. _Lbs.no. 872 Surgical Innovation and Its Evaluation. abs. no. 879 Third Party Reimbursement Aspects of Physician Compensation. abs. no.
abs. no. 186
Effect of a Mandatory Second Opinion Program on Medicaid Surgery Rates. An Analysis of the Massachusetts Consultation Program for Elective Surgery. abs. no. 240 Effect of O:ganization of Medical Care Upon Health Manpower Distributton. abs. no. 242 Effectiveness of Alternative Approaches to Utilization Review of PhysicJans Office Practices. abs. no. 8011 Factors At_cting Differences Services. abs. no. 296 Fundamentals 328
of Second
in Me,'care
Opinion
Reimbursements
901 Toward a Physician Payment Policy. Evidence From the Economic Stabilization Program. abs. no. 908 Use of Hospital Services Under Two Prepaid Plans. abs. no. 920 Use of Physician Services Under Two Prepaid Plans. abs. no. 922 Who Pays for Pech'atric Care. Out of Pocket and Third-Party Party Paymeats for Physician Visits. abs. no. 940
for Physicians' Medicare
Programs
for Elective
Surgery.
abs. no.
Admim'strative Commercial
Costs of Medicare Contractors. Intermediaries. abs. no. 10
How Business Can Use Specific Techniques to Control Health Cadre Costs. abs. no. 465 hnpact of Comprehensive National Health Insurance on Demand for
Ambulatory Pharmaceutical Services for Medicare ject. abs. no. 24 Aspects of Meals'acre in Colorado. abs. no. 8002
Health ,_lanpower. abs. no. 477 hnpact of Family Structure on Children "sHealth Care Use. abs. no. 478 Impact of National Health Insurance on New York. abs. no. 482
Cost-Benefit Analysis Mandatory Medicare Costs, Financing, and Distributional Effects to Medicare. abs. no. 170
Insurance
Discounting
Benefits,
Out-of-Pocket
of Uni-
Payments,
and the Demand
for Meda'cM
and Differential
Pn'cing Practices
Blue
Cross Plans
Recipients.
Versus
A Pilot Pro-
Participation. abs. no. 164 of a Catastrophic Supplement in the Health Care Field. abs.
VII-27
no Effects
216
no. 738
of ,_tedicare and MedicaM
on Access
ro and Quality of Health
Care.
Pubh'e Regulation
of Health
Care Providers.
abs. no. 765
abs no. 253 Equal "treatment and Unequal Benefits. A Re-examination of ,'he Use of Medicare Services by Race, 1967-1976. abs. no. 270 Estimaled Cost of Implementing the Regulations Limiting Payment Under Federal Health Programs to Maximum Allowable Costs (MAC'S) and
Regulatory Environment for Physician Compensation. abs. no. 789 Reimbursement for DurabJe Medical Equipment. abs. no. 79 [ Report of the HEW Task Force on Implementation of the Report to the President From the President's Commission on Mental Health. abs. no. 799
Estimated Acquisition Costs (EAC'S). Expanding Health Benelqts for the Elderly. abs. no. 290
Rethinking Health Policy for the Elderly. A Six-Point Program. abs. no. 809 Risk Differential Between Medicare BenelTciaries Enrolled and Not Enrolled in an HMO_ abs. no. 815
Expenditures 291
for Health
Care. Federal
abs. no. 274 Pblume IL Prescription
Programs
Drugs.
and Their Effects.
abs. no.
Social _lfare no. 840
Expenditures
Under Public Programs,
Fiscal
Year 1977. abs.
Fact Book on Aging. A ProtTle of America "s Older Population. abs. no. 295 Factors Affecting Differences in Medicare Reimbursements for Physicians' Scr ¢ices. abs. no. 296 Geographz_" Variatlbn in Physicznns' Fees. Payments to Physz_ians Under _Iedicare and Medicaid. abs. no. 335 ,
Study of Physician Reimbua"sement Under Medicare and Medicaid. I abs. no. 866 Study of Physician Reimbua_ement Under Medicare and Medicaid. IL abs. no. 867 S)_tenl of Hospital UmYorm Reporting (SHUR). abs. no. 884
Health and the War on Poverty_ A Ten- Year Appraisal. abs. no 354 Health Care Cost Containment Experiments. Policy, Individual Rights, and the Law. abs. no. 358
Ten Years of Medicare. Impact on the Covered Population. abs. no. 894 Ten Years of Short-Stay Hospital UOlization and Costs Under Medicare (1967-1976). abs. no. _95
Health Costs Cast Be Reduced by Millions of Dollars if Federal Fulty Carry Out GAO Recommendations. abs. no. 384
Third Party Reimbursement 901
Health Insurance in the Medicare Health Insurance. Public Programs. Abstracts). abs. no. 398
Agencies
Years. abs. no. 394 1978-June, 1980 (A BibIiogrnphy
With
Home Health Care Services. Tighter Fiscal Controls Needed. abs. no. 437 Home Health. The Need for n National Policy to Better Provide for the Elderly. abs. no. 438 Impact of a Change abs no. 475
in Regulations
Implementing the End-Stage 492 lncenti,_e Tax for Medic'a_e,
Renal
on Costs in an Experimenta! Disease
Program
MedA-ald and Na_onal
Program.
of Medicare. Health
abs. no.
Insurance.
abs.
Aspects
of Physician
Working Papers on Major Budget Programs. abs. no. 947 Meatal health services Alcohol and Health. Alcoholism Program ized Information abs. no. 13
and Program
Considerations in the Des, gn of Mental Health Insurance. abs. no. 116
Persons Enrolled in the Health Insurance 34edicare. Health Insurance for the Aged and Rci_nbursement by State and County. abs. _ledicarc, _4edical Practice, and the ,_ledical Medicare Reimbursement. abs. no. 579
Program. abs. no 576 Disabled, 1977. Section no. 577 Profession. abs. no. 578
in
2. 1.
Issues
in Selected
Health
Management Through the Operation of a ComputerSystem. L ActuaJqal Data on UuTizaNon of Services.
Medicare Medicare
_Iedicare Assignment Rates of Physicians. Their Responses to Changes Reiqlbursement Polic_; abs. no. 574 Medicare Coverage for the Treatment of Alcoholism. abs. no. 575 ,41edicare. Health Insurance for the Aged and Disabled, 1975. Section
abs. no.
abs. no. 12
Alcoholism Alcoholism Community Comparison 96
Amendments of 1980. abs. no. 572 Physiczan Payment Incentives. abs. no. 573
Volume
Too Old, Too Sick, Too Bad. Nursing Homes in America. abs. no. 905 Use of Medicare Benefits Under HIP's 3-Year Incentive Reimbursement Experl)'nent. abs. no. 921
no. 496 Medicaid, Medicare, and Private Health Insurance Coverage in Five Urban, Low-Income Areas. abs. no. 549 Medicare After 15 Years. Has It Become a Broken Promise to the Elderly. abs. no. 571 and Medicaid and ._4edicald
Compensation.
Volume
Services Hand,_ook for Prepaid Group Plans. abs. no. 14 Within Prepaid Group Practice HMOs. abs. no. 15 Mental HealS, Centers. The Federal Investment. abs. no. 90 of Group Meal(cat Care Insurance Benefits to Charges. abs. no. Health
BenelTts
Under
National
Cost Containment and Q_ah'ty Assurance Requirements for Third Party Coverage for Ambulatory Psychiatric Care. abs. no. 148 Cost of BenetTts for Alcoholism in a National Health Insurance Program. abs. no. 158 Cost-Financed Mental He_,lth Facility. abs. no. 168 Current and Future Development of Intermediate Care Facilities for the Mentally Retarded. A 9urvey of State Oftieials. abs. no. 174 Current Issues in National Insurance for Mental Health Services. abs. no. 177
Medicare Reimbursement Controversies and Appeals. abs. no. 580 Medicare Second Surgical Opinion Demonstration Project. Gr,_,ater New YoJk. abs. no. 581 Medicare. The Politics of Federal Hospital Insurance. abs. no. 582 _4edlgap. States Response to Problems with Health Insurance for the Elder. ly. abs. no. 583
Day
Multzple Health Insurance Coverage. The Overlap of Dread E,_tta Cash Policies With Other Types of Coverage. abs. Paying (or Physician Services Under ,_tedicare and ._Iedicald. Physicians' Charges Under Medicare. Assignment Rates and
Health Insurance Bibliograohy. abs. no. 390 Health Insurance Coverage for Alcohol_Drug Addiction Treatment for Virginia State Employees. A Feasibility Evaluation. abs. no. 391 Health Insurance Coverage, for Alcoholism, 1975. abs. no. 392
Disease and no. 597 abs. no. 671 Beneticiary
Hospitah'zation as a Cost-Effective Alternative to Inpatient Care. A Pilot Study. abs. no. 179 Deciphering DeinstituNomdization. Complexities in Policy and Program Analysis. abs. no. 180 Deinstitutionalization and Mental Health Services. abs. no. 181 Economics and the Chrome _Iental Patient. abs. no. 234
Liaoihty. abs. no. 695 Preh?ninary Results from a Risk-Sharing Health __talntenanee Orgamzatint,, abs. no. 715 P_ivate tlealth Insurance to Supplement Medicare. Volume Labs. no. 730 Private Physicians and Public Programs. abs. no. 732
Health Promotion Progra_,s in Occupational Settings. abs. no. 417 Historical Development of the California Pilot Program to Provide Health Insurance Coverage for Alcoholism. abs. no. 432 Impact of Alcohol, Drug Abuse and Mental Health Treatment on Medical Care Utilization. A Review of the Research Literature. abs. no. 476
Prote_s_bnal
Impact
VII-28
Standards
Review
Organization
1979 Program
Evaluation.
abs.
of Proposition
13 o_ Mental
Health
Services
Health
in California.
Care
abs. no.
Programs
484 Improving Health in America. U.S. Public Health Service Highlights of 1977-80. abs. no. 495 Insurance Cost Savings Due to an Adequate Alcoholism Health Benet_t. abs.
Control of Hospital Costs by Rate-Setting Controlling Hospital Costs. The Revealing Controlling Hospital Costs. The Revealing no. 137
no. 510 Insunng Intensive Psychotherapy. abs. no. 513 Law and Legislative Summatfes. Federal 1979. First Session, Congress. abs. no. 527
Corporate Role in Containing Health Care Costs. abs. no. 145 Cost Containment by a Third Party Payer. Negotiations of Surgical abs. no. 149 Cost Containment Mechanisms. abs. no. 152
Law and Le_o'sIative Summ_vqe&
States
Ninety-Sixth
1979. abs. no. 528
Cost Containment.
Medical
System
abs. no. 133 Case of Indiana. abs. no. 136 Case of Indiana. Surnmark: abs.
Rehabilitation
or Reform.
Fees.
abs. _o. t53
Mech'care Coverage for the Treatment of Alcoholism, abs. no. 575 Mental Disorder and Primary MedicM Care. An Analytical Review of the Literature. abs. no. 584 Mental Health Services for Medicaid Enrollees in a Pretmid Group Practice
Cost Containment Through Risk-Sharing by Primary Care Physicians. A History of the Development of United Healthcare. abs. no. 155 Diagnosis Related Group (DR G) Management Information System 5_udies. abs, no. 8009
Plan. abs. no. 585 Mental Health Services_
Discounting and Differential no. 216
Utilization
by Low Income
Enrollees
in a Prepaid
Pricing
Effects of the Payment abs, no. 254
National Health Insurance and the Market abs. no. 613 National Health Insurance, Psychotherapy,
Estimated Cost of Implementing the Regulations Limiting Payment Under Federal Health Programs to Maximum Allowable Costs (MAC'S) and Eat'mated Acquisition Costs (EAC'S). abs. no. 274
Services.
and the Poor. abs. no. 627
Policy Issues in Financing Mental Health Sen'vices. abs, no. 702 Private Health Insurance Benetlts for Alcoholism, Drug Abuse and Mental Illness. abs. no. 728
Evaluation of Alternative Payment Approach. ribs. no. 280 Evalustion of Market Mechanisms
Public" Health and the Law. Issues and Trends. abs, no, 762 Relationship Between Utilization of Mental Health and Somatic
Factors Affecu'ng Differences Services. abs, no. 296
Services
Among
797 Report of the HEW
Low Income Task Force
Enrollees
in Two Provider
on Implementation
Health
Plans. abs. no.
of the Report
to the
President From the President's Commission on Mental Health. abs. no. 799 Report to the President From the President's Commission on Mental Health. Volume L abs. no. 801 Study to Determine the Relationship of Community HeMth Centers, Cornmunity
Mental
Health
Provision of Mental abs. no. 873
Centers,
and Drug
Health Services
Treatment
to CHC Registrants.
Centers
Fee-For.Service
Summary of Impact of Alcoholism Treatment on Medical Care Utilization and Cost, 1979. abs. no. 875 Survey of Mental Health Service Coverage Within Health Maintenance Organizations. abs. no. 881 Utilization and Cost of Mental Illness Coverage in the Federal Employees Health Benefits Program, 1973. abs. no. 924 Methods of payment determination Adding a Dose of Competition to the Health Care Industry. abs. no. 7 Altering Medicaid Provider Reimbursement Methods. ahs. no. 17 Alternative Physician Payment Methods. Incentives, Eaiciency, and National Health Insurance. abs. no, 19 Analysis of Case Mix Complexity Using Information Theory and Diagnostic Related Grouping. abs. no. 32 Analysis of Prospective Payment Systems in Upstate New York, abs. no, 35 Analysis of the Effects of Prospective Reimbursement Programs on Hospital Expenditures. abs. no. 37 Ancillary Services Review and PSROs. What Can the Demonstration Programs Tell Us. abs. no. 40 Aspects of Medtcare in Colorado. abs. no. 8002 Capital Requirements and Capital Financing in a Hospital-Based Group Practice Prepayment Plan. abs. no. 65 Capitation for Pharmacy Services. abs. no. 8004 Case for a National Health Service. abs. no. 68 Case for Negotiated Rates. abs. no. 69 Compensation Arrangements Between Hospitals and Physicians. abs. no. 101 Considerations in the Design of Mental Health Benetlts Under National Health Insurance. abs. no. 116
Strategies
Maintenance
Care Delivery
for Hospitals.
of Cost Control.
in Medicare
Fee-for-Service Physician Payment. Development. abs. no. 308
Organizations.
A Conceptual
abs. no. 283
Reimbursements
Analysis
System,
for Physicians'
abs. no. 307
of Current Methods
and Their
Financial Management Under Third Party Reimbursement. abs. no. 312 Foreign HaspitMs Reimbursement Systems. abs. no. 8017 Fundin 8 Rural Nurse Practitioner Care. abs. no. 329 Health Care Costs. Pn'vate Initiatives for Containment. abs. no. 364 Health Care Guidance. Commercial Health Insurance and National Health
for the
Final Report.
Health
on the HeMth
Care Field. abs.
Group Practice Plan and in an Indel_endent Practice Plan. abs. no. 586 Mental Wellness Programs for Employees. abs. no. 587 for Pn'vate Psychiatric
Mechanism
Practices in the Health
Pokey. Health Health
abs. no. 369
Care in the American Economy. Planning and Regulation Effects
Number 3, abs. no. 370 on Hospital Costs. abs. no. 414
History and Organization of Pretreatment Review, a Dental Utilization Review System. abs. no. 433 Hospital Cost Containment. Selected Notes for Future Policy. abs. no. 449 Hospital Production. Can Costs Be ContMned. abs. no. 453 Hospital Rate Setting. This Way to Salvation. abs. no. 454 Hospital Regulation Through State Rate Review. Mandated Interference or a Noble Intrusion. abs. no. 455 Hospital Reimbursement by Diagnosis Related Groups. Preliminary Bibliography abs. no. 456 Impact of State Government Rate Setting on Hospital Management. abs. no. 488 Issues Involved in the Development of a Prepaid Capitation Plan for LongTerm Care Services. abs. no. 522 Mandated Community-Rating and Underlying Reimbursement Issues. abs. no, 542 Medicare Reimbursement. abs. no. 579 Mode of Payment and Length of Stay in the Hospital. More Work for PSROs, abs, no, 592 National Hospital Rate-Setting Study. A Comparative Review of Nine Prospeetive Rate-Setting Programs. abs. no. 637 Negotiating Reimbursement Contracts. The Michigan Expetqence. abs. no. 640 New Health Professionals. Nurse Practitioners and Physician 's Assistants, abs, no. 645 New
Jersey Hospital Reimbursement Under S-446. Elements and El?L.cts. 1980. abs. no. 646 New York Case Mix Study. abs. no. 8031 Nursing Home Cost Studies and Reimbursement Issues. abs. no. ,652 Perceived Health Insurance Coverage. abs. no. 676
V11-29
Perspc'ctz yes on Medicines .,n Soczct). aby, k_o 0_51 Physiclbl, Eatcnde[ Rciq_burscment tYxpc-rlnJca[ abs
Gotng Bare. Continuance abs. no. 336
no. 685
and Conversion
Provzsions
ih Health
Insurance'.
Physiclhr, Partlc'lpatlon 1)13",'ate _$lco'icald Programs. abs no. 690 Physiciar, s" Charges _'ndcr $tedwarc. A._slgnment Rates and BcaetlcJa 0 Liabi.'it). abs no 695 Pohcy l._sues m F)nancl)_g Alcntal ltealth Services. abs. no. 702 Prospective Rat; Re#nburs_mcnt arid Co_t C_ontainment. Formula Reim-
Health..4 Victim or Cause of lmqation, abs. no. 348 Health and Retirement. Pohcy and Research Issues. abs. no. 352 Health and the War on Poverty. A Ten-Year Appraisal abs. no. 354 Health ( "arc"Cost lntIation in the Umted States. Toward a UniHcd Then 0' of (_use and Control. abs. no. 362
burscqwnt m .'Vc_, ]'k,r_,. abs. no 750 Prospcctwc Rate Setting. abs. no. 751 Prospective Ret?nbuzsemcnt m Rhode Island. Additlona! Perspectwes. abs. no. 752 Prospective Ret)ltbldsement System Based on Patient ( "use-Mix {be New
Health Care in the America_r Economy. Number 3. abs. no. 370 Health Care Systems in Wmld Perspective. abs. no. 380 Health _14alntenance Organizauous Can Help Control Health ¢ arc Costs. abs. no. 406 Health Status, ,_4edical Care Lffilization, and Outcome. An Annotated Bibli-
Jers_/ Hospitals 1970-198l. abs. no. 753 Prospccnve ReJ?nbmsemcm: T,_rough Budget Review. New Jersey, Rhode Island and Western Penns ylvam_, abs no. 754 Public Regulation of lteaL'h _ are P_wv_ders. abe. no 765 Re-e._ammmg the Rhode lslamt Eape_ience with Prospective Retmbursemczlt abs. no. 775
ography of Empt_ical Stvd_es. Volume 2. abs. no. 424 Health. United States, 1980. abs. no. 428 Impact of Somal and Econom _Z" Changes on Flnanctal Security Systems. abs. no. 486 Impacts of Health Maintenance Organization Growth on Community Health Care Costs. abs. no. 491
Reform _nd ReguLl_Jb_ m Long-_lOrm C, re. abs no 779 Rcgulatir, g Health Care. 7he Struggle l_>r Control abs. no. 781 Reimbur:cmeot Alcernaovcs tbr tlomc Flcalth Care. abs. no. 790 Re_bur_,emec, t for ttospztM Services. abs. no. 792 Reimbursement t_± Phys_cmns' 3_rv_ces. abs. n() 793 Research and Dcai_,ostratlon_ m Health Ca_c 1;inanc_hg, 1978-1979. abs. no. 832 Short-Run Ho'sp_tal Re_ponscs to Rcm_bursemcnt Rate Changes. abs. no. 831 Some lss,_c._ m LimLrmg Hospital Cost Rem_bursement. A Marylnn(t Expertonce. abs. no. 845 Some Ste'te and Federal Perspectives on Medtcatd. abs. no. 846 Summac)" of Rate Review m ._4aryland. abs. no. 876 Third Pa;_ty Pc)meat for NonphyMcian Health Practitioners. Reahties and Recommendations. abs no 9(10
lntlanon, Unemployment and the Medicaid Program. abs. no. 504 Insurance, Regulation, and Hospital Costs. abs. no. 512 Laws of Moti_m in the For-ProI_t Health Industry. A Theory and Three Examples. abs. no. 529 Malpractice Crisis. What W_s It All About. abs. no. 537 Medicaid. Current Issues and Potential Reforms. abs. no. 547 National Health Insurance a,,;an Issue in Poh2ical Economy. The lmplica. tions of the Kennedy Health Secun'ty Act for Developing a Strategy to Effect Major Reorganization of Health Care Delivery in America. abs. no. 615 National Health Insurance. Some Costs and Effects of Mandated Employee Coverage. abs. no. 628 Politics of Health Care. abs. no. 707 Prospective Rate Reimbursement and Cost Containment. Formula Reimbursement in New York. abs. no. 750
Thud Pa_tv Reimbursement 901
Prospective Reimbursement no. 752
.4.,peers
of Physic'inn
Compe,,sation.
abs. no.
Third-Pa_ty Payment_ for New Health Professionals. An Alternative to FracHonal Rcm_bursemenr m Outpatient Care. abs. no. 902 Toward _' Ph)sic_n Pa> mcnt Poh'¢y. Evidence From the Economic StabL% zat_b'_ Progrnm. abe. no. 908 Use of _ledicare Benel_ts Under HIP's 3- )'car Incentive Reimbursement Experiment. abs no. 921 What We Haw (And Haven't) Learned From Prospective Payment Programs, abs. no. 935 National
economic
conditions
,_ Rhode
Island.
Additional
Perspectives.
abs.
Public Hospital and its Local Ecology in the United States. Some Relationships Between the "'Plight of the Public Hospital'" and the "'Plight of the Cities" abs. no. 763 RapM Rise of Hospital Cos_. abs. no. 771 Responsibility of the Indiviu'ual. abs. no. 806 Restructunhg Federal Medicaid Controls and Incentives. abs. no. 807 Social Welfare Expenditures Under Public Programs, Fiscal Year 197Z abs. no. 840 Status of Children, Youth and Families, 1979. abs. no. 858 Strategies for Financing National Health Insurance. Who Wins and Who
Access to Ambulatvry Care and *he U.S. Economy. abs. no. 1 Cons_nrter-Choiee Health Plan. ln_lation end Inequity in Health Care Today. Alternatives tot Cost Control and an Analysis of Proposals h_r NatLmal Health Insurance. abs. no. 128 Cost of Disea._c and Illness in the Umtcd States in the Year 2000 abs. no. 160
Loses. abs. no. 862 Study of Physician Reimburs,.-ment Under Medicare and Medicaid. Volume Labs. no. 866 Trends in Facility Use. An Evaluation of the Impact of Adverse Economic Conditions on the Status of the Poor. abs. no. 909 Unemployment, Eligibility Rules and the Loss of Health Insurance Benefits.
Disabihc < Insurance. l°t_glam Issues and Research. abs. no. 213 Does America Spend Too ="cinch on Health Care. abs. no. 222
abs. no. 915 Urban Fiscal Crisis in the United States,
Earning_ of Allied Health Pcrsonz_el. Are Health no. 227 Economics in Healt,_ Care. abs. r:o. 235
_/brkers
Underpaid.
abs.
Effect of Uacn_ploymct_t Insurance Payments on the Health Insurance eragc of the _t;emph)yed. abs _o 246 Effects of the 1974- 75 Rcccsslou at_ Health Care tbr the D_sadvantaged. no. 255
Covabs.
Employar Provided ()_oup Hcalth Ptans and the Unemployed. abs. no. 262 Employtlent, _,'nemployment, and Health Insurance. Behavioral and Descripftve Anal) s_s of Health Insurance Loss Due to Unemployment. abs. no. 265 Erosion ,t_he Mcdwal Nl_ctplace. abs no. 272
VII-30
National
Health
Insurance,
and
Municipal Hospitals. abs. no. 916 Voluntary Hospitals Suffer From Fiscal Erosion. Their Existence is Being Threatened. City Could Lose 5,200 Beds, 20,000 Jobs. abs. no. 931 National health insurance (NItl) Alternative Physician Payment Methods. tional Health Insurance. abs. no. 19
Incentives,
Etlicteney,
and Na-
American Medical Association and Compulsory National Health Insuranee. The Molding of P, xblic Opinion, 1920-1965. abs. no. 28 Analysis of the Potential Impacts of National Health Insurance Programs on Collective Bargaining. Final Report. abs. no. 38 Canadian Approaches to Health Policy Decisions. Naobnal Health lnsur-
Health
Care
Programs
ante.
abs. no. 62
abs. no. 594
Canadian Nati_mal Health Insurance. 63 Case for a National Health Service.
National National National
Health Health Health
Insurance. Insurance. Insurance.
Considerations in the Design of Mental Health Benelqts Under National Health Insurance. abs. no. 116 Consumer Preferences for Health lns_ce, abs. no. 8007
National National National
Health Health Health
Insurance. Insurance Insurance
Consumer-Choice Health Plan. lntlation and Inequity in Health Care Today. Alternatives for Cost Control and an Analysis of Proposals for
National 612
Health
National Health Insurance. Cost of BenelTts for Alcoholism
National Health Insurance abs. no. 613
and the Market
National Health Insurance abs. no. 614
as an Agent
abs. no. 158 Current Issues in National
Lessons
for the United States. abs. no.
abs. no. 68
abs. no. 128 in a National
Insurance
Health
for Mental
Insurance
Health
Program.
Services.
abs. no.
177 Demand for Supplementary Health Insurance, or Do Deductibles Matter. abs. no. 188 Dental Care Demand. Point Estimates and Implications for National Health Insurance. Drug Coverage no. 225
abs. no. 191 Under National
Health
Insurance.
Economic Class and Risk Avoidance. Care Insurance. abs. no. 229 Effect on Future Physician Requirements Health Insurance. abs. no. 247 Eltects of the Payment Mechanism abs. no. 254
The Policy Options.
Exporience
under
of an HMO
on the Health
Pubh'c
abs.
Medical
Policy At_cr National Care Delivery
System.
Insurance
abs. no. 605 abs. no. 606 abs. no. 607 A Social Placebo. abs. no. 60_ and Corporate Benefit Plans. abs. no. ,509 and Income Distn'butlon. abs. no. 611 and Primary
Medical
Care for Cht7dren. abs. no.
for Private PsychiattT_" Services.
for Containing
Health-Care
Costs.
NaNonal Health Insurance as an Issue z)7 Political Economy. The [replications of the Kennedy Health Security Act for Developing a Str,_tegy to Effect Major Reurganization of Health Care Delivery in AmeFica. abs. no. 615 NationaI
Health Insurance.
National 619
Health
Insurance.
National Health Insurance National Health Insurance gram. abs. no. 623
Bene[its,
Costs, and Consequences.
Conflic_ng
Goals and Poh_y
abs. no. 616
ChoiCes. abs. no.
Issues. The Adequacy of Coverage. abs. no. 622 Issues. The Cost of a National Prescrl)_tion Pro-
National Health Insurance Issues. The Unprotected Population. abs. no. 624 National Health Insurance Issues. Viability of the Cost-Sharing Concept. abs. no. 625
Financing of Hcalth Care. abs. no. 316 Forward Plan for Health FY 197g-82. abs. no. 320
National Health Insurance Proposals. Provisions of Bills Introduced 94th Congress as of February 1976. abs. no. 626
Future of Private Third-Party Reimbursement Gm_le to Selected References on National Medicine (1930-1973). abs. no. 346
National Health Insurance, Psychotherapy, and the Poor. abs. no. 627 National Hcalth Insurance. Some Costs andEffects of Mandated Employee Coverage. abs. no. 628
Systems. abs. no. 333 Health Care and Socialized
Health Health
Care. An American Crisis. abs. no. 355 Care Issues for Industry. abs. no. 373
National 629
Health
Insurance.
What Now,
Health Health Health
Care System in the United States. abs. no. 379 Economies and Health Care. Irreconcilable Gap. abs. no. 385 Employment Requirements Under Alternate Health Insurance
National Health National Health no. 631
Insurance, Insurance.
1979. abs. no. 630 96th Congress second
session,
Volume
2. abs.
National Health no. 632
Insurance.
96th Congress
session,
Volume
3. abs_
Schemes. abs. no. 386 Health Insurance. What Should Health
Maintenance
be the Federal
Organizations.
meat. abs. no. 403 Hospital Capital Expend_'ture
A
Role. abs. no. 399
Guide
to Planning
and
Devedop-
National New
Controls.
suits, abs. no. 444 How Much Will U.S. Medicine
Their Desired
and Expected
Change in the Decade
Impact of Comprehensive National Health Manpower. abs. no. 477
Health
Ahead.
Insurance
Re-
abs. no. 470
on Demand
for
Health
Directions no. 643
Program
for Infants,
in Public Health
NHI Won't Control Costs, Ordering Social Objectives. Insurance as Policy abs. no. 664
What Later,
second
Cl_'ldren and
Care. A Prescription
What Never.
in the
Youth.
the Medical
Impact of National Health Insurance on New York. abs. no. 482 Impact of National Health Insurance on the Use and Spending for Sight Correction Services. abs. no. 483 Impact of the Rhode Island Catastrophic Health Insurance Plan. abs. no.
PerspecNves on Health Promotion and Disease Prevention States. abs. no. 680 Physician Participation in Health Insurance Plans. Evidence abs. no. 689
489 Incentive
Policy Options and the Impact no. 703
lax for Medicare,
Medicaid
and National
Health Insurance.
abs.
no. 496 Information Needs of National pies, Issues, and Legislative
Polls. Health Health Insurance. Recommendations.
A Discussion of Prinaiabs. no. 507
Insurance.
abs. no. 633
for the 1980s. abs.
Quality, or Access. abs. no. 648 National Health Service and National
Options in Organizing
of National
abs. no.
Health Insurance
Health
Care System. in the United on Blue Shield. Revisited.
abs.
abs. no. 709
Proceedings of the National Conference Health Insurance. abs. no. 734
on Drug Coverage
Under National
Insuring Intcnszve Psychotherapy. abs. no. 513 Insuring the Nation's Health. An Evaluation of Three Approaches. abs. no. 514 Interfacing National Health Insurance and Income MMntenance. Why
Proposals for National Health Insurance in the USA. Origins and Evolution, and some Perceptions for the Future. abs. no. 745 Public Insurance in Private MedicM Markets. Some Problems of National Health Insurance. abs. no. 764
Health and Welfare Reform Go Together. abs. no. 516 Major l_sues in the Financing and Management of Health Care. abs. no. 536 Medical Care System Under National Health Insurance. Four Models. abs. no. 554 ._ledic'al i_lalpractice Litigation Under National Health Insurance. Essential
Reimbursement Policy Under Drug Insurance. Administrative Expediency or Economic Validity. abs. no. 795 Rethinking National Health Insurance. abs. no. 810 Role of Health Insurance in the Health Services Sector. abs. no. 816 Role of the Private Sector in National Health Insurance. abs. no. 820
or Expendable. abs. no. 559 • lodclling the Effects of National
Setting NationM Priorities. Agenda for the 1980"s. abs. no. 830 Social Surveys and Health Policy. Imph'cations for National Healtl_ lnsur-
Health
Insurance
in the United
States.
VII-31
ante. abs. m). 839 Societal Rc.sponsiblTit)
to: Malp_ac_Jcc
Illness. abs. no. 728 Private Health Insurance
abs. no. 841
Strategt,:s for Financh,g _%_n,mat H¢'alth Insurance. Who Wins and _ho Loses. abs. no 802 Textbook /or Employee Benefit Plan F_ustees, Admimstrators and Advisots abs. no. 897 Theoret;cal Analysis of the lmpact of _ational Health Insurance on C_msumer Behavior m the Health (_re _VIarket. abs. no. 898 Three
World Systcm_
of 3dedlca;
Care. ]',-ends and Prospects.
abs. no. 904
Toward a Commumo_-Ba__ed Nanbnal Health Servtce. abs. no. !)06 Urban ill, col Cns_ _]_ lhe United Statea Nanonal Health Insurance, Munictpnl
Hospitals.
abs
Non-employment related plar_s Cancer Insurance, A Review
no
916
of Poblic!l
,4vaITabl_ _ Document_ An
abs. no.
Examination
of Dread
Econon_ics of Medical Malpracttcc. abs no. 239 Emplo)'mcnt, L"nempl_vnten_, and Health ln._.,_ran, e. Behavioral
and De-
of Heal,_,_ l_lsurance Loss Due to Unemployment.
abs.
Analysis and Planmng for hnproved Dl_tribution Services. Final Report. abs. no. 31
Health Care in the 1980s. 371
National
Who Provides.
Ahead
Survey
Was It All About.
abs. rt,_. 537
_Vludtgal. Statc.s R_p,,n_e .If. abs. no. 583 ,_Iultipl,_ Health
_o ,°:oblems
h:._uranca
c,,v_age.
_ith Health Insurance -l_c Overlap
for the Elder-
of Dread
Disease
and
of Recent
Research
Third Party Payment Recommendations. Outcome/evaluation Administration's AdministraOve Commercial
Interim
Re-
Who Pays. abs. no.
at the Supply
Manpower Policy for Primary Health Care. abs. no. 543 Nurse PractiNoners. A Review of the Literature 1965-1979.
• lalpra,'tice
What
and
System Changes on the Nation "sRequirements in 1985. zbs. no. 479
Physicians for the Future. abs. no. 696 Stud)" of the Utilization ana Effect of Temporary 8044
Crtsi._
Personnel
Committee,
Who Plans.
Health Manpower for the _ation. A Look Requirements. abs. no. 410 Health, United States, 1980. abs. no. 428 Impact of Health tared Nurses
of Nurstng
Adwsory
From ( harttable lnna_uio _ to Pi_bl_c Accountability A Review of Selected Soh_tions to the _4alpractice Problem. abs. no. 324 htdt'vidual Accident attd Health Loss Ratio Dilemma. abs. no. a99 A4alpcactice. Funding Emerges as _ Crincal Issue. abs. no. 538 _4edica' ._lalpractice Insurance. A Legtslator's View. abs. no. 557 Mcdica _Malpractice Pre- Trial Screw.nine Panels. A Review of the Evidence. abs. no. 560
abs. no. 729
Nurses
Graduate ,_/Iedical Education port. abs. no. 338
800 ] Cancer Insurance. Explo_?_g k_-ar ?br _rofit. D_sease Insurance. abe. no. 04
scr:)_t_ve Anal)o_s no 265
and
Prans in 1976. An Evaluation.
ProHle of Health-Care Coverage. The Haves and Have-Nota. abs. no. 740 Trends in State Administration of ._Iedicald Programs. abs. no. 912 Unemployment, Ehgibility Rules and the Loss of Health Insurance BenclTts. abs. no. 915 Who Are the Uninsured. D_ta Prewew 1. abs. no. 937
in Health
for Nonphysician abs. no. 900
Nursing
Economics.
and
the
for Reg_s-
abs. no. 651
Services.
abs. no.
abs. no. 882
Health Practitioners.
Reclines
and
of health administration Program _r Health Cost Containment. abs. no. 9 Costs of _redicare Contractors. Blue Cross Plans Versus Intermediaries.
abs. no. 10
Eat _a Cash Poli,_'s With O_her Types of Coverage. abs. no. 597 Pain and Prol_t. Th_ Politics of MMp_acttL'e. abs. no. 667 Private Health Insurance _o Supplement A4ed_:are. Volume Z abs. no. 730 Rcv_e_ ,,f the :_led/cM A4Mpractiee Problem in the United States. abs. no. 81 i
Altering Medicaid Provide._ Reimbursement Methods. abs. no. 17 Analysis of Case Mix Complexity Using Information Theory and Diagnostic Related Grouping. abs. no. 32 Analysis of the Effects of Prospective Reimbursement Programs on Hospital Expends'tares. abs. no. 37
Soc'_al Aspect_ no 833
Canadian Approaches once. abs. no. 62
Soc_ta_
of the Rate StrucLtre
Responsibility
of __lcdical _4alpractice
lnsu,,ance,
abs.
to_ Alalp_-acnc_ _ abs. m). 84 1
to Health
Policy
Decisions.
National
Health
Insar-
abs. no. 212
Changing Role of the Hospital. Options for the Future. abs. no. 80 Comparative Experiences in Controlling Expenditures for Prescription Drugs in State Medie&d Programs. abs. no. 92 Comprehensive Market and Regulatory Strategies for Medical Care. abs. no. 109
Effect _f L:nempl_Lvmcnt lnsuran,ve Payntents on the Health lnsmance Coyczage of Lhe Unemployed abs. no. 246 Emplo) cr Provided Group Health Plans and the Unemployed. abs. no. 262 E'mphoment Related Health B_efits m Private Nonfarm Business Establi_h vents tn the l 'nt ted States. I "blame L Determinants of the Decision by Cstabh_hsncnt._ :c_ Otter a _iroup Health Plan. abs. no. 263
Consumer Attitudes Towmd Health Policy and Knowledge About Health Legislanon. abs. no. 119 Containment of Hospital Cbsts. A Strategic Assessment. abs. no. l 31 Controlling Hospital Costs. The Revealing Case of Indiana. abs. no. 136 Controlling Hospital Costs. The Revealing Case of Indiana. Summary. abs. no. 137
hinplo_ ment L 'nL-mp/_.,y_ent, acid HcaRh Insurance. Behavioral and De_crtytt_ c Anal) sts of Healt_ t,_surancc Loss Due to Unemploy_nent. abs. no. 205
Controlling the Use and Co'.;t of MediCal Services. The New ,_4exico Expcrimental _VIedt'cal Care Review Organizau'on. A Four- Year Case Study. abs. no. 143
Health Care Ftnancing Option._ lot Col_3rado. abs. no. 368 Ifcalth Insurance Coverage of _"cterans Data Preview 4. abs. no. 393 Insuran ee Coverage and Access lmpbcatiJns for Health Policy. abs. no. Medically lnditeent. ,4 5tare Perspective ,m a Nat_bnal Problem. abs. no. Muln)_l.: Health Insurance Coverage. 7_e Overlap of Dread Disease _.._t_a _a._b Policie_ 1¢7th O_her _ypes of Co_z, rage. abs. no. 597 Naz,m_4 Health ln_trar_ c ls_,cs. The Adequacy of Coverage. abs. no. .\'atk,[_4 Health lns_trancc Is._ucs 7he Unpro_c_'tcd Population. abs. no. Nan_,_i:4 llealth hlsura,,_ce t_ha: No_; What Later. What Never. abs.
Cost Containment and Health Planning. A Bibliography. abs. no. 147 Cost Containment in the Health Care Industry. abs. no. 151 Cost Containment Through Employee Incentives Program. abs. no. 154 Cost-Benelft Analysis Mandatory MediCare Participation. abs. no. 164 Current Developments in the National Health Planning Program. abs. no. 175 Department of Health, Education, and Welfare, OflTce of the Inspector GeneraL Annual Report, January 1, 1979 to December 31, 1979 abs. no. 197
Non-participants in health care programs Changing Medicaid Population. abs. no. 78 Disabtlttp, Health Status, and L.nh_at_)_ or ttealth
_)2 9 Private klcal._h lnstJt ancc 3eneftts
V11-32
t'o_ At_:'ohol_rn,
Services.
Drug Abuse
511 570 and 622 624 no.
a_d ,Vlental
Directions for the "80s. Fin,zl Report of the Panel to Evaluate tire Health Statistics System. abs. no. 210
the Coopera-
Health Care Programs
Economics
in Health
Effect of a Mandatory Rates. An Analysis
Care. abs. no. 235
no. 752
Second Opinion Program on Medicaid Surgery of the Massachusetts Consultation Program for
Elective Surgery. abs. no. 240 Evaluating Hospital Productivity. abs. no. 279 Evaluation of Alternative Payment Strategies for Hospitals. Approach. abs. no. 280
A Conceptual
Public Versus Private Administration of Health Insurance. tire Economic Efficiency. abs. no. 766
A Stu Iy in Rein-
Rate-Making Process for Developing Plans. abs. no. 772 Regulatory Environment for Physician Compensation. abs. no. 789 Reimbursement Management. abs. no. 794 Relationship Between Diagnostic Information A reliable at Admission
and
Evaluation of Health Manpower Shortage Area Cn_elia. Final Report. abs. no. 281 Evaluation of the Formation and Operation of Health Care Delivery Systerns for Public Assistance Beneficiaries Enrolled in Prepaid Health Plans in California. abs. no. 286
Discharge for Patients in One PSRO Setting. abs. no. 796 Rising Hospital Costs Can Be Restrained by Regulating Payments and Iraproving Management. abs. no. 814 Sa_'ngs to CHAMPUS From Requirement to Use Uniformed Services Hospitals, abs. no. 822
Evaluation of the Maximum Allowable Cost (MAC) for Drugs Program. Phase I Report. Final Design Report and Report of Pilot Study Analysis. abs. no. 287 Federal Government's Role in Ambulatory Services Development. A Management Perspective. abs. no. 304
Some State and Federal Perspectives on Medicaid. abs. no. 846 Stronger Management Needed to Improve Employee Organization Health Plans' Payment Practices. abs. no. 863 Study of the Adrm'nistration of the Employee Retirement Income SecLgity Act. abs. no. 871
Financial Management line and Annotated
Too Old, Too Sick, Too Bad. Nursing Homes in America. abs. no. 905 Trends in State Administration of Medicaid Programs. abs. no. 912
of Health Care Organizations. Bibh'ography. abs. no. 311
A Referenced
Out-
Financial Management Under Third Party Reimbursement. abs. no. 312 Findings and Implications of Field Visits to Six Welfare Benefit Plan Administrative Organizations. First Interim Report. abs. no. 318
Vertically Linked Health Organizations. What We Have (And Haven't) Learned grams, abs. no. 935
Forecasting. A Cost Control Tool for Health Care Managers. abs. no. 319 Future Health Care Organization. abs. no. 330 Health Care Business. International Evidence on Private Versus Public
When a Solution Organizations.
Health Care Systems. abs. no. 356 Health Care Cost Containment in West Germany. abs. no. 359 Health Care Dilemma. Problems of Technology in Health Care Delivery. abs. no. 367 Health Care Issues for Industry.
Is Not a Solution. abs. no. 936
Medicaid
and
Payment
Health
for PrepaM
Group
Plans.
Pro-
Maintenance
Outcome/evaluation of qnMity assurance Achievements and Problems of Merle'acid. abe. no. 4 Achieving Optimum Utilization of Ancillary Services. An Annotated ography, abs. no. 6 Alcoholism Services Handbook
abs. no. 373
abs. no. 929 From Prospective
Bibli-
abs. no. 14
Health Maintenance Organizations Can Help Control Health Care Costs. abs. no. 406 Health Maintenance Organizations. Federal Financing is Adequate But HEW Must Continue Improving Program Management. abs. no. 407 HMOs From the Management Perspective. abs. no. 436 Hospital Cost Containment. Selected Notes for Future Policy. abs. no. 449 Hospital Cost Inflation and Health Insurance. A Complex Market Model. abs. no. 451 Insurance, Regulation, and Hospital Costs. abs. no. 512 Managing Medicaid Drug Expenditures. An Analysis of Divergent Approaches, abs. no. 541 Medicaid Experience. abs. no. 548 Medicare. The Politics of Federal Hospital Insurance. abs. no. 582 Negotiating Reimbursement Contracts. The Mictu'gan Experience. abs. no. 640 Nurse Practitioners. A Review of the Literature 1965-1979. abs. no. 651
Alternative Oral Health Service Delivery Systems. abs. no. 18 Assessing Qua_'ty of Care and Oral Health in a Population With Dental Insurance. abs. no. 42 Changing Patterns and Implications for Cost and Quality of Dental Care. abs. no. 79 Community Mental Health Centers. The Federal Investment. abs. no. 90 Comlz_qson of the Qua_'ty of Maternity Care Between a Health-Malntahence Organization and Fee-For-Service Practices. abs. no. 99 Cost Containment Mechanisms. abs. no. 152 Costs, Risks, and Benefits of Surgery. abs. no. 171 Doctors, Damages and Deterrence. An Economic View of Medical Malpractice, abs. no. 221 Effect of PSROs on Health Care Costs. Current Findings and Future Evaluations. abs. no. 244 Effects of Advertising Lessons From Optometry. abs. no. 249 Effects of Income Maintenance on the Medical Care Utilization and He,alth
Of_Tce of Personnel Management Should Promote Medical Necessity Pro= grams for Federal Employees" Health Insurance. abs. no. 656 Oft_ce of Personnel Management's Comprehensive Medical Plans Network Experiment. abs. no. 657
Status of Rural Families. abs. no. 252 Effects of Meth'care and Medicaid on Access to and Quality abs. no. 253 Evaluation of Meda'cal Practices. abs. no. 284
Planning for Posthospital Care. A Followup Study. abs. no. 698 Potential Market Competition in the Medical Care System of Baltimore, Maryland. abs. no. 711 Preliminary Analysis of the Costs of Maintaining Pension and Health Benefits in Selected Plans. abs. no. 714
Evaluation of the Effects of National Health Service Corps Physician Placements on Medical Care Delivery in Rural Areas. abs. no. 8013 Evaluation of the National Long-Term Care Channeling Demonstration. abs. no. 8014 Health Care Guidance. Commercial Health Insurance and National H',alth
Preliminary Results From a Risk-Shauqng Health Maintenance Organizetion. abs. no. 715 Private Sector Perspective on the Problems of Health Care Costs. abs. no.
Policy. abs. no. 369 Health Care in the American Economy. Number 3. abs. no. 370 Health Costs Can Be Reduced by Millions of Dollars if Federal Agencies
733 Proceedings of the 28th Annual Group Health Institute, New York, York, June 18-21, 1978. abs. no. 735 Professional Standards Review Organization Program. abs. no. 737
Fully Carry Out GAO Recommendations. abs. no. 384 Health Planning as a Regulatory Strategy. A Discussion of its History and Current Uses. abs. no. 415 Health. What Is It Worth. Measures of Health Benefits. abs. no. 429
Professional Standards Review Organization 1979 Program Evaluation. no. 738 Prospective Reimbursement in Rhode Island. Additional Perspectives.
New
abs. abs.
of Health
Care.
Hospital Cost Containment. Selected Notes for Future Policy. abs. no. 449 Hospital Production. Can Costs Be Contained. abs. no. 453 Issues in Regulating Quality of Care and Containing Costs Within Private
VII-33
.¢e c'tor ?, me). abs. no. 521 Joint Health Cost c_mtainment Program. to. 524
Hospital
Utilization
Report.
abs.
Impact of Membership m an Enrolled, Prepaid Population on Utilization Health Services in _r Group Practice. abs. no. 48 l Impact of NationM He_.lth Insurance on New York. abs. no. 482
Just'_c for the Patient and the Dentist. Quality Assurance AcNvities of the W K. Kellogg Foundation and the American Fund for Dental Health.
Impact of Proposition 484
_bs. no. 525 _Ia_taging Medicaid Drug Expenditures. _ches. abs. no. 54 ! Medicaid Expemcnce. abs. no, 548
Improving Health Magnitude States.
An Analysis
of Divergent
Appro-
Me, ffcaid ._4_71_.Fact or Fiction. abs. no. 550 M_diedl Care Plan.s. How to Control the Costs. abs. no. 553 On ._a)4ng the Piddler to Change the Tune. Further Evidence Prom Ontario Regarding the hnpact of Universal Health Insurance on the Organizetion and Patterns of Meda_al Practice. abs. no. 660 Phy_i_-ian Reimbursement and Hospital Use in HMOs. abs. no. 691
13 on Mental
Health Services
in Califorma.
of
abs. ,o.
Access to Health Care Among the Poor. The Neighborhood Center Experience. abs. no. 493 and Determinants of Physician Initiated Visits in the United abs. no. 534
Mail-Order Meddcine. An Analysis of the Sears Roebuck Foundation's Community MedicM Assistance Program. abs. no. 535 Maintaining the Elderly in the Community. abs. no. 8024 Measurement of Expench'tures for OutpaNent Physician and Dental Services. Methodological no. 544
Findings
from the Health
Insurance
Study.
abs.
Physicians: Knowledge of Cost. The Case of Diagnostic Tests. abs. no. 697 pro/eJsional Standards Review Organization Program. abs. no. 737 Pro_:osed Framework for Health and Health Care Policies. abs. no. 748 PSh'O An Evaluation of the Professional Standards Review Organization Programs, Volume 1I. ,4 Cost-Benet_t Context for PSRO Utilization C, ntzol A_tivit_es abs. no. 759 Qu_lit) As.,urancc L_ n Prepaid Group Practice. abs. no. 76'7 QuMi U Ass ,u:aace in Health Care. abs. no. 768 QtJ_li(v Health Car_. Fhc Role of Continuing Medical Education. abs. no. 769 Quality of ,_l_dlc'al Care. abs. no. 770
Mental Disorder and t_imary Medical Care. An Analytz_al Review of the Literature. abs. no. 584 National Ambulatory Medical Care Survey. 1977 Summary. United States, January-Devember 1977. abs. no. 598 Neighborhood Health Canters. A Decade of Experience. abs. no. 641 NHI Won't Control Casts, Quality, or Access. abs. no. 648 Paying for Primary Care. Time for a Change. abs. no. 672 Perle'attic Care. Charge_; Payments and the Medical Setting. abs. no. 674 Physician Extender Reimbursement Experiment. abs. no. 685 Pressures and Problem,,; for Organized Ambulatory Services in the Next Decade. abs. no. 718
Rc-,:xamL'n)_g the Rhode Island Experience with prospective Reimburse. mcnt abs no. 77> Regulation and the Quality of Dental Care. abs. no. 785 Re,search and Demonstrations in Health Care Financing, 197g-1979. abs. no. 802
Primary Health Care in an Academic Medical Center. abs. no. 725 proceeddngs of the 28th Annual Group Health Institute, New York, New York, June 18-21, 2978. abs. no. 735 Social Me,clue. The Advance of Organized Health Services in America. abs. no. 834
Some
Some Aspects no. 842
Aspects f_.. 842
of Ambulatory
Care L'nder ._IedJk'ald in New
Sur,,N'cal [nnovatlou and Its Evaluation. abs. no. 879 U'se o! Mcdica:e Bane/its Under HIP's 3- Year Incentive Eaperiment. abs. no. 921 Veterans Admintstrat*on Hospitals. An Economic Analysis _?_te:prise. abs. no. 930 Outpatient
York City. abs.
Re_inbursement of Government
facilities
Access to Ambulatory Altcmanve Services.
Alternatives to lnstitutiooaJ Care. An Analysis of State Initiatives. abs. no. 8001 Assessment or'Member Satz_¢act_bn in an HMO. Understanding the lnteraction of Variables and Their Implications. abs. no. 44 Changing Health Care Perspectives From a New Medical Care Setting. abs. no. 77 Co_ _munit) Mental Health Centers= The Federal Investment. abs. no. 90 C_ot,trolhng the Use and Cost of Medical Services. The New Mexico Expertmental Medical abs. no. 143
Care Review
Organization.
A Four- Year Case Study.
Care Under ,_ledicaid
in New
York City. abs.
Study to Determine the Relationstup of Community Health Centers, Community Mental Health Centers, and Drug Treatment Centers for the Provision of Mental Health Services to CHC Registrants. Final Report. • ' abs. no. 873 Substitution of Outpatient Care for Inpatient Care. Problems and Experience. abs. no. 874 Variations
('are and the U.S. Economy. abs. no. 1 Fhc Case of Free Clinics. abs. no. 20
of Amb_'atory
in Utilization
Who Initiates
of HeMth
Visits to a Physician.
Services Data
by Children. Preview
abs. no. 928
3. abs. no. 939
Participants In health gate programs Access to Medical Care. The Impact of Outreach Services on Enrollees o1" a PrepaM Health hlsurance Program. abs. no. 3 Achievements and problems of Med_'cald. abs. no. 4 Adequacy of Pn'vate Health Insurance Coverage. abs. no. 8 Alcoholism Within Preoald Group Practice HMOs. abs. no. 15 American Attitudes Toward Health Maintenance Organizations. abs. no. 25 Aspects of Medicare i_ Colorado. abs. no. 8002 Assessment of Member Satisfaction in an HMO. Understanding tion of VaJqables attd Their ImplicaNons. abs. no. 44
the Interne.
Co, t-Financed Mental Health Facility. abs. no. 168 Day Hospitalization as a Cost-Effective Alternative to Inpatient Care. A Pilot Stud)_ abs. no. 179 Delivery Prospers in Diversity. abs. no. 184 Feaeral Government's Role in Ambulatory Services Development. A Management Perspective. abs. no. 304 Final Report to the Legislature on Ambulatory Care. abs. no. 309 Health Pur_onnel. Meeting the Explosive Demand for Medical Care. abs. no. 411
Build Study 1979. abs. no. 54 Canadian National Health Insurance. Lessons for the United States. abs. no. 63 Catastrophic Illness in an HMO. abs. no. 74 Changing Medicaid Po, oulation, abs. no. 78 Chffdren and Dental _tre. Charges and Probability of a Visit by Individual Characteristics. abs. no. 85 Comparison of Group Medical Care Insurance Benefits to Charges. abs. no. 96
tte2 ith, L')_zt¢_l S ate_ 1980, abs. no 428 Ho.,p_taL Based _ersus Free-Standing Primary Care Costs. abs. no. 459 Hc,_p_tal-Sponsozed Primary Care Group Practices. A Developing Modality of Care. abs no _60
Comparison of the Qwdity of Maternity Care Between a Health-Mainte. nance Organizatior_' and Fee-For-Serv_e Practices. abs. no. 99 Comparisons of prepaid Health Care Plans in a Competitive Market. The Seattle Prepaid Health Care Project, abs. no. 100
V1i-34
Health
Care
Programs
Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Volume VIII, Overview. abs. no. 110 Consumer Responsibility in a PrepaM Group Health Plan. abs. no. 123 Consumer Satisfaction in a Health Maintenance Organization, abs. no. 125 Contrasts in IIMO and Fee-for-Service Performance. abs. no. 132
ography of Empirical Studies. Volume 4. abs. no. 426 Health Status, Socioeconomic Status, and Utilization of Outpatient .Services for Members of a Prepaid Group Practice. abs. no. 427 HMO Enrollment Decision. A Transactions Analysis and Literature Review. abs. no. 434
Cost-Financed Mental Cost-Sharing in Health abs. no. 169
Impact of the Rhode Island Catastrophic Health Insurance Plan. abs. no. 489 Insurance Coverage andAccess. Implications for Health Pohcy. abs no. 511
Costs, Financing, to Medicare. Design
Health Facility. abs. no. 168 Insurance. Its Effects on Health Service
and Distributional abs. no. 170
for a Corporate
Design of Failure. 200
Health
Health
Effects
of a Catastrophic
Care Monitoring
System.
Policy and the Structure
Utih'zation. Supplement
abs. no. 199
of Federalism.
Medicaid, Medicare, and Private Health Low-Income Areas. abs. no. 549 MedJ_aM
abs. no.
Participation
and Nledical
Medical Care Use by a Group no. 555
Insurance
Coverage
in Five Urban,
Care. abs. no. 551
of Fully Insured
Aged.
A Case St,My.
abs.
Development of Health Insurance. abs. no. 205 Disability, Heaith Status, and Utilization of Health Services. abs. no. 212 Disenrollment From a Prepaid Group Practice. An Actuarial and Demographic Description. abs. no. 217 Economic Class and Risk Avoidance. Expen'ence under Public Med_'cal Care Insurance. abs. no. 229
Medical Group Practice and Health Maintenance Organizations. abs. no. 556 Medicare Coverage for the Treatment of Alcohulism. abs. no. 575 Medicare. Health Insurance lbr the Aged and Disabled, 1975. Section 2. Persons Enrolled in the Health Insurance Program. abs. no. 576 Medicare. Health Insurance tbr the Aged and Disabled, 197Z Section 1.
Effect of Duration of Membership in a PrepaM Utilization of Services. abs. no. 241
Reimbursement by State and County. abs. no. 577 Mental Health Services for MedicaM Enrollees in a Prepaid
Group
Health Plan on the
Effect of Unemployment Insurance Payments on the Health Insurance erage of the Unemployed. abs. no. 246 Effects of Medicare and Medicaid on Access to and Quah'ty of Health abs. no. 253 Empiricial Study of the Differences Between ibles in Health Insurance. abs. no. 257 Employee
Benelfts
Family and Individual
CovCare.
Deduct-
1979. abs. no. 259
Group Practice
Plan. abs. no. 585 Mental Health Services. Utilization by Low Income Enrollees in a Prepaid Group PracHce Plan and in an Independent Practice PIan. abs. no. 586 Multiple Health Insurance Coverage. The Overlap of Dread Disease and Extra Cash Policies With Other Types of Coverage. abs. no. 597 National Health Insurance Issues. The Adequacy of Coverage. abs. no. 622 Nurse Practitioners.
A Review
of the Literature
1965-1979.
abs. no. 651
Employer Provided Group Health Plans and the Unemployed. abs. no. 262 Employment Related Health Benegts in Pn'vate Nonfarm Business Establishments in the United States. Volume 1. Determinants of the Decision
On the Cost of National Health Insurance in Quebec. abs. no. 661 Perceived Health Insurance Coverage. abs. no. 676 Poh'cy Analysis n4th Social Security Research Files. abs. no. 701
by Establishments to Offer a Group Health Plan. abs. no. 263 Employment Related Health Benet_ts in Private Nonfarm Business Establishments in the United States. Volume II. Description of Selected Data. abs. no. 264
Poh'tical Economy of Federal Health Programs in the United Historical Review. abs. no. 705 Preliminary Results From a Risk-Sharing Health Maintenance riGa. abs. no. 715
Employment,
Preh'minary
Unemployment,
scn)_tive Analysis no. 265 Enrollment
Choice
and Health
of Health Insurance in a Multi-HMO
Insurance.
Behavioral
and De-
Loss Due to Unemployment.
Setting.
The Roles
of Health
abs. Risk,
Study
of Disenrollees
From
vania, abs. no. 716 Primary Health Care in an Academic l_'vate
HeMth
Insurance
Health
Service
Mecb'cal Center.
Plans in 1976: An Evaluation.
States.
An
Organiza-
Plan of Pennsylabs. no. 725 alas. no. 729
Financial Vulnerability, and Access to Care. abs. no. 266 Equal Treatment and Unequal Benelfts. A Re.examination of the Use of Medicare Services by Race, 1967-1976. abs. no. 270 Estimates of Preventive Versus Nonpreventive Medical C_re Demand in an HMO. abs. no. 276
Private Health Insurance to Supplement Private Industry Health Insurance Plans. er in 1974. abs. no. 731 PreceedJ'ngs. 27th Annual Group Health June 19-22, 1977. abs. no. 736
Evaluation of the Formation and Operation of Health terns for Public AssisUmce Benel_ciaziea Enrolled Plans in California. abs. no. 286
Reimbursement for Durable Medical Equipment. abs. no. 791 Relationship Between Utilization of Mental Health and Somatic Health Services Among Low Income Enrollees in Two Provider Plans. abs. no.
Factors Affecting Differences Servz_es. abs. no. 296
in Medicare
Care Delivery Sysin Prepaid Health
Reimbursements
for Physicians"
797 Rethinking
Employee
Benel_ts
Medicare. Volume I. abs. no. 730 Type of Admim'stration and InsurInstitute,
Assumptions.
Los Angeles,
Califortda,
abs. no. 808
Factors tive Factors Health
Affecting the Choice Between PrepaM Group Practice and AlternaInsurance Programs. abs. no. 297 Affecting the Choice Between Two Prepaid Plans. abs. no. 298 and Health Insurance. The Pubh'c's View. abs. no. 350
Risk Differential Between Medicare Benet_ciaries Enrolled and Not Enrolled in an HMO. abs. no. 815 Selected Bibliographic Research Guide to Health MMntenance OrganizatiGriS and Prepaid Group Practice. abs. no. 825
Health
and the War on Poverty.
Simultaneous
Health Health
Insurance Insurance
Health Maintenance 408
A Ten- Year Appraisal.
abs. no. 354
Coverage of Veterans. Data Preview 4. abs. no. 393 Plans. Promise and Performance. abs. no. 397 Organizations.
Product
Health Status, Medical Care Utilization, and ography of Empirical Studies. Volume Health Status, Medical Care Utilization, and ography of EmpiriCal Studies. Volume Health Status, Medical Care Utilization, and ography of Empirical Studies. Volume Health Status, Medical Care Utilization, and
Life Cycle Approach. Outcome. 1. abs. no. Outcome. 2. abs. no. Outcome. 3. alas. no. Outcome.
An Annotated 423 An Annotated 424 An Annotated 425 An Annotated
abs. no. BibliBibliBihhBibli-
Logit
of Plan Memberstu'p
in the Federal
Benet_ts Program. abs. no. 832 State Employee Health Insurance Plans. A Survey Financing. abs. no. 852 Study of Dental Service Prepayment
Employees
of Coverage,
in the Private Sector.
Health Benet_ts,
Final Report.
abs.
no. 865 Survey Results, July 1980. HMO Enrollment and Utilization in the U.S. abs. no. 883 Ten Years of Medicare. Impact on the Covered Population. abs. no. 894 Ten Years of Short-Stay Hospital Utilization and Costs Under Medicare (1967-1976). abs. no. 895 Trends in State Administration of Mea_'cMd Programs. abs. no. 912
VII-35
-,i¢_1_}.',_ ,,_-,_z. _dg:_.rs_: R_e, _l_,l ,.*_-"_,s_ of Ilcalth Insurance BeneEts. abs _o. 9 i 5 L _e o( Mcdlcm_ Jcuci_. L uder tllP'_ 3-Fca_- l_t_eodve Reimbursement E._t_eriment. abs. no. 921
Impact ot Family Structure ca1 Children "s Ifealth Care Use. abs. no. 4?8 Insurance Cbverag¢ and Ac::e._s. Implications for Health Policy. abs. no. 511 Interim Report to Congres._ ca Occupatlb_al Diseases. abs. no. 517 National Health Insurance. abs. no. 605
Use o1"Ph)_'ician Sere'ices Undel" Two Prepaid Plans. abs. no. 922 UttTizn_ioo and Cbst of ,_4entai l/loess Coverage in the Federal _mployees
National National
Health Bene,qts Progzam, 1973. abs. no. 924 Vanatl_ms in Utilization of a Multi-State c'ompany Dental Plan. abs. no. 927 VartM1k,ns in Utillzatibn of Health Services by Children. abs. m_. 928 [_tcra± s Ad;tn)dstrar:b_ HosnL_dls. An _COtlOlgnc Analysis of Government Emerpr_e. abs. no. 930 _ho A_e th= £_t_uce_L Data Preview i. abs no. 937 Who _)l_>oses Pre_ead McdieaI C'are. Sw ;.ey Resul_ from Two Marketings of )_hree New Pccpap_rne_ut Plans. abs. no. 938 Why D) !L,1IOs Sccm to _rovide ,_lore Health Maintenance Services. abs. ,o 941 _)" 'Yew Enrollees Choose to loin Orpup Health Plan, Inc'. abs. no. 942 _km_e_, _)ck, at_d _eai_h. Chailengc_ ro Corporate Policy, abs. no. 943 B'?m_cL 3 Healt# _do_mcat. Fennnist A/ternatives to Medical Control. abs. rw 944
New Group Health Insurance. abs. no. 644 Office of Health Matntenance Organizations. 5th Annual Report to the Congress. abs. no. 655 Ot]qce of Personnel Managcment's Comprehensive _4edieal Plans Network Expermwnt. abs. no. 657 Pediatric Care. Charges, P_ymentS and the Medical Setting. abs. no. 674 Primary Care in Durham County. Who Gives Care to Whom. ahs. no. 724 Social Surveys and Health Policy. Implications for National Health Insetante. abs. no. 839 State of Hawail Prepaid Health Care Act (Chapter 393, HRS) and Related Rules and Regulations. abs. no. 855 Status of Children, Youth _md Families, 1979. abs. no. 858 Two Decades' of Health Services. Social Survey Trends in Use and Expenditure. abs. no. 913
H?vtO Census Sm-vey, 1977. Summary. H.,_[O Census 19dO. abs. no. 635
Use and Expenditures Participation
in health
Alcoh,z'ism Program izcd lntormarkm _b_. no. 13
care programs 3.la_:agcmc.ot fhrough the Operation of a ComputerS)stem. L 4c'_usnal Data on Utilization of Services.
Aual)_ of the Potential _ntpac_ of National Health Insurance Programs oil ,TollectL e 2n._almng. Final Report. abs. no. 38 Uonsun,er Acceptance of H_lOs. abs. _o. 118 Consun,el Influence on t_e Quality o£Dental Care. abs. no. 121 Coasun'er Participation and Community Organization Practice. Imph;:afinns ol'Nat_onal Health Legislation. abs. an. 122 _bn._un er Snt_fac_bn. 4 _Io_el for Health ServT"ces Admim'strators. abs. no. 124 Cost of t 'atas_roph_e lilac3:,, abs. no. 159
tore Survey.
Analyse_
abs. no. 634
From the National
._Iedicai
Care Expendi-
abs. no. 9] 9
Wasted tleMth Dollars. abe. no. 932 Who Are the Uninsured, Data Preview 1. abs. no. 937 Who Initiates Visits to a P_ys_2an. Data Preview 3. abs. no. 939 Pharmaceutical services AmbMatory Pharmaceutical Services for .Medicare Recipients. A Pilot Projeer. abs. no. 24 Capitation for Pharmacy Services. abs. no. 8004 Comparative Experiences _n Controlling Expenditures for Prescription Drugs in State Medicaid Programs. abs. no. 92 Comparing the _Iedical Utilization and Expenditures of Low Income Health Plan Enrollees _'_th Medicaid Recipients and With Low Income
C_st-Bcnet_t St,_) _of a Hype;teas_bn ,%secning and Freatment Program at thv ½b_k Settb,.e. a0s no. 165 Dch_c., U ,_f Heatth Chtw m L :ban &'ndcr_erved Areas. abs. no. 183 Denta! Prcp,_._nem Plans abs. no. 196 Dcs,_r_)_iun of the Hca_'_h fi))_anc_)xg Model. A 7"ool for Cost Estimatmn. ahs. n.._. t9_ Determining Hcalti_ A_eeas. abs. no 20.5 Ditfcrv_ cc_ by Age Groups in Health Care Spending. abs. no. 207 D2._enroghneut From a Prepaid (Troop Practie-e. An Actuarial and Demograt hm l)escr:i_t_or_ a_s. t,.c_ 217 Et_ects .rod (bs_ of Day-Care Servtc'es for the Chronically Ill..4 Rando. ±razed E._iacHmcnt. ab_ no. 24_ Eft'_cts ol'._hc 1974- 75 Recess_bn on Health Care for the D_sadvantaged. abs. .o 2>_ Emp/_,)'._.e Bcoetits lu lndustr k 4 PHot Survey. abs. no. 258 EmployT_ent Rcla_ Health gev.etTts in Private Nonfarm Business Est_b,qsk.'_c:'._ _,m the _ :u?e,_ States. Volume IL Descrtpdon of Selecfed Data. ab_ i,o. 264 _i_3odc'¢ of l_l_csa.a¢_d Access fo (arc ib the Inner City. A CbmpaHson of H _!0 at, d Nou-H_IO Populations abs. no. 209 Eqtm> m Health Serwec-s. ff_:_v_ncal Analyses in Social Polic). abs. no. 271 F_?mnc_'.,8 ttealth tia;c, abs. no. J 15 ",Yoing ba;e. c_ontmuance and _onvers_b_ Provisions m Health in,surance, abs. no. 330 _utdc [,_ _4cdic-a_c_ [);_ta 3'ource3 Volume One. abs no. 345
Enrollees Having Medicaid Eligibility. ahs. no. 95 Consumer Expenditure Patterns. Volume I. Food, Household Supphes, Persunni and HeMth Care Products. abs. no. 120 Containing Costs in Tht_d P_rty Drug Programs. Selected Bibliography and Abstracts. abs. no. 129 Cost-Effectiveness of a Restrictive Drug Formulary, Louistana vs. Texas. abs. no. 166 Determinants of Physician _tnd Pharmacist Support of Generic Drugs. abs. no. 202 Drug Coverage Under Natic,nal Health Insurance. The Policy Options. abs. no. 225 Drug Prcscn)at_bn Rates Befi_re andAfter Enrollment of a Medicaid Populat_bn in an HMO. abs. no. 226 Estimated Cost of Implementing the Regulations Limiting Payment Under Federal Health Prograt_s to ,_Iax#num Allowable Costs (MAC'S) and Estimated AcqmMtian Costs (EAC'S). _.bs. no. 274 Evaluation ot'the _lax_)-num Allowable Cost (,_IAC) for Drugs Program. Phase I Report. Final De.s_gn Report and Report of Pilot Study Analys_s. abs. no. 287 Expand_bg Health BcneI_ts lbr the Elderly. Volume IZ Prescrtption Drugs. abs. no. 290 Extending Canachan Health Insurance. Opt_bns for Pharmacare and Denticare, abs. no. 294 Federal Control o£Pharmaeeutical Costs. The _IAC Experience. abs. no. 303
Hcal:h and Taxes, An Assessment of the _$4edical Deduction. ab,,;, no. 3:53 Health Cam. An A:nedean Ctis'i._. abs. to. 355 Health Care __cm :b ihc L.nited St_te_. abs no. 379 Health. 5_ta._trophi_' 14eaich lilsL_ance, abs. no. 382 Healt,_ lo._tll_O_ _ 1;_ .qte t _tcd 5"tares. [mph'cations for the Uni:ed K_ngo d,,,_ a_ uo 3";'5
Health Care System in the United States. abs. no. 379 How Business Can Use SpecitTc Techniques to Control Health Care Costs. abs. no. 465 Impact of Comprehens;_ National Health Insurance on Demand for Health Manpower. abs. no 477 Insurance BenetTts, Out-of-Focket Payments, and the Demand for Medical
VII-30
Health
Care
Programs
Care. Managing aches, Medicaid National
A Review of the Literature. abs. no. 509 Medicaid Drug Expenditures. An Analysis of Divergent Approabs. no. 541 and Cash Welfare Recipients. An Empiricai Study. abs. no. 546 Health Insurance Issues. The Cost of a National Prescription Pro-
gram. abs. no. 623 Perspectives on Medicines Proceedings
in Society.
of the National
or Economic
Validity.
Conference
on Drug Coverage
Health
Expediency
Health,
to the Health
of Physicians'Services.
Evidence
Advance
in Medical
Care Industry.
Care.
bn Length.of-Visit.
abs. no. 16
Altering Medicaid Provider Reimbursement Methods. abs. no. 17 Alternative Physician Payment Methods. Incentives, Efficiency, and National Health Insurance. abs. no. 19 American Medical Association and Compulsory ance. American
National
Health
Insur.
The Molchng of Public Opinion, 1920-1965. abs. no. 28 Medicine. Challenges for the 1980s. abs. no. 29
Analysis of Economic Performance Can Fee-for-Service Reimbursement no. 57 Compensation
Arrangements
101 Conference and Unresolved Problems. Consequences of Increased Third-Party abs. no. 115 Cost Containment no. 150
Education
Cost Containment
Through
Hospitals
and Physicians.
abs. no. 112 Payments for Health
abs. no.
Care Services.
EtTorts in United States Mech'cal Schools. Risk-Sharing
by Primary
History of the Development of United Crisis in Health Care. abs. no. 173
Healthcare.
States,
Intluence
abs.
Care Physicians.
A
abs. no. 155
States.
for Containment. A Look
Ahead
of Competition
by Prepaid
of an Individual Practice tion. abs. no. 505
Group
Association.
and Demand
in the Market
Magnitude States.
Initiated
of Physician
abs.
of
Organizefor Mecb'cal
for Physician
Cost Containment
and Determinants abs. no. 534
Role
on the Development
Maintenance
Linking Physicians, Hospital Management, Medical Care. abs. no. 533
Serv,(ces. and Better
Visits in the United
Mail-Order Meda'cine. An Analysis of the Sears Roebuck Community Medical Assistance Program. abs. no. 535 Malpractice Crisis. What Was It All About. abs. no. 537
Foundatmn's
Malpractice. Funda'ng Emerges as a Critical Issue. abs. no. 538 Manpower Policy for Primary Health Care. abs. no. 543 Medicaid Mills. Fact or Fiction. abs. no. 550 Mech'cal Benet_t Cost Containment Medical 556
Drugs.
The
Insurance Beneffts, Out-of-Pocket Payments, and the Demand Care. A Review of the Literature. abs. no. 509
Group
Practice
in the U.S.A.
and Health
Maintenance
Medical Malpractice. The Response CahTornia. abs. no. 562
of Generic
Areas.
Practice Health
Determinants no. 202
Support
and the
Selected Notes for Future Policy. abs. no. 449 Current Issues and Descriptive Evidence. abs.
Medical Malpractice Insurance. A Legislator's Mecb'cal Malpractice Litigation Under National or Expendable. abs. no. 559 Medical Malpractice Suits. abs. no. 561
and Pharmacist
abs. no. 364
at the Supply
1980. abs. no. 428
Cutting Cost Without Cutting the Quality of Care. Shattuek Lecture. abs. no. 178 Demand for General Practitioner and Internist Services. abs. no. 186 Dental Prepayment Plans. abs. no. 196 of Physician
Toward a Uni_Ted The,ory
Access to Medical Care in Underserved Practice. abs. no. 494
Interaction of Supply abs. no. 515
in Medical Group Practices. abs. no. 33 Coexist With Demand Creation. abs.
Between
United
Initiatives
for the Nation. abs. no. 410
Hospital Cost Containment. Hospital.Based Physicians. no. 458 Improving Group
abs. no. 7
in the United abs. no. 362
Care Costs. Private
Health Manpower Requirements.
abs. no. 795
a Dose of Competition
Allocation
Under National
Admim_trative
Some Economic Consequences of Technological The Case of a New Drug. abs. no. 843 Physicians Adding
Health Care Cost lnllation of Cause and Control.
abs. no. 681
Health Insurance. abs. no. 734 Reimbursement Policy Under Drug Insurance.
Graduate Medical Education Nattonal Advisory Committee, Interim Report. abs. no. 338 Group Practice Recommendations of the Committee on the Costs of Medieel Care. A New Look at an Old Issue. abs. no. 343 Health. A Victim or Cause of InlTation. abs. no. 348
abs. no. 552 Organizations.
abs. no.
View. abs. no. 557 Health Insurance. Essential
of Physicians
to Premium
Increases
in
Doctors and Their Autonomy. Past Events and Future Prospects. abs. no. 219 Doctors and Their Workshops. Economic Models of Physician Behavior. abs. no. 220 Economic Foundations of National Health Policy. abs. no. 231 Economics of Medical Care. A Policy Perspective. abs. no. 238
Medicare and Medicaid Physician Payment Incentive_ abs. no. 573 Mech'care Assignment Rates of Physicians. Their Responses to Changes in Reimbursement Poh'cy. abs. no. 574 Medicare, Medical Practice, and the Medical Profession. abs. no. 578 Mental Disorder and Primary Medical Care. An Analytical Review o1"the Literature. abs. no. 584
Economics of Medical Malpractice. abs. no. 239 EtTect of Physician-Controlled Health Insurance. abs. no. 243 Effectiveness of Alternative Approaches to Utilization Review uians Ofl_ce Practices. abs. no. 8011
National Ambulatory Medical Care Survey. 1977 Summary United S_tes, January-December 197Z abs. no. 598 National Health Insurance, Canada's Path, America's Choices. abs. no. 618 National Health Insurance in Canada. abs. no. 620
Eta'cots of Financial
Incentives
on Physicians"
Specialty
of Physi-
and Location
Duel-
On the Cost of National
Health
Insurance
in Quebec.
abs. no. 661
sions, abs. no. 250 Ethical and Economic Aspects of Governmental Intervention in the Mech'. cal Care Market, abs. no. 278 Evaluation of Mech'cal Practices. abs. no. 284 Evaluation of the Effects of National Health Service Corps Physician Placemeats on Medical Care Delivery in Rural Areas. abs. no. 8013 Fee-Fur-Service Health Maintenance Organizations. abs. no. 307 Fee-for-Service Physician Payment. Analysis of Current Methods and Their Development. abs. no. 308 Financial Management Under Third Party Reimbursement. abs. no. 312
On the Rationing of Health Services and Resource Availability. abs. no. 662 Pain and Pro/it. The Politics of Malpractice. abs. no. 667 Participation of Private Practice Dentists in Mech'caid. abs. no. 668 Per-Case Reimbursement for Mech'cal Care. Final Report. abs. no. 675 Physician Acceptance of Medicaid Patients. abs. no. 682 Physician and Cost Control. abs. no. 683 Physician Control of Blue Shield Plans. Staff Report. abs. no. 684 PhysicJan Glut Will Force Hospitals to Look Outward. abs. no. 686 Physician Licensure. Competition and Monopoly in American Medicine, abs. no. 687
Geographic Variation in Physicians" Fees. Payments Medicare and Medicaid abs. no. 335
Physician Migration in Response to Income Opportunities Health Insurance in Quebec. abs. no. 688
to Physicians
Under
Under
Unive, rsal
VII-37
Physician Participation in health Insurance Pl_qs. Evidence on l_lue Shield. abs. no. 689 Phyaician Participation in State ,_led_caid Programs. abs. no. 690 Physician Reimbursement and Hospital Use in H_IOs. abs. rto. 691 Physician Responsibility for the Cost of Unnecessary Medical Services. abs.
Checkbook's GLude to Health Insurance Plans for Federal Employees. For Distr_ct of Columbia, Maryland, and Virginia (Also covers D.C Oovernmeat Employees), abs. no. 83 Competing tbr Acute Care Dollars. The Economics of Risk Reduction. ahs. no. 102
no. 692 Physician-Induced Demand for Medical Care. abs. no. 693 Physicians" Charges Under Medicare. Assignment Rates and Liability. abs. no. 695
Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Volume VIII, Overview. abs. no. 110 Contrnlhng the Costs of I',etirement Income and Medical Care Plans. abs. no. 142
t_eneticia;y
Physicians for the Future. abs. no. 696 Physicians' Knowledge of Cost. The Case of Diagnostic Tests. at_s. no. 697 Price Setting in the Market for Physicians" Services. A Review of the Liters. tare. abs. no. 722 Private Cost Containment. abs. no. 727
Corporate Role in Containing Health Care Costs. abs. no. 145 Cost Containment Through Risk-Sharing by Primary Care Physicians. A History of the De velopment of United Healthcare. abs. no. 155 Cost of Benellts for Alcoholism in a National Health Insurance Program. abs. no. 158
Private
Cost of Catastrophic
Physicians
and Public Programs.
abs. no. 732
abs. no. 159
Cost-Financed Mental Htalth Facility. abs. no. 168 Costs, Financing, and Dis,_ributionai Effects of a Catastrophic Supplement to Medicare. al0s. no. 170 Dental and Vision Care _enetlts in Health Insurance Plans. abs. no. 189 Dental Insurance Plans. aas. no. 195
Regulatory Responses
Digest of Selected Health and Insurance 1977- 79 Edition. abs. no. 209
Environment for Physician Compensation. abs. no. 789 of Canadian Physicians to the Introduct_bn of Universal Meda_al
Care Insurance. Resurvey of Private Role Role
The First Five Years in Quebec. abs. no. ;$04 Practice Physicians, 1979. abs. no. 8037
of Health Insurance in the Health Services Sector. abs. no of Physician Education in Cost Containment. abs. no. 818
Social Aspects no 833 Some _ffeets
of the Rate Structure of Quebec
Health
of Medical
Insurance.
Malpractice
Drug Coverage no. 225
8 t6
Insl_rance.
Economic 233 abs
Economics
Under National
Viability
Health
Plans. Insurance.
of Community-Operated
in Health
Volume I. Health
abs. no. 844
Benel_ts.
The Policy Options.
Prepaid Health
abs.
Plans. abs. no.
Cart'. abs. no. 235
EmpitT_ial Study of the Differences Between Family ibles in Health Insurgs_ce. abs. no. 257
and Individual
Deduct-
Strategies for Controlling the Cost of State _Iedical Assistance Programs. abs. no. 861 Study of Physician Reimbursement Under _led_care and ]ledicaM. Volume /.abs. no. 866
Employee BeheSts In Ind_stry. A Pilot Survek: abs. no. 258 Employment Related Health Benefits in Private Nonfarm Business Establishments in the United States. Volume I1. Description of Selected Data. abs, no. 264
Study of Physician Reimbursement lI. abs. no. 867
Estimating Evaluation
Dnder Medicare
and _Iedicaid.
Study of Physicians" Fees. abs. no. 868 Study of the Responses of Canadsan Physicians to the Introduction versai MedJ_al Care Insurance. The First Five Years in Quebec. 872 Supply Elasticities
Plan
lllness,
Quali(y Health Care. The Role of Continbing Medical Education. abs no. 769 Quality of Meclical Care. abs. no. 770 Rates of Surgical Care in Prepaid Group Practices and the LTdependent Setting. What Are the Reasons for the Differences. abs. no. 773
for Physician
Services.
Voh_nc
of Uniabs. no.
the Cost of Health Insurance Programs. abs. no. 277 of Market _gleehanisms of Cost Control. abs. no. 283
Financing Health Care. abs. Jlo. 315 Going Bare. Conu)Tuance and Conversion abs. no. 336 Group Benefit Survey. Plazas Covenhg ers, 1980. abs. no. 340
abs. no. 878
Provisions
in Health
Salaried Employees
Insurance.
of U.S. Employ-
Survey of Recent Research in Health Economics. abs. no. 882 Technology and the Governance of the Health Care lndustr)_ The Dilemma of Reform. abs. no. 891 Use of Physician Services Under Two Prepaid Plans. abs. no. 922 Who htitiates Visits to a Physician. Data Preview 3. abs. no, 939
Group Insurance Cost Containment Strategies. abs. no. 342 Group SpecitTc and Aggregate Stop-Loss Insurance. An Attractive Market. abs. no. 344 Health Care, An American Crisis. abs. no. 355 Health Care Business. International Evidence on Private Versus
Women's Health Movement. no. 944
Health Care Systems. abs. no. 356 Health Care Cost Containment. Challenge to Industry. abs. no. 357 Health Care Cost Containment Experiments. Policy, Individual Rights, and the Law, abs. no. 358 Health Care Costs, Private Initiatives for Containment. abs. no. 364 Health Insurance Coverage for Alcohol/Drug Addiction Treatment for Vir. ginia State Employees. A Feasibility Evaluation. abs. no. 391
Feminist
Alternatives
to Medical
design/program provisions (under health plans) Adequacy of Private Health Insurance Coverage. abs. no. 8 Ambulatory Care Systems, Volume IV. Designing Medical Health Maintenance Organizations. abs. no. 23
C,gntrol, abs.
Services
for
Background Papers on Industry's Changing Role in Health Care Delivery. abs no, 46 Benel_t R_ghts and Privacy. The Insurance System and Fertili(y Control. abs. no. 48 Benefits in Medical Care Programs. abs. no. 49 Can Health Maintenance Organizations Be Successful. An Ana(vsis ot' 14 Federally Qualified HMOs, abs. no. 59 Canadian National Health Insurance. Lessons for the United States. abs. no. 63 Catastrophic Health Insurance. abs. no. 72 Changing Patterns and Implications for Cost and Quality of Dental C_a_e. abs. no. 79 Characteristics of Group Health Plans. abs. no. 8005
VII-38
New
Public
Health Insurance Coverage for Alcoholism, 1975. abs. no. 392 Health Insurance Industry, Structural and Strategic Issues in an Uncertain Environment. abs. no. 396 Health Insurance Study. ahs. no. 8020 Health Meantenance Orga_izations, A Guide to Planning and Developmeat. abs. no. 403 Histot4cal Development of the California Pilot Program to Provide Health Insurance Coverage lot Alcoholism. abs. no. 432 History and Organization of Pretreatment Review, a Dental Utilization Review System. abs. no. 433 HMOs From the Management Perspective. abs. no. 436 Hospital Inflation. A Diag_,osis and Presertption, abs. no. 452 How Cheap is a Life. abs. no. 467
Health Care Programs
Impact Impact
of HMOs. Evidence and Research Issues. abs. no. 480 of National Health Insurance on the Use and Spending
Correcffon Services. abs. no. 483 Impact of the Rhode Island Catastrophic 489 Mech'caM
Experience.
Health
Insurance
for Sight
Plan. abs. no.
Analysis of Programs to Limit Report. abs. no. 34
Mech'cal Care Plans. How to Control the Costs. abs. no. 553 Medical Technology. A Different View of the Contentious Debate Costs. abs. no. 565 Medicare Second Surgical Opinion Demonstration Project. Greater
Over New
Capital
Expenditures.
Draft Final
Analysis of Requirements for a Cost Benefit Structure for the Military Medical System With Initial Focus on CHAMPUS. abs. no. 36 Better Services at Reduced Program Recommended
abs. no. 548
Hospital
Costs Through an Improved for Veterans. abs. no. 50
"'Personal
Care"
Can Health Maintenance Organizations Be Successful. An Analysis of 14 Federally Ouali6ed HMOs. abs. no. 59 Cancer Insurance. Exploiting Fear for ProtTt. An Examination of Dread Disease Insurance. abs. no. 64
York. abs. no. 581 National Commission on the Cost of Medical Care. 1976-1977. Volume 1. Commission Recommendations Task Force Reports Research Agenda.
Capital Requirements and Capital Financing in a Hospital.Based Group Practice Prepayment Plan. abs. no. 65 Care of the Aged. Old Problems in Need of New Solutions. abs. no. 66
abs. no. 599 National Health Insurance
and Corporate
Carter Administration, Congress Conference. abs. no. 67
National
and Health
Health
Insurance
ence. airs. no. 610 National Health Insurance
BenetYt Plans.
Resources.
and the Market
The European
Health Insurance Health Insurance
Experi-
for Private Psychiatric
abs. no. 613 National Health Insurance in the Federal Repubh'c Implications for U.S. Consumers. abs. no. 621 National National
abs. no. 609
Services.
of Germany
and its
Issues. The Adequacy of Coverage. abs. no. 622 Issues. The Cost of a National Prescription Pro-
gram. abs. no. 623 New New
Case for a National
Service.
A National
Lesd.=,rship
abs. no. 68
Chip Commission. Final Report. abs. no. 86 Competition and Regulation. The Consumer Choice rive. abs. no. 103 Competi_on 105
in the Health
Care Sector.
for Change in the Health
Conference on Health Promotion 1978. Volume If. Conference
abs. no. 647
Policy.
Case for Negotiated Rates. abs. no. 69 Child Health. America's Future. abs. no. 84
Conditions
Group Health Insurance. abs. no. 644 York State Long Term Health Care Program.
Health
and Health
Past, Present
Care System.
and Disease Summaries.
Health
Plan Alterna-
and Future.
abs. no.
abs. no. 111
Prevention, February abs. no. 114
16-18,
Note on the Comparison of the Hospital Cost Experience of Three Competing HMO's. abs. no. 650 Overview of Health Insurance Study Pubh'cations. abs. no. 666
Consumer Participation and Community Organization Practice, Implications of National Health Legislation. abs. no. 122 Consumer-Centered vs. Job-Centered Health Insurance. abs. no. 126
Perceived Health Insurance Coverage. abs. no. 676 Potential Impact of Mandatory Cafeteria Style Health the Cost of Health Insurance. abs. no. 8033
Consumer-Choice Health Plan. A National-Health-Insurance Proposal Based on Regulated Competition in the l_7"vate Sector, abs. no. 127 Consumer-Choice Health Plan. Inflation and Inequity in Health Cnte To-
Private Sector 733 Proceedings Health
Perspective
on the Problems
of the National Conference Insurance. abs. no. 734
Proceedings. 27th Annual Group Health June 19-22, 1977. abs. no. 736
of Health
Benelit
for
Care Costs. abs. no.
on Drug Coverage Institute,
Programs
Under National
Los Angeles,
Cz_Tornia,
day. Alternatives National Health Controlling Controlling
for Cost Control and an Analysis Insurance. abs. no. 128
of Proposals
for
MedJczu'd Utilization Patterns, abs. no. 138 l_'sing Hospital Costs. abs. no. 139
Cost and Regulation no. 146
of Medical
Technology.
Future
Poh'cy Directions.
abs.
Prol_le of Employee BenetTts. abs. no. 739 Rate-Making Process for Developing Plans. abs. no. 772 Restructuring Federal Mesh'enid Controls and Incentives. abs. no. 807 Second Surgical Opinions. What Have We Learned. abs. no. 823
Cost Containment and Ouah'ty Assurance Requirements for Third Party Coverage for Ambulatory Psyclu'nttic Care. abs. no. 148 Cost Containment. Medical System Rehabilitation or Reform. abs. no. 153 Cost of Catastroptu'c Illness. abs. no. 159
Social Medicine. abs. no. 834
Cost Reimbursement no. 163
The Advance
of Organized
Health
Services
in America.
and Price Competition
Social Security Programs Throughout the World, 1977. abs. no. 837 State Employee Health Insurance Plans. A Survey of Coverage, BenelYts, Financing. abs. no. 852
Cost-Effec_'veness Costs, Financing, to Medicare.
State
Council on Wage and 1_7"ceStnbib'ty Report abs. no. 172
Health Legislation Catastrophic Health
Report Vol. 8 No. 3. State Comprehensive Insurance Legislation. abs. no. 853
and
in the Hospital
Industry.
of Primary and Secondary Prevention. abs. no. 167 and Distributional Effects of a Catastroptu'c Supplement abs. no. 170 on Rising Health
Care Costs.
Steps to Control lnllation in Health Care Costs. abs. no. 860 Strategies for Financing National Health Insurance. Who Wins and Who Loses. abs. no. 862 Textbook for Employee BenezTt Plan Trustees, Adrm'nistrators and Advi-
Current Emphasis on Preventive Meda'uine. abs. no. 176 Deinstitutionah'zation and Mental Health Services. abs. no. 181 Delivery of Health Care in America. abs. no. 182 Deb'very of Health Care in Urban Underserved Areas. abs. no. 183
sots. abs. no. 897 Use of Physician Services Under Two Prepaid Plans. abs. no. 922 V_ations in Utilization of a Multi-State Company Dental Plan. abs. no. 927
Dental Care for Handicapped People. Special Report. abs. no. 193 Disnbih'ty. From Social Problem to Federal Program. abs. no. 211 Disabih'ty Insurance. Trends Since World War II. abs. no. 214
Working
Disability Policies and Government Progrnms_ abs. no. 215 Doctors and Their Workshops. Economic Models of Physician abs. no. 220
Policy
With the Insurer.
abs. no. 948
initiatives
Achievements and Problems of Medicaid. abs. no. 4 Alternative Services. The Case of Free Chnies. abs. no. 20 Alternatives 8001
to Institutional
Alternatives
to Nursing
Alternatives
to Prepayment
Care. An Analysis
Homes.
Doing Better and Feeling abs. no. 223
of State Initiatives.
abs. no.
abs. no. 21
Finance
for Hospital
Drug Coverage no. 225 Economics
Services.
abs. no. 22
Employment
and
abs.
Worse.
Under National the Chronic
Related
The Poh'tical Pathology ttealth
Mental
Health Benelfts
Insurance.
Patient.
Beh.zvior.
of Health
Policy.
The Policy Option..;. abs.
abs. no. 234
in Private
Nonfarm
Business
E,stab-
VII-39
lishments in the United States. Volume L Dete__minants of ,_e DecisiorJ by Establishments to Offer a Group Health Plan. abs. no. 263 Entering a Nursing Home. Costly Implications for Medicald arid the £'lda,'1): abs. no. 267 Estimating the Cost of Health insurance Programs. abs. no. 277
How Interested Groups Hare Responded to a Proposal for Economic Cornpetition in Health SeTvic'cs. abs. no. 468 How Things Work in the Real World of Hospital Finance. abs. no. 47l Idea Whose Time Has Come, Less Health Insurance. abs. no. 473 Illness Prevention and Medical Insurance. abs, no. 474
Expanded Health Expanding Health no. 289
Incentive Tax for Medacare, Medicaid no. 496 Income and Illness. abs. no. 497
Care CoveraBe Alternatives. abs. no. gO 15 BenetTts for the Elderly. Volume L Lung- Terr:l Care
abs.
and National
Health
Insurance.
abs.
Expanding Health BenelTts for the Elderly. Volume H Prescription Drug_. abs. no. 290 Expenditures for Health Care of Children and Youth in the UJ:ited States. abs. no. 292 FederM Control of Pharmaceutical Costs. The MAC Experier_ce. abs. no. 303
Increases in Hospital Expenses, 1976-1979. A Companion of Ststes With Mandatory Cost ContMnment Programs and States Without Mandatory Cost Containment ProBrams. abs. no. 49g Insurance, Regulation, and Hospital Costs. abs. no. 512 Issues in Dental Health Policies. abs. no. 519 Legislative Response to #,,e &Iedscal Malpractice Crisis: Constitutional lm-
Final Report to the Legislature on Ambulatory Care. abs. no. 309 Forward Plan for Health FY 1978-82. abs. no. 320 Framework for Capital Controls in Health Care. abs. no. 323 Future Roles for the Federal Government in the Development of HMO's. abs, no. 334 Graduate Medical Education National Advisory Committee, L_tetTin Report, abs, no, 338
plfcations, abs. no- 530 _fajor Issues in the Financ_hg and Management of Health Care. abs. no. 536 Malpractice Crisis. What Was It All About. abs. no. 537 Malpractice. Fundsn 8 Emerges as a Critical Issue. abs. no. 538 The Malpractitioners, abs no. 539 Medicaid and Cash Welfare Recipients. An Empirical Study. abs. no. 546 MediCaid. Current Issues and Potential Reforms. abs. no, 547
Group Practice Recommendations" of the Committee on the Costs oI',SdeCbcat Care. A New Look at an Old Issue. abs. no. 343
MedicaM Experience. Medical ,hdalpractice
Health. Health Health Health Health Health
Medscal Malpractice Suit.,;. abs, no. 561 Medical Malpractice. The Response of Physicians to Premium Increases in California, abs. no. 562 Medical Technology and Hospital Costs. abs. no. 566 ,_:Iedical Technology. The Culprit Behind Health Care Costs. abs. no. 568 Medically Indigent. A State Perspective on a National Problem. abs. no. 570
A Victim or Cause of [ntTation. abs. no. 348 and Health Care. Policies in Perspective. abs. no. 349 and Retirement. Policy and Research issues, abs. no. 352 and the War on Poverty. A Ten- Year Appraisal. abs. r:o. 354 Care Cost Containment. Challenge to Industry. abs. no. 357 Care Cost Increases. abs. no. 361
Health Care Costs. Why Regulation Fails, Why Competition to Get There From Here. abs. no. 365 Health
Care Financing
Options
for Colorado.
Ebrks,
itow
abs. no. 368
abs, no. 548 Insurance. A Legislator's
Medicare After 15 Years. Has It Become abs. no. 571 Medicare
and _dedicaid
Fhysician
View, abs. no, 557
a Broken Promise
Payment
incentives,
to the Elderly.
abs. no. 573
Health Care in the American Economy. Number 3. abs. no. 370 Health Care Policy and Poh'tics. Does the Past Tell Us Anything, About the Future. abs. no. 375 Health Care System in the United States. abs, no. 379 Health, Catastrophic- Health Insurance. abs. no. 382 Health Costs Can Be Reduced by ,_/[illions of Dollars if Federal Agencies Fully Carry Out GAO Recommendations, abs. no. 384 Health Maintenance Organizations as an Instrument for Cost Containnwnt Poh_y. abs. no. 405 Health Maintenance Organizations, Federal Financing is Adequate Bu_ HEW Must Continue Improving Program Management. abs. no. 407 Health Plan. The Only Practical Solution to the SoatTh 8 Cost uf Medical Ca_,e. abs. no. 412
Medigap, States Response to Problems with Health Insurance for the Eiderly, abs. no. 583 Modifying ,_redicald Eligibility and BenetTts, abs. no. 595 National Health Insurance Proposals. Provisions of Bills Introduced in the 9,lth Congress as of F,_,bruary 1976. abs. no. 626 National Health Insurance. 96th Congress second session, Volume Z abs. no. 631 National Health Insuranae_ 96th Congress second session, Volume 3. abs. no. 632 National Health Program rut Infants, Children and Youth, abs. no. 633 National H_IO Development Strategy Through 1988. abs. no. 636 New Directions in Public F-lealth Care. A Prescription for the 1980s. abs. no. 643
Health Planning no. 416
New Health Professionals, abs. no. 645
Health Health Health
in the United States. Issues in Guideline
Development.
abs.
Promotion Programs in Occupational Settings. abs. no. 417 Services Research. abs. no. 421 Status and Use of Mech_al Services. Evidence on the Poor, the Bh_ck,
and the Rural Elderly. abs. no. 422 High Cost of Hospitals and What to Do About lt. abs. no. 431 Historical Development of the California Pilot Program to Provt_¢ Health Insurance Coverage for Alcoholism. abs. no. 432 Home Health. The Need for a National Policy to Better ProvAle for the Elaerly. abs. no. 438 Homemaker Services. Essential Option for the Elderly. abs. no 439 Hospice,. Prescription for Terminal Care. abs. no. 442 Hospital Cost Contm)Tment Act of 1979. abs. no. 447 Hospital Cost Containment Programs. A Policy Analysis. abs. no. 448 r Hospital Cost Containment. Selected l_otes for Futlzre Policy. abs. no. a.49 Hospital lntqation. A Diagnosis and Prescription. abs. no. 452 Hospital Production. Can Costs Be Contained. abs. no. 453 Hospital-Based Physicians. Current Issues and Descriptive Evidence. abs. no. 458
VII-40
Nurse
Practitioners
and Physician
"s Assistants.
On Broadening the DelTni.ffon of and Removing Regulatory BartTers to a Competitive Health C_,:e System. abs. no. 658 Opening Up the HeMth System. Public and Private Sector Friction. abs. no. 663 Ordering Social Objectives. National Health Service and National Health Insurance as Policy Options in Organizing the Medical Care System. abs. no. 664 Over_ew of Health Insurance Study Pubh_ations. abs. no. 666 Pain and Protit. The Politios of Malpractice. abs. no. 667 Patient Outcomes in Three Alternative Long-Term Care Settings. abs. no. 669 Paying for Ph)_iclan Services Under Meek'care and Medicaid. abs. no. 671 Perspecnves on Health Promotion and Disease Prevention in the United States. abs. no. 680 Physician Extender Reimb_arsement Experiment. abs. no. 685 Phys_ctan Participation in State MediCaid Programs. abs. no. 690 Physician Reimbursement and Hospital Use in HMOs. abs. no. 691 Physicians arid New Health Practitioners, Issues for the 1980s. abs. no. 694
Health Care Programs
Physicians for the Future. Policy Issues in Financing Potential for a Compe_tive
abs. no. 696 Mental Health Services. abs. no. 702 Health Care System in Boston, Massachusetts.
abs. no. 710 Potential Impact of Mandatory
Cafeteria
Style Health
BenelTt Programs
for
Societal Responsibility for Malpractice. abs. no. 841 Some State and Federal Perspectives on Medicaid. abs. no. 846 Spy in the House of Medicine. abs. no. 850 Standards for Adequate Minimum PersonM Health Service& Status of Competition in the Health Industry. abs. no. 859
abs. n_,. 851
the Cost of Health Insurance. abs. no. 8033 Poverty and Health. Economic Causes and Consequences of Health Problem& abs. no. 712 Preliminary Results From a Risk.Sharing Health Maintenance Organization. abs. no. 715
Structure of Health Insurance and the Erosion of Competition in the Medical Marketplace. abs. no. 864 Study of Health Maintenance Orgaru'zations. abs. no. 8043 Study of Physician Reimbursement Under Medicare and Medicaid. Volume II. abs. no. 867
Prel_id Private
Supplementary 877
Health Plans and Health Maintenance Organizations. abs. no. 717 Health Insurance BenelTts for Alcohoh'sm, Drug Abuse and Mental
Illness. abs. no. 728 Pn'vate Health Insurance to Supplement ProceedJbgs of the National Conference Health Insurance. Profile of Health-Care Promoting
Medicare. Volume/. abs. no. 730 on Drug Coverage Under National
abs. no. 734 Coverage. The H_ves and Have-Nots.
Competition
in the Health
ninE. abs. no. 743 Promoting Health. Consumer
Industry.
Education
The Role
and National
abs. no. 740 of Health
Policy.
abs. no. 744
Proposals Proposals
for the Regulation of Hospital Costs. abs. no. 746 to Restructure the Financing of Private Health Insurance.
747 Proposed
Framework
for Health
and Health
Care Policies.
Plan-
abs. no.
abs. no. 748
Health Insurance
and Cost-Consciousness
Strategy.
abs. no.
Surgical Innovation and Its Evaluation. abs. no. 879 Tax Subsidies for Medical Care. Current Policies and Possible Alternatives. abs. no. 889 Technology and the Governance of Reform. abs. no. 891 Terminal
Care. Issues
Third Party Payment Recommendations.
of the Health
and Alternatives,
Care Industry.
The Dilemma
abs. no. 896
for Nonphysician abs. no. 900
Health
Practitioners.
Realities
and
Third-Party Payments for New Health Professionals. An Alternative Fractional Reimbursement in Outpatient Care. abs. no. 902 Thirty-To-One Paradox. abs. no. 903
Health
Needs
of the Aged and Medical
to
Solutions.
Pubh'c Hospital and its Local Ecology in the United States. Some Relationships Between the "'Plight of the Public Hospital"and the "Plight of the Cities". abs. no. 763 Public Insurance in Private Medical Markets. Some Problems of National
Too Old, Too Sick, Too Bad. Nursing Homes in America. abs. no. 905 Toward a Community-Based National Health Service. abs. no. 906 Toward a National Health Policy. Pubh'c Poh'cy and the Control of H_althCare Costs. abs. no. 907
Health Insurance. abs. no. 764 Quah'ty Assurance in Health Care. abs. no. 768 Quality Health Care. The Role of Continuing Medical Education. abs. no. 769 Rapid Rise of Hospital Costs. abs. no. 771 Reducing Medicaid Expenditures Through Family Responsibility. Critique of a Recent Proposal. abs. no. 778 Reductions in Public Health Care Coverage. abs. no. 8036 Reform and Regulation in Long-Term Care. abs. no. 779 Regulating Hospital Costs. The Development of Public Policy. abs. no. 782 Regulation of Health Facih'ties and Services by "CertilTcate of Need. '. abs.
Toward a Physician Payment Poh'ey. Evidence From the Economic Stabilization Program. abs. no. 908 Use of Tax Subsich'es for the Cost of Comph'anee With Safety and Health Regulations. abs. no. 923 Utilization and Cost of Mental Illness Coverage in the Federal Employees Health BenelTts Program, 1973. abs. no. 924 Veterans Administration Hospitals. An Economic Analysis of Goverr_rnent Enterprise. abs. no. 930 Working Papers on Major Budget and program Issues in Selected Health Programs. abs. no. 947
no. 788 Reimbursement or Economic
Policy Under Drug Insurance. Validity. abs. no. 795
Administrative
Expediency
Relationship Between Diagnostic Information Available at Admission Discharge for Patients in One PSRO Setting. abs. no. 796
and
Policy/changes re health care Adding a Dose of Competition to the Health Care Industry. abs. no. 7 Adnu'nistration's Program for Health Cost Containment. abs. no. 9 American Biomedical Network. and Future. abs. no. 26
Health
Care Systems
Report of the HEW Task Force on Implementation of the Report to the President From the President's Commission on Mental Health. abs. no.
American ance.
799 Report to the President From the President's Health. Volume/. abs. no. 801
Blue Cross. What Went Wrong. abs. no. 52 Can Fee-for-Service Reimbursement Coexist no. 57
Research
and Demonstrations
no. 802 Responsibility
of Families
in Health
Commission
Care Financing,
for Their Severely
Disabled
on
Mental
1978-1979.
Elders.
abs.
abs. no. 805
in America
Medical Association and Compulsory National Health The Molding of Pubh'c Opinion, 1920-1965. abs. no. 28
Catastrophic
Health
Insurance.
With Demand
abs. no. 72
Catastrophic Illness Expense. Implications United States. abs. no. 73
for National
Health
Comprehensive Market and Regulatory Strategies for Medical no. 109 Conference and Unresolved Problems. abs. no. 112
Review of the Medical 811
Controlling 134
Rising
Health
Costs.
Problem
Public and Private
in the United
Responses.
States.
abs. no.
abs. no. 813
Rising Hospital Costs Can Be Restrained by Regulating Payments and Iraproving Management. abs. no. 814 Role of State and Local Governments in Relation to Personal Health Setvices, abs. no. 819 Rx for Health Care Economics. Competition, Not Rigid NHI. abs. no. 821 Setting National Priorities. Agenda for the 1980's. abs. no. 830 Social Perspective on Risk Reduction. abs. no. 836
Cost Control
Health
Care Costs. A National
Challenge
Insur-
Crestiur_. abs.
Restructuring Federal MedJ'cau_t Controls and Incentives. abs. no. 807 Rethinking Health Po_'cy for the Elderly. A Six-Point Program. abs. no. 809 Rethinking National Health Insurance. abs. no. 810 Malpractice
Present
for Hospitals.
Leadersltip
Poh'cy in the
Conference.
C_re, abs.
abs. no.
abs. no. 156
Deciphering Deinstitutionalization. Complexities in Policy and Program Analysis. abs. no. 180 Dental Care for Everyone. Problems and Proposals. abs. no. 192 Description of the Health Financing Model. A Tool for Cost Estimation. abs. no. 198 Determining Health Needs. abs. no. 203 Diagnosis and the Dole. The Functlbn of Illness in American Distributive
V]II-41
PoJi'tics. abs. no. 206
_19
Doi)_g Oetter and Feell)_g WOrse. 7he Poiltlcai t'ntholog) ot'He_t;th Policy. abs. no. 223 Economic Foundations of National Health Policy. abs. no. 231 Economics in Health Care. abs. no. 235 Economics of ?dedical Care. A Policy Perspective abs. no. 238 Effect of Unemployment Insurance Payments on the Health lnsu._nce _bv-
Need.s o! the Elderly. abs. no. 639 Opemng Up the Health Sy,.tem. Public and Private Sector Friction. abs. no. 663 Paymem" tot ttospital Services. Objectives and Alternatives. abs. no. 673 Physk'ian Responsibilicv for the Cost of Unnecessary ,_Iedic'al Services. abs. no. 692
erage of the Unemployed. abs. no. 246 Effects of Hospital Cost Containment on the DcvelopmerJt
Physl_a._s amI New Healttt Practitioners. Issues for the 1980s. abs. no. 694 Politics and Economics of Hospital Cost Containment. abs. no. 706
a_fd Use of
Mech_al Technology. abs. no. 251 Employer Provided Group Health Plans and the L,q_employed. a_s. no. 1262 Epidemiologic Revolution, National Health Insurance and the Role of Health Departments. abs. no. 268
Politics or Health Care. abs. no. 707 Polls Health Insurance. aT:s. no. 709 Preventive Medicine USA. Health Promotion tion. abs. no. 721
Equity in Health Services. EmpiriCal Analyses in Somal Policy. abs. no. 271 Federa/ Health Dollar, 1969-1976. A Charthook Analys_s of Acn ,'ities 5upported and Strategies Pursued _)_Federal Expe_Tdltures for Health. abs. no. 305
Pricing, Demanders, and the Supply of Health Care. abs. no. 723 Proposals foI National Health Insurance in the USA. Origins and Evolution, and some Perceptl_ns rot the Future. abs. no. 745 Prospects and Problems in Health Services Research. abs. no. 755
Fee-for-Service Physician Payment. Analysis Development. abs. no. 308 Financing Health Care. abs. no. 315 FinancJhg of Health Care. abs. no. 317
Prospects for Health Services in the United States. abs. no. 756 Public Choice m Health. Problems, Politics and Perspectives on Formulating National Health Policy. abs. no. 761 Public Healt,# and the Law. Issues and Trends. abs. no. 762
Future Issues in Health Care. Social Services. abs. no. 331 Health Health
Policy and
A_'ecting
Legislative
:_leti_od.,_ and T_)eir
:he Rationing
and Labor Power. A Theoretical lnves_l)gat_on, Care. An AmeriCan Cn_is. abs. no. 355
Health Care Cost Elements ooi_s, abs. no. 360 Health Care in Transition. Health Health Health Health Health Health
ot'CL_rent
o,r _ted,'ca:
abs. no. :LS1
a_td Planm)_g
('bnsidera-
abs. no. 372
Care Pohk'y in a Chang_)_g Environment. abs. no 376 Care. Regulation, Economics, Ethics, Practice. abs. no. 377 Cost Problem. Is Regulation Our Only Hope. abs. no. 3'.';3 Insurance Bibl_bgraphy. abs. no. 390 Insurance. What Should be the Federal Role. abs. no. 399 Reform. The Outlook for the 1980s. abs. no. gl8
Repeated Hospitalization lot the Same Health Chats. abs. no. 798
and Consumer
Disease.
A Multiplier
Rising Cost of Catastrophi,: Illness. abs. no. 812 Social MedJk'me. The Advance of Organized Health abs. no. 834 Social Nature of Chronic Strategies in," Controlling
Health
Educa-
of National
Services
in Amends.
Disease and Disability. abs. no. 835 t_e Cost of State Medical Assistance
Programs.
abs. no. 861 Systems Approach to Heah'h Insurance Policy Information. A Preliminary Taxonomy of Health Insurance Issues, Program Options, Problems and Solutions. abs. no. 885 Technology and the Goverrmnce of the Health Care Industry. The Dilemma of Reform. abs. no. 891
HMOs and the Politics of Health System Reform. abs. no. 435 Hospital Care tn America. ahs. r_o. 445 Impact of Health System Changes on the Nat_On '_ Requsremencs for Registered Nurses in 1985. abs. no. 479 Improving Health in America. U.S. Pubhc HcaitI, Scrvtce High, lights of 1977-80. abs. no. 495 lntlation, Unemployment and the Medicaid Program. abs. no. 504 InHuencing Federal, State, and Local Oral Health Policies. abs. no. 506
Technology and the Quality of Health Care. abs. no. 892 Trends in Multihospital Systems. A Multiyear Comparison.
abs. no. 911
Premium determination/tmder_riti_g Build Study 1979. abs. no. 54 Can Health _taintenance Organizations Be Successful. An Analysis of 14 Federally Quali_Ted HMOs. abs. no. 59 Containing Health Benet_t Costs. The Self-Insurance Option. abs. no. 130
Information Needs of National Health Insurance. A Discussion of Pri_,ciplea, Issues, and Legislative Recommendations abs. no. 50_ Interfacing National Health Insurance and Income ._Iaintena_,ce. Why Health and Welfare Reform Go Together. abs. no. 516
Costs. Financing, and to Medicare. abs. Determining Present Dollars and Sense of
Issues ia Health Care Regulation. abs. no. 520 Issues Involved in the Development of a Prepaid Cap_tion Plan/or LongTerm Care Services. abs no 522 Linking Physicians. Hospital _4anagem_nt, Cos_ C_mtainment _,_d Bcltcr ._4e,hZ'al Care. abs. no. 533 34agnitude and Determ_)_ants of Phys_zan hn't_atcd V_sits in t._e Uni,!ed States. abs. no. 534
Financial Analysis of Alternative Methods of Funding Bene/Tts. abs. no. 310 Group Benefit Survey. Plan:;' Cbvering Salaried Employees ers, 1980 abs. no. 340 Group Spect_c and Aggre_;ate Stop-Loss Insurance. An Market. abs. no. 344 Health Care Guidance. Commercial Health Insurance and
Mcd_'a; Technology_ Policies and Problems. abs. no. 567 Med_ca;-e. The Politics of Federal Hospital Insurance. abs. t_o. 582 National Commission on the Cost of Medical Care. 1976-197Z _blume 1. Commission Recommendations Task Force Reports Researc_ Agenda. abs. no. 599
Policy. abs. no. 369 Hosp_2al Self-Insurance Pro,_ram. Employee ,_IedicM Benet_ts. abs. no. 457 How Business Can Use Spe,_.itYc Techniques to Control Health Care CostS. abs. no. 465 Individual Accident and Health Loss Ratio Dilemma. abs. no. 499
National Commission on the Cost of ,_ledical Care. 1970-197Z _blume 2. Collected Papers. abs. no. 600 National Health Insurance as an Issue in Political _.onom)_ The Implications of the Kennedy Health Security Act for Developing a 5tzategy to Effect Major Reorgamzation of Health Care Delivery in Am,°.rica. a_s. no. 615
Mandated Community-Rating and Underlying Reimbursement Issues. abs. no. 542 Medical Group Pracu_e and Health _laintenance Organizations. abs. no. 556 Medical Risks. Patterns of _Iortality and Survival. abs. no. 563 Net Claim Costs and Reserves for Accident-Only and Intensive-Care.Only
National
VII-42
Health
Insurance.
Conflicting
Goals and l_olicy Cho_:es
abs. no.
Hospital
Distributional Effects of a Catastrophic Supplement no. 170 and Future Health Claim Costs. abs. no. 204 Husp_'tal Malpractice Insurance. abs. no. 224
Coverages.
Group
Medical
of L(S. EmployAttractive National
New Health
abs. no. 642
Health Care Programs
Proceedings. 27th Annual Group Health Institute, Los Angeles, California, June 19-22, 197Z abs. no. 736 Rate-Making Process for Developing Plans. abs. no. 772 SociM Aspects of the Rate Structure of Mecb_al Malpractice Insurance. abs. no. 833 Veterans Administration Hospitals. An Economic Analysis of Government Enterprise. abs. no. 930 Prepaid plans Access to Medical Care. The Impact of Outreach Services on Enrollees a Prepaid Health Insurance Program. abs. no. 3 Achieving Cost-Effective Practice in a Prepaid Plan. abs. no. 5 Alcoholism Services Handbook for Prepaid Group Plans. abs. no. 14 Alcoholism Within Prepaid Group Practice HMOs. abs. no, 15 Ambulatory Care Systems. Volume IV. Designing Medical Services Health Maintenance Organizations. abs. no. 23 American A tKtudes Toward Health Mmntenance Organiza_ons. abs. no. Analysis of Economic Performance in Medical Group Practices. abs. no. Aspects of Medicare in Colorado. abs. no. 8002
of
for 2$ 33
Disenrnllment From a Prep_u2t Group Practice. An Actuarial and Dcmographic Description. abs. no. 217 Drug Prescription Rates Before and After Enrollment of a Medicaid PopulaNon in an HMO. abs. no. 226 Economic Viability of Community-Operated Prepaid Health Plans. ab!_. no. 233 Effect of Duration of Membership in a Prepaid Group HeMth Plan on the UNlization of Services. abs. no. 241 Effect on Future Physician Requirements of an HMO Policy After National Health Insurance. abs. no. 247 Employee Health BeheSts. HMOs and Mandatory Dual Choice. abs. no. 260 Enrollment Choice in a Multi-HMO Setting. The Roles of Health Risk, Financial Vulnerability, and Access to Care. abs. no. 266 Episodes of Illness and Access to Care in the Inner City. A Comparison of HMO and Non-HMO Populations. abs. no. 269 Estimates of H,_lO Growth and Related Cost Sa vines 1978-90, abs. no. 275 Estimates of Preventive Versus Nonpreventive Medical Care Demand in an HMO. abs. no. 276
Assessment of Member Satisfaction in an HMO, Understanding the Interaction of V_Lqables and Their Implications. abs. no. 44 Attempts to Control Health Care Costs. The United States Experience. abs. no, 45
Evaluation of the Formation and Operation of Health Care Delivery Systerns for Public Assistance BenelTciaries Enrolled in Prep_u_t Health Plans in California. abs. no. 286 Factors Affecting the Choice Between Prepaid Group Practice and Altcrna-
Background Papers on Industry's Changing Role in Health Care Delivery. abs. no. 46 Can Health Maintenance Organizations Be Successful. An Analysis of 14 Federally QuulilTed HMOs. abs. no. 59 Capital Requirements and Capital Financing in a Hospital-Based Group Practice Prepayment Plan. abs. no. 65 Catastrophic Illness in an HMO. abs. no. 74 Changing Health Care. Perspectives From a New Medical Care Setting. abs. no, 77 Comparative Absence Experience Among Employees Covered by a Prepaid or a Blue Cross_Blue Shield Health Insurance Program. abs. no. 91 Compaling the Medical Utib'zation and Expenditures of Low Income Health Plan Enrollees With Medicaid Recipients and With Low Income Enrollees Having Medicaid EligibiIity. abs. no. 95 Comparison of Organizational Sponsorship and Service Arrangement Variables Among Prepaid Medical Group Practices in the United States. abs. no. 97 Comparison of the Hospital Cost Experience of Three Competing HMOs. abs. no. 98
dye Insurance Programs. abs. no, 297 Factors Affecting the Choice Between Two Prepaid Plans. abs. no. 298 Fee.For-Service Health Maintenance Organizations. abs. no. 307 FinancJM Projection in Prepaid Dental Care Plans. abs. no. 313 Foundations for Medical Care. An EmpiJ4eai Investigation of the Debvery of Health Services to a Med_'caM Population. abs. no. 322 Future Roles for the Federal Government in.the Development of H1WO's. abs. no. 334 Group Practice Recommendations" of the Committee on the Costs of Medical Care. A New Look at an Old Issue. abs. no. 343 Health Care Financing Options for Colorado. abs. no. 368 Health Care Issues for Industry. abs. no. 373 Health Care System in the United States. abs. no. 379 Health Care Trends. Minneapotis/St. Paul. Summary Highlights. abs. no. 381 Health Insurance Bibliography. abs. no. 390 Health Insurance Coverage for Alcoholism, 1975. abs. no. 392 Health Insur_ce Plans. Promise and Performance. abs. no. 397 Health Maintenance Organization Act Amendments of 1978, abs. no. 401
Comparison of the Quality of Maternity Care Between a Health-Maintenance Orgam_ation and Fee.For-Service Practices. abs. no. 99 Comptuqsons of Prepaid Health Care Plans in a Competitive Market. The Seattle Prepaid Health Care Project. abs. no. 100 Competition in the Delivery of Medical Care. abs. no. 104 Competitive Response of Blue Cross and Blue Shield to the Health Maintenance Organization in Northern CAdifornia and HawMi. abs. no. 106 Comprehensive Bibhography on Health Maintenance Organizations, 19741978. Volume I, abs. no. 108 Consumer Acceptance of liMOs, abs. no. 118
Health M_tanance Organization Planning Model to Evaluate an Alternarive Health Care Deh'very System for the State of Georgi_ abs. no. 402 Health ._Iaintenanee Orgnnizations. A Guide to Planning and Dgve4opmeat. abs. no. 403 Health Maintenance Organizations and Prepaid Group Practices. A Bibliography, abs. no. 404 Health Maintenance Organiza_ons as an Instrument for Cost Contaiomenr Policy. abs. no. 405 Health Maintenance Organizations Can Help Control Health Care Costs. abs. no. 406
Consumer Responsibility in a Prepaid Group Health Plan. abs. no. 123 Consumer Satisfaction in a Health Maintenance Organization. abs. no. 125 Consumer-Centered vs. Job-Centered Health Insurance. abs. no. 126 Contrasts in HMO and Fee-for-Service Performance. abs. no. 132 Corporate Role in Containing Health Care Costs. abs. no. 145
Health Maintenance Organizations. Federal Financing is Adequate But HEW Must Continue Improving Program ManagemenL abs. no. 407 Health Maintenance Organizaabns. Product Life Cycle Approach. abs. no. 408 Health Maintenance Organizations. Selected Bibh'ography. abs. no. 4(19
Cost Containment Through Risk-Sharing by Primary Care Physicians. A History of the Development of United Healthcare. abs. no. 155 Cutting Cost Without Cutting the Quality of Care. Shattuck Lecture. abs. no. 178 Delivery Prospers in Diversity. abs. no. 184
Health Services and Health Hazards. The Employee's Need to Know. abs. no. 419 Health Status, Socioeconomic Status, and Utilization of Outpatient Services for Members of a PrepMd Group Practice. abs. no. 427 HMO Enrollment Decision. A Transactions Analysis and Literature Re-
Dental Care and the Health 190
view. abs. no. 434 HMOs and the Politics
Dental
Care for Everyone.
Maintenance Problems
Organization
and Proposals.
Concept.
abs. no. 192
abs. no.
HMOs
From
of Health
the Management
System
Perspective.
Reform.
abs. no. 435
abs. no. 436
VII-43
How Business Can Stimulate a Competitive Health Care S)_rcm. abs. no. 464 How Interested Groups Have Responded to a Proposal for Economic Cornl_etition in Health Services. abs. no. 468
Segting. What Are t_qe Reasons for the Differences. abs. no. 773 Recent Alternative Delivery System Development in Denver. abs. no. 777 Reimbursement for Hospital Services. abs. no. 792 RcJmbursement for Physicians" Services. abs. no. 793
Impact of Alcohol, Drug Abuse and Mental Health Treatme_ f on Medical (Tare Utilization. A Review of the Research Literature. abs. no. 476 Impact of liMOs. Evidence and Research Issues. abs. no. 480 Impact of Membership in an Enrolled, PrepaM Population on Un'lizaNon of HeMth Services in a Group Prac_ce. abs. no. 481 ImpactS of Health Maintenance Organization Growth on Commumty Health Care Costs. abs. no. 491
Relationship Between Utilization of Mental Health and Somatic Health Services Among Low Income Enrollees in Two Provider Plans. abs. no. 797 Risk Differential Between Medicare Beneficiaries Enrolled and Not Enrolled in an HMO. abs. no. 815 Selected, Annotated Bibliography on Health Maintenance Organizations, 1974-1978. Volume II. abs. no. 824
Improving Health in America. U.S. Public Health Service 1977-80. abs. no. 495 Industry and HMOs, A Natural Alliance. abs. no. 500
Selected Bibliographic Research Guide to Health Maintenance Organizedons and Prepaid Group Practice. abs. no. 825 Simultaneous Logit of Plan Membership in the Federal Employees Health
Highlights
of
Influence of CompedNon by PrepMd Group Practice on the _Oevelopment of an Individual Practice Association. Health Maintenance OrganizeriGa. abs. no. 505
Benefits Program. abs. no. 832 Specific Issues Related to Utilization no. 849
Kaiser's Financial Strategies and Some Cues for Other HMOs. abs. _o. 526 Management and Policy Issues in HAIO Development, 1979. abs. nn. 540 Mandated Community-Rating and Underlying ReimbursemeJ_t Issues. abs. no. 542
State of Hawaii PrepaM Health Care Act (Chapter 393, HRS) Rules and RcgulaNons. abs. no. 855 Status of Competition ir_ the Health Industry. abs. no. 859 Study of Health Maintenance Organizations. abs. no. 8043
Medical 556
Summary of Impact of Alcoholism and Cost, 1979. abs.no. 875
Treatment
on Medical
Survey of Mental Organizations.
Coverage
Within
Group
Practice
Mental Health Services Plan. abs. no. 585
and Health for Medicaid
Maintenance Enrollees
Organizathms.
in a Prepaid
abs. no.
Group Practice
Mental Health Services. UtilizaKon by Low Income Enrollee5 in n PrepaM Group Practice Plan and in an Independent Practice Plan. abs. no. 586 Mental Wellness Programs for Employees. abs. no. 587 Metropolitan Comprehensive Care Program. A Health Systems Organizetion Demonstration. abs. no. 590 NaNonal l_tional
HMO HMO
Census Survey, 1977. Summary. Census 1980. abs. no. 635
abs. no. 63_,
Health Service abs. r_o. 881
and Content
of Care in HMOs.
abs.
and Related
Care Utilization
Health
Maintenance
Survey Results, July 1980. HMO Enrollment and Utilization in the U.S. abs. no. 883 Textbook for Employee Benefit Plan Trustees, Administrators and Advisots. abs. no. 897 Theory and Practice in NIinneapolis-St. Paul. abs. no. 899 Trends in _tedical no. 910
Care ,Costs. Do HAlOs
Lower
the Rate
of Growth.
abs.
Nati_mal HMO Development Strategy Through 1988. abs. no. 636 Note on the Compa_son of the Hospital Cost Experience of T?_'ree Compet, ing HMO's. abs. no. 650 Otifce of HeMth Maintenance Organizations. 5th Annual Report _o the Congress. abs. no. 655 On Broadening the Definition of and Remowng Regulatory Barriers to a Cbmpeo2ive Health Care System. abs. no. 658 Overview of Group Practice HMOs. Survey Results, March 1979. abs. no. 665
Use of Hospital Services Under Two Pret_id Plans. abs. no. 920 Use of Physician Services Under Two Prepaid Plans. abs. no. 922 Utilization of Services of an HMO by New Enrollees. abs. no. 925 Variations in Utilization of Health Services by Ctu'ldren. abs. no. 928 When a SoluNon Is Not a Solution. MedicMd and Health Maantenanee Organizations. abs. no. 936 Who Chooses Prepaid Medical Care. Survey Results from Two Marketings of Three New Prepayment Plans. abs. no. 938 Why Do HMOs Seem to Provide More Health Maintenance Services. abs.
Payer, Provider, 670
no. 941 Why New Enrollees
Consumer.
Industry
Confronts
Health Care Costs. abs. no.
Perceptions of Medical Care. The Impact of Prepayment. abs. no. 6"77 Physician Reimbursement and Hospital Use in HAlOs. abs. no. 69l Potenual Market Competition in the Medical Care System of Baltimore, Afaryland. abs. no. 711 Preliminary Results From a Risk-Sharing Health Maintenance Organizetion. abs. no. 715
Choose
to Join Group
Working Papers on Major Budget Programs. abs. no. 947
Health
and Program
Present legislation/regulations Achievements and Proble, ms of Medicaid, Alcohol and Health. abs. no. 12
Plan, Inc. abs. no. 942
Issues
in Selected
Health
abs. no. 4
Preliminary Study of Disenrullees From Health Service Plan of Perms)lvania, abs. no. 716 Prepaid Health Plans and Health Maintenance Or_anizations. abs. no. 717 Pressures and Problems for Organized Ambulatory Services in the Next Decade. abs. no, 718 Preventive Health Care in the HMO. Cost Benefit Issues. abs. no. 720
Analysis of Workers' Compensation Laws. abs. no. 39 BenelTt Recovery in Medicaid. An Examination of the Development and Implementation of a Benefit Recovery System in the State of Minnesota, abs. no. 47 Benefit Rights and Pn'va:y. The Insurance System and Fertih'ty Control. abs. no. 48
Private Health Insurance Plans in 1976." An Evaluation. Proceedings of the 28th Annual Group Health Institute, York, June 18-21, 1978. abs. no. 735
Brown Lung Disability. Costs, Compensation and Controversy. An Exploratory Policy Study. abs. no. 53 California Health Facih'ties Commission, A Case Study of Government
abs. no. 729 Ne_ York, New
Proceedings. 27th Annual Group Health Institute, Los Angeles, California, June 19-22, 1977. abs. no. 736 Public Insurance in Pn'vate Medical Markets. Some Problems of National Health Insurance. abs. no. 764
Regulation, abs. no. :;6 Can Health Be Planned. Or, Why Doctors Should Do Less and Patients Should Do More. Forecasting _he Future of Health System Agencies. abs. no. 58
Quality Assurance in a Prepaid Group Practice. abs. no. 767 Rate-Making Process for Developing Plans. abs. no. 772 Rates of Surgical Care in Prepaid Group Practices and the independent
Can Health Maintenance Organizations Be Successful. An Analysis of 14 Federally Quah'_ed HMOs. abs. no. 59 Carter Administration, Congress and Health Policy. A National Leadership
VI1-44
Health Care Prol_rams
Conference,
abs. no. 67
Federal
Community Mental Health Centers. The Federal Investment. Complex Puzzle of Rising Health Care Costs. Can the Private Together. abs. no. 107 Conditions for Change in the Health
Care System.
abs. no. 90 Sector Fit it
Government's
Financial Status Amendments
abs. no. 111
Role in Ambulatory
Services
agement Perspective. abs. no. 304 Federal Taxation and Regulatiun of Health
Development.
Insurance
of Social Security Program of 1977. abs. no. 314
A Man-
Plans. abs. no. 306
At?er
the Social
Security
Constitutionality of Medical Malpractice Reform Legislation. A Supplemental Report. abs. no. 117 Consumer Attitudes Toward Health Policy and Knowledge About Health Legislation. abs. no. 119
Finch'ngs and Implications of Field Visits to Six Welfare Benefit Plan Administrative Organizations. First Interim Report. abs. no. 318 Foundation for Health Care Regulation, PL 92-603 and PL 93-641. abs. no. 321
Consumer Participation and Community Organization Practice. tions of National Health Legislation. abs. no. 122 Control of Hospital Costs by Rate-Setting, abs. no. 133 Controlling M_dicaid Utilization Patterns. abs. no. 138
Future Roles abs. no. Going Bare. abs. no.
Controlling ControIh'ng
Rising Hospital Costs. abs. no. 139 the Use and Cost of Meab'cal Services.
mental Medical abs. no. 143
Care Review
Cost and Regulation of Me_'cal no. [46 Cost Containment Mechanisms.
Organization.
The New Mexico
Impb'ca-
Exl_ri-
Technology.
A Four- Year Case Study. Future Policy Directions.
abs.
abs. no. 152
Graduate port.
for the Federal Government 334 Continuance and Conversion 336
MedJ_al Education sbs. no. 338
Nadonal
Group Benefit Survey. Plans Coveting era, 1980. abs. no. 340
Health Health Health
Crisis in Health Care. abs. no. 173 Current and Future Development of Intermeth'ate
Health Care Cost ContMnment the L_w. abs. no. 358
Mentally Retarded. Current Developments 175
A Survey of State 01Wcials. abs. no. 174 in the National Health Planning Program.
abs. no.
Provisions Advisory
of HMO's.
in Health
Committee,
Salaried Employees
Insurance. Interim
Re-
of U.S. Employ-
Group Practice Recommendations of the Committee on the Costs of Medical Care. A New Look at an Old Issue, abs. no. 343 Health. A Victim or Cause of lntlation, abs. no. 348
Cost Effective Acute Care Facilities Planning in Michigan. abs. no. 157 Cost-Effectiveness of a Restrictive Drug Formudary, Louisiana vs. Texas. abs. no. 166 Care FaciliU'es for the
in the Development
Health Health Health
and Health Care, Policies in Perspective. abs. no. 349 and Retirement. Po_cy and Research Issues. abs. no. 352 and Taxes. An Assessment of the Medical Deduction. abs. no. 353 Experiments.
Po_'cy, Individual
Rig, hts, and
Care Financing Opu'ons for Colorado. abs. no. 368 Care in the American Economy. Number 3. abs. no. 3"/0 Care in Transition. abs. no, 372
Deinstitutionalization and Mental Health Services. abs. no. 181 Design of Falltrre. Health Policy and the Structure of Federalism. abs. no. 200 Distribution of Nurse Practitioners and Physician Assistants. Imph'cadons of Legal Constraints and Reimbursement. abs. no. 218 Doctors and Their Autonomy. Past Events and Future Prospects. abs. no.
Health Care Reimbursement Is Federal Taxation of T_-Exempt Pro_ders. abs. no. 378 Health Care System in the United States. abs. no. 379 Health Economics and Health Care. Irreeuncilable Gap. abs. no. 2185 Health Insurance Industry. Structural nnd Strategic Issues in an Ur_certain Environment. abs. no. 396
219 Economics
Health Maintenance Health Maintenance
of Cost Containment.
abs. no. 236
Organization Act Amendments of 1978. abs. no. 401 Organizations. A Guide to Planning and Develop-
Econorm_s of Industrial Health. History, Theory, Practice. abs. no. 237 Effect of a Mandatory Second Opinion Program on Medicaid Surgery Rates. An Analysis of the Massachusetts Consultation Program for Elective Surgery, abs. no. 240 Effect of PSROs on Health Care Costs. Current Findings and Future Evaluations. abs. no. 244 Effect of SSI on Medicaid Caseloads and Expenditures. abs. no. 245 Effectiveness of Certificate of Need Programs. abs. no. 8012
meat. abs. no. 403 Health Maintenance Organizations. Federal Financing is Adequate But HEW Must Continue Improving Program Man_emeat. abs. no. 407 Health Plan. The Only Practical Solution to the Soaring Cost of Medical Care. abs. no. 412 Health Planning and Regulation. A Manual for State Legislators. abs. no. 413 Health Planning and Regulation Effects on Hospital Costa. abs. no. 414
Effects of Meth'care abs. no. 253
Health Planning as a Regulatory Current U,_s. abs. no. 415
Employee 260
and Medicaid
HeaJth Beavers.
HMOs
on Access
to and Quality
and Mandatory
Dual
of Health Choice.
Care.
abs. no.
Health Planning no. 416
Strategy.
in the United States.
A Discussion
Issues in Guldeh'ne
of its History Development.
and abs.
Estimated Cost of Implementing the Regulations Limiting Payment Under Federal Health Programs to Maximum Allowable Costs (MAC'S) and Estimated Acquisition Costs (EAC'S). abs. no. 274 Ethical and Economic Aspects of Governmental Intervention in the Meakcal Care ._Iarket. abs. no. 278 Evaluation of Health Manpower Shortage Area Criteria. Final Report. abs. no. 281 Expanding Health Benelfts for the Elderly. Volume IL Prescription Drugs. abs. no. 290 Expenditures for Health Care. Federal Progr_,ms and Their Effects. abs. no. 291
Health Services and Health Hazards. The Employee's Need to Know. abs, no. 419 HIAA Re_4ews State Cost Control Regulation. abs. no. 430 HMOs and the Polities of Health System Reform. abs. no. 435 HMOs From the Management Perspective. abs. no. 436 Hospital Cost Containment Act of 1979. abs. no. 447 Hospital Cost Containment. Selected Notes for Future Poh'cy. abs. no. 449 Hospital Cost Control in Maryland. abs. no. 450 Hospital Rate Setting. Tins Way to Salvation. abs. no. 454 Hospital Regulation Through State Rate Review, Mandated Interference or a Noble Intrusion. abs. no. 455
Exploratory Study of the Acceptance of Current Federal Health Care Policy by Hospital Administrators, Trustees, and Physicians. abs. no. 293 Factors Affecting Differences in Meth'care Reimbursements for Physicians" Services. abs. no. 296
Impact of a Change in Regulations on Costs in an Experimental Program. abs. no. 475 Impact of Proposition 13 on Mental Health Services in California. abs. no. 484
Federal Control 303
Impact of Rate Regulation tals. abs. no, 485
of Pharmaceutical
Costs.
The MAC
Experience.
abs. no.
on the Diffusion
of New
Technologies
in Hospi-
VII-45
Impact
of State CertitTeate-of-Need
tion. abs. no. 487 Impact of State Government 488
Laws on HcMth
Rate Setting
C_re Co_ zs and L"tJ/:zao
o_ He.spite] ,_.lanagc-_enz.
abs ,'_o.
Private Health
Insurance
Professional Standards Professional Standards no 738
to Supplement
Medicare.
Revzew Organization Re_Tew Organization
Volume 1. abs. no. 730
Program. abs. no. 737 1979 Program Evaluatzbn.
abs.
Impact of the 1974 Health Care Amendments to the ._LRA on Co!le_t_,ve Bargaining in the Health Care Industry. abs. no. 490 Implementing the End-Stage Renal Disease Program of Med, car_,, abs. a_
Proposals for the Regu/aObn of Hospital Costs. abs. no. 746 Proposed' Framework for Health and health Care Policies. abs. no. 748 Prospecove Rate Setting. abs. no. 75 l
492 Increases
Pro_pectlve Reimbursement no 752
in Hospital
Expenses,
1970-1979.
Mandatory Cost Containment Cost Containment Programs.
A c_mparL_on
Programs and States abs. no. 498
of States
Wu,_
_Tth_at_glar:d_z,_r/
in Rhode
Island. Additional
Prospecttve Reimbursement System Based on Patient J.ecsev Hospitals 1976-1981. abs. no. 753
Perspectives. Case-Mix
Inllation in Hospital Costs and Charges in _taryland. abs. r,o. 503 IntIuenaing Federal, State, and Local Oral Health Policies. abs. no 506 Insurance, Regulation, and Hospital Costs. abs. no. 512
PSRO. An Evaluauon of the Professional Programs, Volume II. A Cust-BeneI_t Control Activities. abs. no. 759
Interfacing National Health Insurance and Income &laimenanae. Why Health and Welfare Reform Go Together. abs. no. 516 Law and Legislative Summaries. Federal 1979. First Session, Ninetj-S_tP.
Public Health and the law. Issues and Trends. abs. no. 762 Public" Regulation of H,_,alth Care Providers. abs. no. 765 Quah'ty Assurance in Health Care. abs. no. 768
Congress. abs. no. 527 Law and Legislative Summaoes.
Quakty of _Iea_'cal Care. abs. no. 770 Reah'tt_s of Rural Ptim._ry Care. abs. no. 776
States
1979. abs. no. 528
Legislative Response to the Medical Malpractice Crisis: Con:;citutional plications, abs. no. 530 Licensing Restrictions and the Cost of Dental Care. abs. no. 531 Malpractice Crisis. What Was It All About. abs. no. 537 Mandated Community.Rating and Underlying Reimbursement no. 542 Mesh'cat 556
Group
Practice
Me:h_al Malpractice Mesh'cat Malpractice Medical _Ialpractiee
and Health
Issues. abs,
Organiza:_,ons.
abs. _o.
Insurance. A Legislator's View. abs. m) 557 Law. 2nd Edition. abs. no. 558 Pre- Trial Screening Panels. A Review o[ _he EvMence.
abs. no. 560 Medicare and ,_ledieaid J_ledicare, Medicare
Maint_,_ance
Amendments
Medical Practice, and the _i4edical Reimbursement. abs. no. 579
lZ_ofess_bn, ab_ no. _78
Health Insurance.
National Health no. 631 National Health New
no. 632 Health
Benet_ts,
abs. no. 616
second
session,
_ olume
2. abs
Insurance.
96th Congress
second
session,
_dumc
3. abs
abs. no. 645 New Jersey Hospital Rein_bursement 1980. abs. no. 646 New York State Long Term Health Office of Health Maintenance Congress. abs. no. 655 the Det_nition
Under
and PhysiciaTt's S-446.
Care Program.
Organizations
El¢ments
abs. no. 047
_th Annual
of and Removing
State Response. Political Economy Historical
abs. no. 704 of Federal Health
Review.
Report
Regulatory
Regulation Regulation Regulation
Prehminary Results From a Risk-Sha_mg tion. abs. no. 715
Health
Regulation.
by 'CertilTcate
of Need. : abs.
Federal
_¢edicaid
Controls
and Incentives.
abs. no. 807
An
Prob-
and Health
Be_e-
Maintenance
Orgamza-
Set-
Social Sect_qty Programs Throughout the World, 197Z abs. no. 837 Some State and Feder_u Perspectives on Medicaid. abs. no. 846 Spy in the House of Medicine. abs. no. 850 Standards for Adequate Minimum Personal Health Services. abs. no. 851 Comprehensive and Catastrophic Overview. abs. no. 8041 Hospital
Cost Cortalnment
Health
Programs,
Insurance
Programs.
el'Hawaii Prepaid Health Care Act (Chapter 393, HRS) Rules and Regulations. abs. no. 855 State Policies and Federal Programs. Priorities and Constraints. Regulation abs. no. 857 to Control
of Health
Services
IntTation in Health
Study o/the Administration Act. abs. no. 871 Summary of Rate Review Tax Subsidtcs for Medical abs. no. 889
[or Employee
Utilization.
Lessons
and Related abs. no. 856
From
Michigan.
Care Costs. abs. no. 860
of the Employee
Retirement
Income
Security
in Maryland. abs. no. 876 Care. Current Policies and Possible Alternatives.
Taxation and Its Effect Upon Public _tedical Demand. abs. no. 890 Textbook
An
abs. no. 854
State ioioati_¢e a,Td
and
Selected Topics in Federal Health Statistics. abs. no. 828 Setting National Priorit,;es. Agenda for the 1980"s. abs. no. 830
State
of dealth
abs. no. 726
Fttcilities and Services
Rising Health Costs. P_'blia and Private Responses. abs. no. 813 Role of State and Local Governments in Relation to Personal Health vtces, abs. no. 819
t,_ a
States.
abs.
and the Quality of DentM Care. abs. no. 785 of Health C_re Delivery. abs. no. 786 of Health C_re in the United States. abs. no. 787
RestructutTng
Steps
Pensso_
from Experience.
Discharge for Patients in One PSRO Setting. abs. no. 796 Report of the HEW Task Force on Implementation of the Report to the President From the President's Commission on Mental Health. abs. no. 799
State
Barriers
Prngram_, in the United
Ictus. abs. no. 712 Prehminary Analysis of the Cbsts of _4aintaining t?ts in Selected Plans. abs. no. 714
VII-46
Regulating the Cost of _realth Care. Can We Learn no. 784
to the
abs. no. 705
and Hospital
Regulating Hospital Co._;ts. The Development of Public Policy. abs. no. 782 Regulating Hospital Labor Costs. A Case Study in the Polities of State Rate Cbmmissions. abs. no. 783
State
of Health Care Delivery abs. no. 708 and Health. Economic Causes and Consequences
Prm_er on Antitrust
Assistants. and Effects,
Competitive Health Care System. abs. no. 658 Planning of Health Care Delivery. abs. no. 699 Poh_y, Politics, and Child Health. Four Decades of Federal
Politics Poverty
lot
96th Congress
Nurse Practitioners
Standards Review Organization Context for PSRO Utilization
Regulatory Environmer_t for Physician Compensation. abs. no. 789 Relationship Between Diagnostic Information Available at Admission
Insurance.
Professionals.
On Broadening
Costs, and Consequences
for New
Reform and Regulation in Long-Term Care. abs. no. 779 Regionahzattbn and Health Policy. abs. no. 780 Regulating Health Care. The Struggle for Control. abs. no. 781
Regulation of Health no. 788
of 1980. abs. no. 572
Medicare Reimbursement Controversies and Appeals. abs. t:o. 580 Medicare. The Politics of Federal Hospital Insurance. abs. _o. 582 Mode of Payment and Length of Stay m the Hospital. M_re Work PSROs. abs. no. 592 National
lzt,,_
abs.
Bene¢Tt Plan
and
Private
Trustees,
Health
Insurance
Administrators
and
and Advi.
Health Care Programs
sots. abs. no. 897
Medicine.
abs. no. 532
Use of Tax Subsidies for the Cost of Compliance With Safety and Health Regulations. abs. no. 923 Variations in State Medicaid Programs. abs. no. 926 Voluntary Hospitals Suffer From Fiscal Erosion. Their Existence is Being Threatened. City Could Lose 5,200 Beds, 20,000 Jobs. abs. no. 931
Medical Self-Care Programs. abs. no. 564 Model Wellness Program. abs. no. 8026 Nadonal Health Insurance and Primary Medical Care for Children abs. no. 612 Personal Responsibility. Key to Effective and Cost-Effective Health. abs.
What We Have (And Haven't) Learned From Prospective Payment Programs, abs. no. 935 Women, Work, and Health. Chsdlenges to Corporate Policy. abs. no. 943 Workers' Compensation and Work-Related Illnesses and Diseases. abs. no. 945
no. 678 Personnel Leadership in Action, Doing Something About Health Care Cost Containment. abs, no. 679 Perspectives on Health Promotion and Disease Prevention in the United States. abs. no. 680
Workers" Compensation no. 946
Poverty and Health. Economic Ictus. abs. no. 712
Preventive
Insurance.
Recent
Trends in Employer
Costs. abs.
services
Age and Medical Care Utilization Patterns. BenetTt Rights and Privacy. The Insurance abs. no. 48
abs. no. 11 System and Fertility
Control.
Causes
and Consequences
of Health
prob-
Prediction Prevention,
and Incentives in Health Care Policy. Rhetoric and Reality. abs. no. 719
abs. no. 713
Preventive Preventive 8034
HeMth Care in the HMO. Cost Benel_t Issues. abs. no. 720 Health Services For Children. What States are Learning. abs. no.
Bibliography on Health Policy and Lifestyle Behavior Change. abs. no. 51 Business Perspective on Industry and HeMth Care. abs. no. 55 Can Health Be Planned. Or, Why Doctors Should Do Less and Patients
Preventive Medicine USA. Health Promotion and Consumer Health Education. abs. no. 721 Promoting Health. Consumer Education and National Policy. abs. no. 744
Should Do More. Forecasting the Future abs. no. 58 Child Health. Amen_a "s Future. abs. no. 84
Prospective MeaYcine. abs. no. 749 Responsihih'ty of the Individual. abs. no. 806 Selected Bibliograpln'c Research Guide to Health
of Health
System
Agencies.
Clinical EBTcacy Assessment program, abs. no. 8006 Comparative National Policies on Health Care. abs. no. 93 Competing for Acute Care Dollars. The Economics of Risk Reduction. no. 102 Conditions for Change in the Health Care System. abs. no. 111 Conference on Health Promotion and Disease Prevention, February 1978. Volume 1. Themes and Policy Sugges_ons. abs. no. 113 Conference on Health Promotion and Disease Prevention, February 1978. Volume IZ Conference Summaries. abs. no. 114
abs.
16-18,
Maintenance
Organiza-
dons and Prepaid Group practice, abs. no. 825 Social Perspective on Risk Reduction. abs. no. 836 Variations in Utilization of Health Services by Children. abs. no. 928 Who Pays for Pedi'atric Care. Out of Pocket and Third-P_u-ty Party Paymeats for Physician Visits. abs. no. 940 Why Do HMOs Seem to Provide More Health Maintenance no. 941
Services.
abs.
16-18, Private health care plans
Cost-Benefit Study of a Hypertension Screening and Treatment Prograrn at the Work Setting. abs. no. 165 Cost-Effecdveness of Primary and Secondary Prevention. abs. no. 167 Current Emphasis on Preventive Mech'cine. abs. no. 176
Adequacy of Private Health Insurance Coverage. abs. no. 8 Alcohol and Health. abs. no. 12 Bacdcground Papers on Industty's Changing Role in Health C_re Delivery. abs. no. 46
Economic Issues m Prevention. abs. no. 232 Economic, Social and Environmental Determinants of Adult Health. Some Implicatzbns for Future Research and Policy. abs. no. 8010 Economics of Industrial Health. History, Theory, Practice. alia. no. 237 Estimates of preventive Versus Nonpreventive Medical Care Demand in an HMO. abs. no. 276
BenetTt Recovery in ,_Ieda'aaid. An Examination of the Development and Implementation of a Benefit Recovery System in the State of Minnesota, abs. no. 47 Benet_t Rights and Privacy. The Insurance System and Fertility Control. abs. no. 48 Catastrophic Health Insurance. abs. no. 72
Executive Fitness Aids Corporate Health. abs. no. 288 Family Health in an Era of Stress. abs, no, 301 Forward Plan for Health FY 1978-82. abs. no. 320
Competing Dental Care Systems in California. abs. no. 94 Comp_uffson of Group Medi'aal Care Insurance BcnelYts to Charges. 96
Health Promotion Programs in Occupational Settings. abs. no. 417 Health Status, ,_Iedical Care Utilization, and Outcome. An Annotated Bibh z ography of Empirical Studies. Volume 1. abs. no. 423 Health Status, Medical Care Utilization, and Outcome. An Annotated Bibliography of EmpinPal Studies. Volume 3. abs. no. 425 Health Status, Socioeconomic Status, and Utiliza_on of Outpatient Services for Members of a prepaM Group Practice. abs. no. 427 How Business Can Promote Good Health for Employees and Their Families. abs. no. 463 How Much Can Business Expect to Earn From Smoking Cessation. abs. no. 469 How to Improve Health and Contain Costs. abs. no. 472 Illness Prevention and Medical Insurance. abs. no. 474
Competition and Regulation. The Consumer Choice Health Plan Alternadye. abs. no. 103 Complex Puzzle of Rising Health Care Costs. Can the Private Sector Fit it Together. abs. no. 107 Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Volume VIII, Overview. abs. no. 110 Containing Costs in Tlu'rd Party Drug Programs. Selected Bibliography and Abstracts. abs. no. 129 Containing Health BenetTt Costs. The Self-Insurance Option. abs. no. 130 Contrasts in HMO and Fee-for-Service Performance. abs. no. 132 Controlling the Cost of Health Care. abs. no. 141 Controlling the Costs of Retirement Income and Medical Care Plans. abs. no. 142
Impact
of Family
Structure
on Children's
Improving Health in America. 1977-80. abs. no. 495
U.S. Public
Health Health
Care Use. abs. no. 478 Service
Highlights
Interim Report to Congress on Occupational Diseases. abs. no. 517 Life Cycle Preventive Services Study. abs. no. 8023 Lifetime ttealth-Monitoting Program. A Practical Approach to Preventive
of
Corporate
Role in Containing
Health
Care Costs.
abs. no.
abs. no. 145
Cost Containment Mechanisms. abs. no. 152 Cost of Catastrophic Illness. abs. no. 159 Cost-Financed Mental Cost-Sharing in Health abs. no. 169
Health Facility. abs. no. 168 Insurance. Its Effects on Health Service
Utilization.
VII-47
Demand for Supplementary Health Insurance, or Do DeductibJ¢.s Matter. abs no. !.88 Dental and Vision Care Benefits in Health Insurance Plans. abs. no. 189 Dental C,_re for Everyone. Problems and Proposals. abs. no. 1_2 Dental Insurance Plans. abs. no. 195
Insuring lntcnsive Psychot.Se_"apy. abs. no. 513 Law and Leglslati_v Sums,aries. States 1979. abs. no. 528 ,_Inil-Order .Medicine. An Analysis of the Sears Roebuck Foundation's Community Meok'cal Assistance Program. abs. no. 535 Major Issues in the Financing and ,_4anagement of Health Care. abs. no. 536
Dental Design
Medicaid, __Iedicare, and Private Health Insurance Low-Income Areas. abs. no. 549
Prepayment Plans. abs. no. 196 for a Corporate Health Care Monitoring
System.
abs. no
199
Coverage
in Five Urban,
DeveIopment of Heaith Insurance. abs. no. 205 Differences by Age Groups in Health Care SpendJng. abs. no. 207 Digest of Selected Health and Insurance Plans. Volume L Health, BeneIits.
Multiple Health Insurance Coverage. The Overlap of Dread Disease and Extra Cash Policies W;th Other Types of Coverage. abs. no. 597 National Commission on the Cost of MedJ_al Care. 1976-1977. Volume 1.
1977-79 Eddtion. abs. no. 209 Disabih'ty, Health Status, and Utilization of Health Services. abs. no. 212 Disabib'ty Insurance. Trends Since World War II. abs. no. 214
Commission Recommendations Task Force Reports Research Agenda. abs. no. 599 National Commission on tile Cost of Medical Care. 1976-1977. Volume 2.
Drug Coverage Under National Health Insurance. The Poh'cy Options. abs. no. 225 Economics of Industrial Health. History, Theory, Practice. abs. no. 237 Effect of Unemployment Insurance Payments on the Health Insurance Coverage of the Unemployed. abs. no. 246
Collected Papers. abs. no. 600 National Health Care Exp_mch'ture Survey. abs. no. 8027 National Health Expenditures, 1979. abs. no. 604 Nadonal Health Insurance abs. no. 605 National Health Insurance and Corporate Benefit Plans. abs. no. 609
Employee Benefits In Industry. A Pilot Survey. abs. no. 258 Employer Provided Group Health Plans and the Unemployed. abs. no. 262 Employment Related Health Benefits in Private Nonfarm Business Establishments in the United States. Volume L Determinants of the Decision by Establishments to Offer a Group Health Plan. abs. no. 263 Employment Related Health Benefits in Private Nonfarm Business Estab-
National Health Insurance Issues. The Adequacy of Coverage. abs. no. 622 National Health Insurance 96th Congress second session, Volume 2. abs. no. 631 Nadonai Health Insurance 96th Congress second session, Volume 3. abs. no. 632 New Group Health Insurance. abs. no. 644
lishments in the United States. abs. no. 264
Data.
Overview of Health Insurance Study PublicaOons. abs. no. 666 Payment for Hospital Set, ices. Objectives and Alternatives. abs. no. 673
Employment, Unemployment, and Health Insurance. Behaviorsl and Descriptive Analysis of Health Insurance Loss Due to Unemployment. abs. no. 265 Evaluation of Market Mechanisms of Cost Control. abs. no. 283
Potential Market Competition in the MedJcal Care System of Baltimore, Maryland. abs. no. 711 Preh_ninary Analysis of the Costs of MaintMning Pension and Health Benefits in Selected Plans. abs. no. 714
Expanding Health abs. no. 290
Private Health Insurance Illness. abs. no. 728
Expenditures 291.
BenetRs
Volume lI, Desclipdon
for the Elderly.
Volume
for Health Care. Federal Programs
of Selected
II. Preseription
Drugs.
and Their Effects.
abs. no.
Benefits
Private Industry Health Insurance erin 1974. abs. no. 731.
for Alcoholism, Plans.
Drug Abuse
and Mental
Type of Administration
and lnsur-
Federal Taxation and Regulation of Health Insurance Plans. abs. no. 306 Fee-foJ_Sur_ce Physician Payment. Analysis of Current Methods and T_eir Development. abs. no, 308 Financing Health Care. abs. no. 315 Going Bare. Continuance and Conversion Provisions in Health Insurance. abs. no. 336
l_'vate Sector Perspee_ve on the Problems of Health Care Costs. 733 Protile of Employee Benelfts, abs. no. 739 Proposals to Restructure the Financing of Private Health Insurance. 747 Public Versus Private Administration of Health Insurance. A Study
Group Benefit Survey. Plans Covering Salaried Employees of U.,S Employera. 1980. abs. no. 340 Group Insurance Cost Containment Strategies. abs. no. 342 Health and Health Care. Policies in Perspective. abs. no. 349 Health and Health Insurance. The Public's View. abs. no. 350 Health Care Business. International Evidence on Private Ve_us Public
tire Economic Effieieztey. abs. no. 766 Rettu'nking Employee Benefits Assumptions. abs. no. 808 Selected Studies in Medical Care and Medical Economics. Annual Report, 1975. abs. no. 827 Social Medicine. The Advance of Organized Health Services in America. abs. no. 834
Health Care Systems. abs. no. 356 Health Care Cost Contm)_ment. Challenge to Industry. Health Care Costs. Private Initiatives for Containment.
Source Book of Health In,';urance Data, 1979-1980. Strategies for Controlh'ng ,:he Cost of State Medical abs. no. 861
abs. no. 357 abs. no. 364
abs. no.
abs. no. in Rein-
abs. no. 847 Assistance Programs.
Health Care Systems in World Perspective. abs. no. 380 Health Economics and Health Care. Irreconcilable Gap. abs. no. 385 Health Insurance Bibliography. abs. no. 390 Health Insurance Coverage of Veterans. Data Preview 4. abs. no. 393 Health Insurance in the Medicare Years. abs. no. 394 Health Insurance in the United States. Implications for the United Kingdora. abs. no. 395 Health Insurance Industry. Structural and Strategic Issues in _ Uncertain Environment. abs. no. 396
Study of Dental Service Prepayment in the Private Sector. Final Report. abs. no. 865 Study of Taft-Hartley Health and Welfare Trust Fund Operations Cost. Summary Report. abs. no. 869 Study of Taft-Hartley Health and Welfare Trust Fund Operations Cost. Technical Report. abs. no. 870 Study of the Administration of the Employee Retirement Income Security Act. abs. no. 871 Textbook for Employee Benefit Plan Trustees, Administrators and Advi-
Health Plan. The Only Practical Solution to the Soaring Cost of Mech'cai Care. abs. no. 412 How Much Can Business Expect to Earn From Smoking Cessation. abs. no. 409
sors. abs. no. 897 Theory and Practice in Minneapolis-St. Paul. abs. no. 899 Trends in Medical Care Costs. Do HMOs Lower the Rate of Growth. no. 910
Industry Roles in Health Care. abs. no. 501 Insurance Coverage and Access. Implicao'oas for Health Policy. Insurance, Regulation, and Hospital Costs. abs. no. 51.2
Two Decades of HeMth Sezvices. Social Survey Trends in Use and Expenditure. abs. no. 913 Unemployment, Eligibility Rules and the Loss of Health Insurance Benefits.
VII-48
abs. no. 51.1
Health
Care
Programs
abs.
abs. no. 915 Variations in Utilization of a Multi-State Company Dental Who Are the Uninsured. Data Preview 1. abs. no. 937 Who Pays for Pediatric meats for Physician
Care. Out of Pocket Visits. abs. no. 940
and
Why Do HMOs Seem to Provide More Health no. 94l Working With the Insurer. abs. no. 948 Providers
of health
Tttird-Party
Maintenance
Party
Pay-
Services.
abs.
of primary
National Commission on the Cost of Medical Care. 1976-1977. Volume 1. Commission Recommendations Task Force Reports Research Agenda. abs. no. 599 National Commission on the Cost of Medical Collected Papers. abs. no. 600
Care. 1976-1977.
Volume 2.
National Commission on the Cost of Medical Care. 1976-1977. Literature Reviews Data Bases. abs. no. 601 National Health Insurance. abs. no. 605
Volume 3.
Needs of the Elderly. abs. no. 639 Personal Responsibility. Key to Effective
care services
America's Health Care System. A Comprehensive Can Primary Care Deliver. abs. no. 60 Case for a National Health Service. abs. no. 68 Challenge
Plan. abs. no. 927
Portrait.
abs. no. 30
no. 678 Physicians and New Health Practitioners. Politics of Health Care. abs. no. 707
Care. abs. no. 75
Primary
Care in Durham
County.
and
Cost-Effective
Health.
abs.
Issues for the 1980s. abs. no. 694
Who Gives
Care to Whom.
abs. no. 724
Changing Health Care. Perspectives From a New Medical Care Setting. abs. no. 77 Comparative National Policies on Health Care. abs. no. 93 Considerations in the Design of Mental Health Benet_ts Under National Health Insurance. abs. no. 116 Current Issues in National Insurance for Mental Health Services. abs. no.
Pn'mary Health Care in an Academic Mea_'cal Center. abs. no. 725 Proceedings of the 28th Annual Group Health Institute, New York, New York, June 18-21, 1978. abs. no. 735 Public Regulation of Health Care Providers. abs. no. 765 Realities of Rural Primary Care. abs. no. 776 Regionalization and Health Policy: abs. no. 780
177 Delivery Delivery
Research in Health Economics. A Survey. abs. no. 803 Selected Studies in Medical Care and Medical EconomJ_s. 1975. abs. no. 827
of Health of Health
Determining
Care in AmeHca. abs. no. 182 Care in Urban Underserved Areas.
Health
Needs.
abs. no. 183
abs. no. 203
Spy in the House
Digest of Hospital Cost Containment Projects, Ttu'rd Ed_'tion. abs. no. 208 Doctors, Damages and Deterrence. An Economic View of Medical Matpractice, abs. no. 221 Effect of Organization of Medical Care Upon Health Manpower DistHbution.
abs. no. 242
Health
HMOs
and Mandatory
Departments.
National Health abs. no. 268
Dual
Insurance
Choice. and
abs. no.
the Role
of
Future Future
Health Care Organization. abs. no. 330 Issues in Health Care. Social Poh'cy and the Rationing
of Mech'aal
Services. abs. no. 331 Guide to Medicaid Data Sources. Volume One. abs. no. 345 Health Care. An American CHsis. abs. no. 355 Health Care Business. International Evidence on PHvate Versus Health Care Systems. abs. no. 356 Health Care Dilemma. Problems of Technology abs. no. 367 Health Health Health
in Health
Care Deh'very.
Care Pohcy in a Changing Environment. abs. no. 376 Care System in the United States. abs. no. 379 Employment Requirements Under Alternate Health
Schemes.
Pubh'c
a Community-Based
Type, Length, Discharge Publicly
Exploratory Study of the Acceptance of Current Federal Health Care Policy by Hospital Administrators, Trustees, and Physicians. abs. no. 293 Financing Health Care. abs. no. 315 Forward Plan for Health FY 1978-82. abs. no. 320
abs. no. 386
abs. no. 850
National
Health
Service.
abs. no. 906
and Cost of Care for Home Health Patients. Summary Feasibility Study. abs. no. 914
sponsored/mandated
health
Better Services at Reduced Program Recommended
of the
abs. no. 9 for the Mil_ry abs. no. 36
Costs Through an Improved for Veterans. abs. no. 50
Brown Lung Disability. Costs, Compensation ploratory Policy Study. abs. no. 53 Can Fee-for-Service Reimbursement Coexist no. 57 Capital Requirements and Capita[ Financing Practice Prepayment Plan. abs. no. 65 Catastrop]u'c Health Insurance, abs. no. 72
Cost of Catastrophic
A Report
plans
Administration's Program for Health Cost Containment. Alcohol and Health. abs. no. 12 Analysis of Requirements for a Cost Benel_t Structure Medical System With Initial Focus on CHAMPUS.
Controlh'n8 the Cost of Health Cost and Regulation of Medical no. 146
Insurance
Re:_rt,
Structure of Health Insurance and the Erosion of Competition in the Medica/Marketplace, abs. no. 864 Taxation and Its Effect Upon Public and PHvate Health Insurance and MedJ'aal Demand. abs. no. 890 Toward
Employee Health BeneSts. 260 Epidemiologic Revolution,
of Medicine.
Annual
and
"'Personal
Controversy.
With Demand
An
Creation.
in a Hospital-Based
Care. abs. no. 141 Technology. Future
_we" Exsbs. Group
Policy Directions.
_bs.
Illness. abs. no. 159
Health in the Future. In the Pink or in the Red. abs. no. 387 Health Maintenance Organizations as an Instrument for Cost Containment Policy. abs. no. 405 Health Personnel. Meeting the Explosive Demand for Medical Care. abs. no. 411 Health Services, Power Centers, and Decision-Making Mechanisms. abs. no. 420 Hospital Care in Ame_aa. abs. no. 445 Hospital Collective Bargaim'ng. Structure and Process. abs. no. 446 Impact of the 1974 Health Care Amendments to the NLRA on Collective Bargaining in the Health Care Industry. abs. no. 490
Dental Care for Everyone. Problems and Proposals. alas. no. 192 Dental Care for Handicapped People. Special Report. abs. no. 193 Development of Health Insurance. abs. no. 205 Differences by Age Groups in Health Care Spending. abs. no. 207 Disability. From Social Problem to Federal Program. abs. no. 211 Disability, Health Status, and Utib'zation of Health Services. abs. no. 212 Disability Insurance, Trends Since World War II. alas. no. 214 Distribution of Nurse Practitioners and Physician Assistants. lmph'cations of Legal Constraints and Reimbursemen_ abs. no. 218 Economics of Industrial Health, History, Theory, Practioe. abs. no. 237 Effects of Inaome Maintenance on the Meab'aal Care Utib'zation and Health
Improving Health in 1977-80. abs. no. The Malpractitioners. Medicaid Experience. Medical Malpractice
Status of Rural Families. abs. no. 252 Epidemiologic Revolution, National Health Insurance and the Role of Health Departments. abs. no. 268 Evaluation of the Formation and Operation of Health Care Delivery I_ysterns for Public Assistance BenetTcianes Enrolled in Prepaid Health
AmeriCa. 495 abs. no. abs. no. Law. 2rid
U.S. Public 539 548 Edition.
Health
abs. no. 558
Service
Hibhh'bhts
of
VII-49
Plans in Califo,qqia. abs. no. 280 Expcnda'tures for Health Care of Children abs. no. 292 Feasibility and Cost-Effectiveness abs. no. 302 Federal Control of Pharmaceutical 303
and Y _uth m t_e l -Red States.
of Alternative
Long-Term
Tile ilIAC
Costs.
_ _'re Settings.
Experi¢_lce.
abs. ,o.
PrJl _r= )4e',J_. ln_zJi_nc¢ lJ¢_¢-fits for Alcoholism, Drug Abuse and :_tental Illness. abs an. 3'28 Proceedings ofthe 28th Annual Group Health Institute, New York, New York, June !8-2A t _78. abs. no. 735 Proposals ,for National H_'a_,'th Insurance lh the L;SA. Origins and Evolution, and some Perceptions for the Future. abs. no. 745 Proposals to Restru¢'ture the Financing of Private Health Insurance. abs. no.
Federal Health Dollar, 1969-1976. A c_hartbook 4nalysi_ of A _wvities Supported and StrategJes Pursued in Federal Ex, ,enditurea _ He_!t)_. abs. no. 305 Fin_u_cing Health Care abs. no. 315 Financing of Health Care. abs. no. 3!7 Forecasting Federal Long-Term Care Expenditures. abs. no. _:016 Health. A Victim or Cause of Inflation. abs. no. 348 Health Care. An American Crisis. abs. no. 35*; Health Care. An American Crisis. abs. no. 355 Health Care Business. International Evidence on Pc;rare V_tsus Public
747 Public" ',_r_as _rJ_a te Administration of Health Insurance. A Study Jn Reinti_c Economic EftTc_ency. abs. no. 766 Reductions m Public- Health Care Coverage. abs. no. 8036 Regulating Health Care. The Struggle for Control. abs. no. 781 Regula.'ic_zl of Health c_re in the United States. abs. no. 787 Rising Hospital Costs C_o Be Restrained by Regulating PaymentS and Iraprovi:_g _Ianagement. abs. no. 814 Role of H:alth t_suranc'." in the Health Services Sector. abs. no. 816 Savings co CHA:$fPUS F;'om Requirement to Use Uniformed Services Hos-
tlealth Care Systems, abs. no. 356 Health Care Systems in World Perspective. abs. no. 380 Health Economics and Health Care. Irreconcilable Gap. abe. _Lo. 385
pitnls, abs. no 822 Selected 7k,pl__'sm Fcde;al Health Statistics. abs. no. 828 Social Sec.u_i:y Program:_ Throughout the World, 197Z abs. no. 837
Health Insurance Coverage of Veterans. Data Preview 4. abs no. 393 Health Insurance in the United States. Imph_atJons for the L'_Tited K_bgabm. abs. no. 395
Social Surveys and Health Policy. Implications for National ante. abs. no. 839 Soc_eta! ResponsT"bility f*_r _/Iaipractice. abs. no. 841
Health Insurance. Pubhc Programs, Abstracts). abs. no 398
Source Book of Health insuraaTce Data, 1979-1980. Spy in the House of ,_ledicine. abs. no, 850
Health Plan, The Only (?are. abs. no. 412
Pracocai
1978-June, Solution
1980 (A Bibliography
to the Snarling
With
Cos_ of ?¢_edicM
Standards for Adequate State _lc.alth Legislation
Health
Issue-
abs. no. 847
,_Iinimum Personal Health Services. abs. no. 851 Report Vol. 8 No. 3. State Comprehensive and
Hospital Backlog. Patients" W'Jth No Place l o Go. abs. no. _.43 Impact of the Rhode Island Catastrophic Health lnsuJance P,'an. abs. no. 489 Income and Illness. abs. no. 497
Catastrophic Health Insurance Leg_slatJbn. abs. no. 853 State Policies and Federal Programs. Priorities and Constraints. abs. no. 856 State Regulation of Hea,_th Services Utilization. Lessons From ._/Iich_gan. abs. no. 857
Insurance Coverage and Access. lmphcations Cur :tealth Pohcy abs. no. 511 Insurance, Regulation, and Hospital costs, abs. ,o. 512 Issue_ Involvwd in the Development _f a PrepaM Capitadon P;an :or 7oneTerm Care Services. abs. no. 522
Stratcg,'es _>r ¢-Ontrolling the Cost of State abs. no. 861 Taxation and Its Effect &)9on Public" and _[edical Demana. ahs. :no. 890
Metropolitan Comprehensive Care Program, non Demonstrat_bn. abs. no. 590
Toward a Community-Based Toward a Physician Payment
A ttealth
Systems
Organiza-
Medical Private
National Health Policy. Evidence
Assistance Health
Programs.
Insurance
and
Service. abs, no, 906 From the Economic Stabili-
Mule')ale Health Insurance Coverage. The O_!ap of Dread ._isease and Extra Cash Policies WRh Other Types of d_verage abs. _o. 597 National Commission on the Cost of Medical Care. 1976-19771 Volume Z
zat_on Program. abs. no. 908 Veterans Administration Hospitals. Enterprise. abs. no. 930
(bllected Papers. abs. no. 600 National Health Care Expenditure Survey. abs qo. 802; National Health Expenditures. 1979. abs. no. 604 National Health Insurance. abs. no. 605
Volumazy Hospitals Sut?br From Fiscal Erosion. Their Existence is Being Threatened. City Could Lose 5,200 Beds, 20,000 Jobs. abs. no. 931 Welfare ,Vlcdicine in America. A Selected Bibhographic Research Guide (1964-77). abs no. 933
National Health Insurance ence. abs. no. 610
and HeaRh
Res, urc_s.
National 619
Contlicting
boats
Health
Insurance
The European
anJ Policy
Choices.
E, rpeHabs. no.
Natl,,hal Health Insurance in the Federal Repubhc of Germany a_td i_%" Implications for L(X Consumers. abs. no. 621 Nat_k,nal Health Insurance Issues. The AdequacT ol'Co_erag¢, abs. no,. 622 Neons of the Elderly. abs. no. 639 New D_?cctions in Public Health Care. A Prescription for t_e 1980s. abs. nm 643 New York State Long Term Health Care Program. abs an. 647 Patient Outcomes" in Three Alternative Long-Term Care Settings. abs. no. 669 Payment for Hospital Services. Objectives Physzeian Participation _b Health Insurance abs. no. 689
and Alternatives. abs. no. 67q Plar,_ EvMenc_= on ._lue SMeld.
An Economic
Analysis
of Government
Who Are the DYdnsured Data Preview 1. abs. no. 937 Who Pays lot Pediatric Care. Out of Pocket and Third-Party manta for Physician
_its.
Reimbursement Altenk,g Medicaid Pro_,ider Reimbursement Methods. abs. no. 17 Alternative Physician Payment Methods. Incentives, Efficiency, and National Health Insararce. abs. no. 19 Benefit Recovery in ?dedicaid. An Examination of the Development and In_vlementation of a Benefit Recovery System in the State of Min. nesota, abs. no. 47 Comparison of Group ._4¢'d_cal Care Insurance Benefits to Charges. abs. no. 96 Cost Containment _dechaoisms. abs. no. 152 Day Hospitahzation as a Cost-Effective Alternative Pilot Study abs. no. 179
to Inpatient
Pullet Analysis with Social Security Research _i;les. abs. _o. _01 Policy, Politics, and Child Health. Four Dec_des of Federal L_ttiative and State Response. abs. no. 704
Diagnosis Related Group (DRG) _lanagement Information abs. no. 8009 Equal Treatment and U_'equai Benel_ts. A Re-examination
Politics of Health Care Delivery. abs Polls. Health Insurance. abs. no. 709
,_ted_b_tre Services b) Race, 1967-1976. abs. no. 270 Expanded Health Care Coverage Alternatives, abs. no. 8015
VII-50
no. 708
Party Pay-
ahs. no. 940
Health
System
Care. A Studies,
of the Use of
Care Programs
Factors Affecting
Differences
in Medicare
Reimbursements
for Physicians"
Some
Services. abs. no. 296 FinM Report to the Legislature on Ambulatory Care. abs. no. 309 Funding Rural Nurse Practitioner Care. abs. no. 329 Geographic Van'ation in Physicians" Fees. MedJcare and MecHcaid. abs. no. 335
Payments
State and Federal
Perspectives
on Medicaid.
abs. no. 846
State Policies and Federal Programs. Priorities and Constraints. abs. no. 856 Study o£Physician Reimbursement Under Medicare and MediCaid. Vbinme /. abs. no. 866
to Physicians
Under
Study of Physl_ian Reimbursement I/. abs. no. 867
Under Medicare
and Medicaid.
Volume
Home HeMth Care Services. Tighter Fiscal Controls Needed. abs. no. 437 Hospital Cost Inllanon and Health Insurance. A Complex Market Model. abs. no. 451 Hospital Reimbursement by Diagnosis Related Groups. Preliminary Bibliography, abs. no. 456 Mandated Community-Rating and Underlying Reimbursement Issues. abs.
Third-Party Payments for New Health Professionals. An Alternative to Fractional Reimbursement in Outpatient Care. abs. no. 902 Urban Fiscal Crisis in the United States, National Health Insurance, and Municipal Hospitals. abs. no. 916 Use of Medicare Benet_ts Under HIP's 3- Year Incentive Reimbursement Experiment. abs. no. 921
no. 542 Measurement of Expenditures for Outpatient Physician and Dental vices. Methodological Findings from the Health Insurance Study. no. 544
Voluntary Hospitals Suffer From Fiscal Erosion. Their Existence is Being Threatened. City Could Lose 5,200 Beds, 20,000 Jobs. abs. no. 931 Working With the Insurer. abs. no. 948
Setabs.
Medicare and Medicaid Physician Payment Incentives. abs. no. 573 Medicare Assignment Rates of Physicians. Their Responses to Changes Reimbursement Policy. abs. no. 574 Medicare. Health Reimbursement
Insurance for the Aged by State and County.
and Disabled, abs. no. 577
197Z
Section
in l.
Service benefit plans AdministraKve Costs of Medicare Contractors. Commercial Intermediaries. abs. no, 10 Assessing Ouah'ty of Care and Oral Insurance. abs. no. 42
Health
Blue
Cross Plans
in a Population
Versus
With Dental
Medicare Reimbursement. abs. no. 579 Medicare Reimbursement Controversies and Appeals. abs. no. 580 Methodology Used to Measure Health Care Consumption During the First Year of the Health Insurance Experiment. abs. no. 588 Modifying Medicaid Eligibility and Benet_ts. abs. no. 595 Needs of the Elderly. abs. no. 639 New Jersey Diagnosis Related Group (DRG) Evaluation. abs. no. 8030
Blue Cross. What Went Wrong. abs. no. 52 Changir_ Patterns and Imph'eanons for Cost and Quality of Dental Care. abs. no. 79 Comparative Absence Experience Among Employees Covered by a Prepaid or a Blue Cross/Blue Shield Health Insurance Program, abs. no. 91 Comparisons of Prepaid Health Care Plans in a Compebtive Marke,t. The Seattle Prepaid Health Care Project. abs. no. 100
New
Competitive Response of Blue Cross and Blue Shield to the Health Maintehence Organization in Northern California and Hawaii. abs. no. 106 Cost of Terminal Care. Home Hospice vs Hospital. abs. no. 162
Jersey Hospital Reimbursement Under S-446. 1980. abs. no. 646 New York Case Mix Study. abs. no. 8031 Overview 665
of Group Practice
HMOs.
Survey
Elements
and Effects,
March
1979. abs. no.
Results,
Discounting and Differential no. 216
Prt_ing Practices
in the Health
Care Field. abs.
Paying for Primary Care, Time for a Change. abs. no. 672 Payment for Hospital Services. Objectives and Alternatives. abs. no. 673 Per-Case Reimbursement for Me_'cal Care. Final ReporL abs. no. 675 Physician Acceptance of Medicaid Patients. abs. no. 682 Physician Control of Blue Stu'eld Plans. Staff Report. abs, no. 684 Physician Participation in Health Insurance Plans. E_qktenee on Blue Shield. abs. no. 689 Physician Reimbursement and Hospital Use in HMOs. abs. no: 691 Physicians' Charges Under Medicare. Assignment Rates and BeneKciary Liability. abs. no. 695 Policies for the Containment of Health Care Costs and Expenditures. abs. no. 700
Enrollment Choice in a MultiHMO Setting. The Roles of Health Risk, Financial Vulnerabih'ty, and Access to Care. abs. no. 266 Evalua_on of Alternative Payment Strategies for HospitMs. A Conceptual Approach. abs. no. 280 Factors Affecting the Choice Between Prepaid Group Practice and Alternatire Insurance Programs. abs. no. 297 Financing of Health Care. abs. no. 317 Findings and Imph'catlons of Field Visits to Six Welfare Benel_t Plan Administrative Organizations. First Interim Report. abs. no. 318 Funding Rural Nurse Practitioner Care. abs. no. 329 Group Dental Expense Insurance Experience. abs. no. 341 HeMth Insurance Plans. Promise and Performance. abs. no. 397
Preventive 8034 Prospective
How Interested Groups Have Responded to a Proposal petition in Health Services. abs. no. 468 Idea Whose Time Has Come. Less Health Insurance.
Health Rate
Services
For Children.
Reimbursement
and
What States
are Learning.
Cost Containment.
bursement in New York. abs. no. 750 Prospective Reimbursement System Based on Patient Jersey Hospitals 1976-1981. abs. no. 753
abs. no.
Formula Case-Mix
Reimfor New
Joint Health Cost Containment Program. no. 524 Medicare Reimbursement Controversies
Hospital
for Economic abs. no. 473
Utih'zation
and Appeals.
Com-
Report:
abs.
abs. no. 580
Prospective Reimbursement Through Budget Review. New Jersey, Rhode Island and Western Pennsylvania. abs. no. 754 Reductions in Public Health Care Coverage. abs. no. 8036 Reimbursement Alternatives for Home Health Care. abs. no. 790 Reimbursement for Durable Medical Equipment. abs. no. 791 Reimbursement Policy Under Drug Insurance. Administrative Expediency or Economic Vah'dity. abs. no. 795 Research and Demonstrations in Health Care Financing, 1978-1979. abs. no. 802
Negotiating Reimbursement Contracts. The Michigan Experience. abs. no. 640 Note on the Comparison of the Hospital Cost Experience of Three Competing HMO's. abs. no. 650 Per-Case Reimbursement for Medical Care. Final Report. abs. no. 6'75 Physician Control of Blue Stu'eld Plans, Staff Report. abs. no. 684 Physician Participation in Health Insurance Plans. Evidence on Blue SMeld. abs. no. 689 Private Health Insurance Plans in 1976: An Evaluation. abs. no. 729
Risk
Private Industry Health Insurance er in 1974. abs. no. 731
Differential Between Medicare rolled in an HMO. abs. no. 815
Beneficiaries
Enrolled
and Not
Role of Fee Schedules in Physician Reimbursement. abs. no. 8038 Social Surveys and Health Policy. Implications for National Health ante. abs. no. 839
En-
Insur-
Plans. Type of Administration
and lnsur-
Program for Elec_ve Surgical Second Opim'on. Surgical Experience gram Participants, 1976-197Z abs. no. 742 Prospective Reimbursement Through Budget Review. New Jersey,
of ProRhode
VII-51
Z_land and Western Pennsylvania. abs. _:o. 754 Reimbursement for Hospital Services. abs. no. 792 Reimbursement for Physicians" Services. abs. no. 793 Short-Run Hospital Responses to Reimbursement Rate 831 Use of Physician
Services
Under Two Prepaid
Source of premium payment AlternaKves to Nursing Homes.
Changes.
abs. no,
Plans. abs. no 922
469 Incentive "Fax for Medicare, Med_cazd and National Health Insurance. no. 496 MedJ2"aid. Current Issues and Potendal Reforms. abs. no. 547 Medical Care Plans. How to Control the Costs. abs. no. 553 National Health Expenditures, tions, abs. no. 603 National National
abs. no. 21
Health Health
Short- Term Outlook
abs.
and Long- Term Projec-
Expenditures, 1979. abs. no. 604 Insurance and Income Distribotion.
abs. no. 611
Alternatives to Prepayment Finance for Hospital Services. abu. no. 22 Analysis of the Potential Impacts of National Health Insurance Programs on Collective Bargaining. Final Report. abs. no. 38 Business Perspective on Industry and Health Care. abs. no. 55 CanadJ'an National Health Insurance. Lessons for the United States. abs. an. 63
National Health Insurance Issues. Viability of the Cost-Sharing Concept. abs. no. 625 National Health Insurance. Some Costs and Effects of Mandated Employee Coverage. abs. no. 628 Neighborhood Health Centers. A Decade of Experience. abs. no. 641 New Group Health Insurance. abs. no. 644
Charges and Sources of Payment Data Preview 2. abs. no. 81
for Dental
Payer, Provider, 670
Charges and Sources of Payment view 5. abs. no. 82
for Visits to Physician
Checkbook's
Guide
to Health
Insurance
Visits With SepaJate
Charges.
OflTces. Data Pre-
Plans for Federal
Employees.
For
Consumer.
Industry
Confronts
Health
Cctre Costs. abs. no.
Perceptions of _¢edical Care. The Impact of Prepayment. abs. no. 677 Personnel Leadership in Action. Doing Something About Health Care Cost Containment.
abs. no. 679
District of Columbia, Maryland, and _ginia (Also covets D C, Goveminent t_mployees), abs. no. 83 Children and Dental Care. Charges and Probability of a Visit by Individual Characteristics. abs. no, 85
Prepaid Health Plans and Health MMntenance Organizations. Pro_71e of Employee Benefits. abs. no. 739 Recent Alternative Delivery System Development in Denver. Rethinking Employee BenetTts Assumptions. abs. no. 808
Comparative National Policies on Health Care. abs. no. 93 Competition and Regulation. The Consumer Choice Health Plan Alternatire. abs. no. 103
Strategies for Financing National Health Insurance. Who Wins and Loses. abs. no. 862 T_dcing Action To Contain Health Care Costs. Part L alas. no. 887
Consumer-Choice
Tax Subsidies
Health
Plan.
A
Based on Regulated Competition Controlling the Costs of Retirement no. 142
National-Health-Insurance
Proposal
in the Private Sector. abs. no. 127 Income and Medical Care Plans. abs.
for Medical
abs. no. 889 Ten Years of Medicare, Veterans Administration
(mpact on the Covered Hospitals. An Economic
EnterpriSe. abs. no. _30 Who Pays for PedJ'atric Care, Out of Pocket meats for Physician Visits. abs. no. 940
Dental Dental
Workers" Compensation no. 946
Insurance
Plans. abs. no. 189
Determining Present and Future Health Claim Costs. abs. no 204 Differences by Age Groups in Health Care Spending. abs. no. 207 Employee Benefits In Industry. A Pilot Survey. abs. no. 258
abs. no. 777
Care. Current Policies and Possible
Corporate Role in Containing Health Care Costs. abs, no, 145 Costs, Financing, and Distributional Effects of a Catastrophic Supplement to Meda_are. abs. no. 170 and Vision Care Benefits in Health Insurance Plans. abs. no. 195
abs. no. 717
Insurance,
Recent
Who
Alternatives.
Populatlbn. abs. no, 894 Analysis of Government
and
Third-Party
Party
Trends in Employer
Supply/availability of services Access m Ambulatory Care and the U.S. Economy.
Pay-
Costs. abs.
abs. no. 1
Employee Benet_ts 1979. abs. no. 259 Employer Acquisition of Health Care Facilities. A Possible Outcome of Escalating Premiums. abs. no. 261 Employment Related Health BeheSts in Private Nonfarm Business Establishments in the United States. Volume I. Determinants of the Decision by Establishments to Offer a Group Health Plan. abs. no. 263 Employment Related Health BeheSts in Private Nonfarm Business Establishments in the United States. Volume IZ Description of Selected Data. abs. no. 264 Federal Taxation and Regulation of Health Insurance Plans. abs. no. 306 Financial Analysis of Alternative Methods of Funding Group Medi'cal Benefits. abs. no, 310 Going Bare. Continuance and Conversion Provisions in Health Insurance. abs. no. 336 Group Insurance Cost Containment Strategies, abs. no. 342 Health and Taxes. An Assessment of the Medical Deduction. abs. no 353
Access to Medical Care for the Elderly. Do Non-Price Banffers Matter. abs. no. 2 Access to Medical Care. The Impact of Outreach Services on Enrollees of a Prepaid Health Insurance Program. abs. no. 3 Allocation of Physicians'Services. Evidence on Length-of-Visit. abs. no. 16 Alternative Oral Health Service Delivery Systems. abs. no. 18 American ,_Ie_cine. Challenges for the 1980s. abs. no. 29 America "s Health Care System. A Comprehensive Portrait, abs. no. 30 Analysis and PlmwYng for Improved Distribution of Nursing Personnel and Services. Final Repmt, abs. no. 31 Annotated Bibliography of Health Economies. abs. no. 41 Aspects of Medicare in Colorado. abs. no. 8002 Assessing the Utilization ztnd Productivity of Nurse Practitioners and Physiclan's Assistants. Me,:hodology and Findings on Productivity. cos. no. 43 Can Fee-for-Service Rein_bursement Coexist With Demand Creation. abs.
Health Health
no. 57 Canadaan Nadonal
Care Issues for Industry. abs. no, 373 Insurance Coverage for Alcohol/Drug Addiction
ginia State Employees. A Feasibility Histo_cal Development of the Calitbrnia
Treatment
Evaluation, abs. no: 391 Pilot Program to Provide
for VirHealth
Insurance Coverage for Alcoholism. abs. no. 432 HMOs From the Management Perspective. abs. no. 436 Hospital Cost Inflation and Health Insurance. A Complex Market Model. abs. no. 451 How Business Can Improve Health Planning and Regulation. abs. no. 462 How Much Can Business Expect to Earn From Smoking Cessation. abs. no.
VII-52
63 Case for a National
Healt_r Insurance. Health
Service.
Lessons for the United
States.
abs. no.
abs. no. 68
Case-Mix Difference Between NonproSt and For-proSt Hospitals. abs. no. 70 Challenge of Primary Cau'e. abs. no. 75 Comparative National Policies on Health Care. abs. no. 93 Consumer-Choice Health Plan. A National.Health-Insurance Proposal Based on Regulated Competition in the Pn'vate Sector. abs. no. 127
Health Care Programs
Consumer-Choice Health Plan. day. AlternaHves for Cost National Health Insurance. Controlling Health Care Costs. 134 Controlling
InHation and Ineqm2y in Health Care ToControl and an Analysis of Proposals for abs. no. 128 A National Leadership Conference. abs. no.
the Cost of Health
Care. abs. no. 141
Health Care System in the United States. abs. no. 379 Health Care Systems in World Perspective. abs. no. 380 Health Employment Requirements Under Alternate Health Schemes. abs. no. 386 Health in the Future. In the Pink or in the Red. abs. no. 387 Health in the United States.
Chartbook.
Cost Containment and Health Planning. A Bibliography. abs. no. 147 Cost Effective Acute Care Facilities Planning in Michigan. abs. no. 157
Health Maintenance abs. no. 406
Crisis in Health Care. abs. no. 173 Delivery of Health Care in America. abs. no. 182 Deh'very of Health Care in Urban Underserved Areas. abs. no. 183 Demand for General Practitioner and Internist Services. abs. no. 186
Health Maintenance Organizations. 408 Health Manpower for the Nation. Requirements. abs. no. 410
Dental Care Demand, Point Estimates Insurance. abs. no. 191
Health Personnel. no. 411
Dental Care Dental Care Determining Distribution
and ImplicaUbns
for NationM
Health
for Everyone. Problems and Proposals. abs. no. 192 for Hands'capped People. Special Report. abs. no. 193 Health Needs. abs. no. 203 of Nurse Practin'oners and Physician Assistant_ Imph'cations
Organizations
Meeting
abs. no. 388
Can Help Control Product A Look
the Explosive
Insurance
Health
Care Costs.
Life Cycle Approach.
abs. no.
Ahead
and the
Demand
at the Supply for Medical
Care. abs.
Health, United States, 1980. abs. no. 428 Home HeMth. The Need for a National Policy to Better Provide Elderly. abs. no. 438 Hospital Backlog. Patients With No Place To Go. abs. no. 443
for the
of Legal Constraints and Reimbursement. abs. no. 218 Doctors and Their Workshops. Economic Models of Physician Behavior. abs. no. 220 Economic Foundations of National Health Policy. abs. no. 231 Economics in Health Care. abs. no. 235
Hospital Cost IniIation and Health Insurance. A Complex Market Model. abs. no. 451 Hospital Cost lnilation Study. abs. no. 8021 Hospital-Spoosored Primary Care Group Practices. A Developing Mehdality of Care. abs. no. 460
Economics of Cost Containment. abs. no. 236 Economics of Medical Care. A Policy Perspective. abs. no. 238 Economics of Mechcal Malpractice. abs. no. 239 Effect of Organization of Medical Care Upon Health Manpower Distribution. abs. no. 242
How Much Will U.S. Meak'cine Change in the Decade Ahead. abs. no. 470 Idea Whose Time Has Come. Less Health Insurance. abs. no. 473 Impact of Comprehensive National Health Insurance on Demand for Health Manpower. abs. no. 477 Impact of Headth System Changes on the Nation's Requirements for Regis-
Effect of SSl on Meds'caid Caseloads and Expenditures. abs. no. 245 Effect on Future Physician Requirements of an HMO Poh'cy Atter National Health Insurance. abs. no. 247 Effects of Financial Incentives on Physicians'Specialty and Location Decisions, abs. no. 250 Effects of the 1974- 75Recession on Health Care for the Disadvantaged. abs. no. 255 Episodes of Illness and Access to Care in the Inner City. A Comparison of HAlO and Non-HMO Populations. abs. no. 269 Equity in Health Services. Empirical Analyses in Social Policy. abs. no. 271 Erosion of the Medical Marketplace. abs. no. 272 Ethical and Economic Aspects of Governmental Intervention in the Mechcal Care Market. abs. no. 278
tered Nurses in 1985. abs. no. 479 Impact of HMOs. Evidence and Research Issues. abs. no. 480 Improving Access to Health Care Among the Poor. The Neighborhood Health Center Experience. abs. no. 493 Improving AcceSs to Metb'cal Care in Underserved Areas. The Role of Group Practice. abs. no. 494 Improving Health in America. U.S. Public Health Service Highlishts of 1977-80. abs. no. 495 Insurance, Regulation, and Hospital Costs. abs. no. 512 Interaction of Supply and Demand in the Market for Physician Services. abs. no. 515 International Dental Care De_'very Systems. Issues in Dental Health Policies. abs. no. 518
Evaluation of Health Manpower no. 281 Evaluation of Health Manpower abs. no. 282
Issues in Dental Health Poh'cies. abs. no. 519 Laws of Motion in the For-Protit Health Industry. A Theory and Examples. abs. no. 529 I.a'censing Restrictions and the Cost of Dental Care. abs. no. 531
Shortage Shortage
Area
Criteria.
Area Criteria.
Final Report Literature
abs.
Review.
Three
Evaluation of the Effects of National Health Service Corps Physician Placements on Medical Care DeUvery in Rural Areas. abs. no. 8013 Federal Government's Role in Ambulatory Services Development. A Management Perspective. abs. no. 304 Forward Plan for Health FY 1978-82. abs. no. 320 Funding Rural Nurse Practitioner Care. abs. no. 329 Future Health Care Organization. abs. no. 330 Future of New Health Practitioners. abs. no. 332
Magnitude and Determinants of Physician Initiated Visits in the United States. abs. no. 534 Mail.Order Meers'cine. An Analysis of the Sears Roebuck Foundation's Community Medthal Assistance Program. abs. no. 535 Manpower PoB'cy for PtT"mary Health Care. abs. no. 543 Medicaid and Cash Welfare Recipients. An Empirical Study. abs. no. 546 Medical Malpractice. The Response of Physicians to Premium Increases in California. abs. no. 562
Graduate Medical Education National Advisory Committee, Interim Report. abs. no. 338 Health Care Business. lnternan'onal Evidence on Private Versus Public Health Care Systems. abs. no. 356 Health Care Cost Containment in West Germany. abs. no. 359 Health Care Cost Inllation in the United States. Toward a UniKed Theory of Cause and Control. abs. no. 362
Medically Indigent. A State Perspective on a National Problem. abs. no. 570 Medicare Coverage for the Treatment of Alcoholism. abs. no. 575 Metropolitan Comprehensive Care ProgrBm. A Health Systems Organization Demonstration, abs. no. 590 Model for Assessing and Effecting Hospital Closure. Final Report. abs. no. 593 National Commission on the Cost of Medical Care. 1976-197Z VolLtrne 1.
Health Care Costs. Why Regulation Fails, Why Competition to Get There From Here. abs. no. 365 Health Care Dilemma. abs. no. 367
Problems
Health
Options
Care Financing
of Technology for Colorado.
in Health abs. no. 368
Works,
How
Care Delivery.
Commission Recommenda5ons abs. no. 599
Task Force Reports
National Commission on the Cost of Medical Collected Papers. abs. no. 600 National
Commission
Care.
Research
1976-197Z
on the Cost of Meda'cal Care. 1976-197Z
Agenda. Volume
2
Volume 3.
VII-53
Literature NationM National 612 New
Reviews
Data
Bases. abs. no
Health Care in Great Britain. Health Insurance and Pn?nary
Directions no. 643
in Public Health
60!
Recommendations.
Lessons for the USA. abs. no. 602 Med_2"al _)re for Chilc'ren. abs. no.
Care. A Prescription
fox the 1980s
abs_
New
Health Professionals. Nurse Practitioners and Physiclan_ • Assistants. abs. no. 645 Nurse Practitioners. A Review of the Literature 1965-!979. abs. no. 651 On _e
Cost of National
On the Ra_oning
Health
of Health
lnsmance
Services
m Quebec.
and Resource
abs. no. 900
Th#d-Party Payments t_,r New Health Professionals. An Alternative Fractional ReimbursEment in Outpatient Care. abs. no. 902 Toward a Community-Ba:sed National Health Service, abs. no. 906 Two Decades of Health Services. Social Survey ture. abs. no. 913
Trends in Use and Expendi-
Vertically Linked Health Organizations, abs. no. 929 Women's Health 34ovemento Feminist Alternatives to Medical no. 94_.
Control. abs.
abs. no. 601
Availability.
abs. no. 662
Therapeutic
services
Ordering Social Objee_ves. National Health Service and Na_'onal Health Insurance as Policy Options in Organizing the Mech'cal ('are System.
Achieving Optimum Utihzation ography, abs. no. 6
of Ancillary
Services.
abs. no. 664 Participation of Private
Cost and Regulation no. 146
Technology.
Future Policy Directions.
Paying for Physician Physician Acceptance Physician Physician
Practice
Dentists
in _ledieaid.
abs. no. 668
Services Under Medicare and Medicaid. of Medicaid Patiehts. abs. no. 682
abs. no. 671
Glut Will Force Hospitals to Look Outward, abs. no, 686 Lieensure. Competition and Monopoly in AmeriCan MedJ_ine.
abs. no. 687 Physician Migration
in Response
to Income
Opportunities
of l_edical
Evaluation of the Natiorml abs. no. 8014 Impact of Long-Term MediCal Technology.
Reimbursement
Long-Term
Care
Third-pretty
for DuraOle
Medical
Equipment,
Policy Options and the Impact of National no. 703
Considerations in the Design of Mental Health Insurance, ab,*. no. 116
Politics
of Health
of Federal
Revisited
abs.
hffNatiw_ and
Care. abs. no. 707
Potential for a Competitive abs. no. 710 Price Setting in the Marlet tore. abs. no. 722
Health
for Physicians'
in Boston,
Services,
A Review
M_ssachusetts.
the Cost of Health
Cost Containment abs_ no, 149
at'the LJtera-
Cost-Sharing in Health Insurance. abs. no. 169
Prl_ner on Antitrust
Dental
Rcgulatinn.
abs no. 726 Implications
Publi_ Choice in Health. Problems, Politics and Perspectives ing National Health Policy. abs. no. 761 Rationing Health Care. abs. no. 774
from
n
o:_ Formulat-
Health
Prepayment
Plans.
Doing Better and Feeling abs, no. 223
Benefits Selected
of Dental Under
Care.
National
Bibliography
Report
of Surgical
on Health
Service
Utilization.
on Rising
HeMth
Care Costs.
abs. no. 196 Worse.
The Political Pathology
of Health
Policy.
Economics of Mech'cal Care. A Policy Perspective. abs. no. 238 Effects of the 1974- 75Recession on Health Care for the Disadvantaged. no. 255
Rusponses of Canadian Physicians to the Introduction of Universal Medical Care Insurance, The First Five Years in Quebec. abs. no. 804
Financial Analysis of Alternative Benetits. abs. no. 310
Setting National Priorities. Agenda for the 1980"s. abs. no. 830 Source Book of Health Insurance Data, 1979-1980. abs. no. 847 Spy in the House of Medicine. abs. no, 850
Financial Financing Financing
Study of Physician Reimbursement Under _ledicare . 11. abs. no. 867 Study of Physicians" Fees. abs. no. 868
Future of Private Third-_arty Reimbursement Systems. abs. no. 333 Group Insurance Cost Cc_ntainment Strategies. abs. no. 342 Health and Health Insurance. The Public's View. abs. no. 350
Study of the Responses of Canadian Physicians to the Introduction versal Medical Care Insurance. The First Five Years in Quebec.
of Uniabs. no.
872 Study of the Utilization and EtYect of Temporary Nursing Servt]=es. abs. no. 8044 Substitution of Outpatient Care for Inpatient Care. Problems _nd Experienee. abs. no. 874 Supply Elastl_ities for PhysJclan ServiCes, abs. no. 878 Survey of Recent Research in Health Economics. abs. no. 882 Theory and Practice in _4inneapolis-St. Paul. abs. no. 899
VII-54
for Nonphysieian
Health
Practitioners.
Realities
and
for the Elderly, Methods
Volume II. Prescription
abs.
Expanding Health Benefits abs. no. 290
and _Ieob'caid. Volume
of Funding
AIanagement Under Third Party Reimbursement. Health Care. abs. no. 315 of Health Care abs. no. 317
Health Insurance abs. no. 389
and
Fees.
Realities of Rural Primary Care. abs. no. 776 Regionaiization and Health Pob'cy. abs. no. 780
Third Party Payment
abs.
abs. no. 791
Payer. Negotiations
Its Effects
Council on Wage and Pt_:e Stability abs. no. 172
and HospRal
Services.
Care. abs. no. 141
by a Third Party
Pricing, Demanders, and the Supply of Health Care. abs. no. 723 Pnknary Care in Durham County. Who Gives Care to Whom. abs. no, 724 Public" Capabilities and Health Care Effectiveness. Comparative Perspective. abs. no. 760
Demonstration.
Medical
abs. no. 49 for Cost and Quality
Containing Costs in Thirn' Party Drug Programs. Abstracts. abs. no. 129 Controlling
Ca_e System
abs.
payors
BeheSts in Medical Care Programs, Changing Patterns and Implications abs, no. 79
Four Decades
Bibli-
on Blue Shield.
abs. no. 689
Policy Politics, and Child Health, State Response. abs. no. 704
Channeling
lbr the Cost of Unnecessary
Physicians and New Health Practitioners. Issues lor the 1080s. abs. no, 694 Phystcians for the Future. abs. no. 696 Planning of Health Care Delivery. abs. no. 699 Insurance
An Annotated
C_u'e on Functionally Disabled Adults. abs. no. 8022 The Culprit Behind Health Care Costs. abs. no. 568
Physician Responsibility no. 692
Under Universal
Health Insurance in Quebec. abs. no. 688 Physician Particl)_atJbn in Health Insurance Plans. Evidence
Health
to
and Cost-Containment
Policies.
Group
Drugs. MedJ'cal
abs. no. 312
The Expeiience
Abroad.
Health Promotion Program,s in Occupational Settings. abs. no. 417 Health Status, Medical Ca,,e Utih'zation, and Outcome. An Annotated Bibliography of Empirical Studies. Volume 1. abs. no. 423 Hospice ,_dovement in the United States. abs. no. 441 Industry Roles in Health Care. abs. no. 501 Issues in Health Care Regulation. abs. no. 520 The ._lalprantitioners. abs no. 539 National Commission on _he Cost of Medical Care. 1976-197Z Volume 1, Commission
Recomm,endations
Task Force Reports
Health
Research
Agenda.
Care Programs
abs. no. 599 National Commission on the Cost of Medical Collected Papers. abs. no. 600
Care. 1976-197Z
National
abs. no. 608
Health
Insurance.
A Social
Placebo.
Volume
2.
Disability Economic Economic Economic,
Policies and Government Programs. abs. no. 215 Cost of lllness Revisited, abs. no. 230 Issues in Prevention. abs. no. 232 Social and Environmental
Determinants
o£Adult
Health
Some
Payment for Hospital Settees. Objectives and Alternatives. abs. no. 673 Private Health Insurance Plans in 1976: An Evaluation. abs. no. 729 Proceedings of the 28th Annual Group Health Institute, New York, New
Imph'cations for Future Research and Policy, abs. no. 8010 Episodes of Illness and Access to Care in the Inner City. A Comp_ison HMO and Non-HMO Populations. abs. no. 269
York, June 18-21, 1978. abs. no. 735 Proposals for National Health Insurance in the USA. Otis'as and Evolution, and some Perceptions for the Future. abs. no. 745 Prospective Rate Reimbursement and Cost Containment. Formula Reimbursement in New York. abs. no. 750 Prospective Reimbursement in Rhode Island. Additional Perspectives. abs.
Fact Book on Aging. A Profile of America's Older Population. abs. no. 295 Facts At Your Fingertips. A GuYde to Sources of Statistical Information on Major Health Topic_ Fourth EoO'tion. abs. no. 300 Federal Taxation and Regulation of Health Insurance Plans. abs. no. 306 Forward Plan for Health FY 1978-82. abs. no. 320 Fundamental Issues in the Praen'ce of Dental Public Health. abs. no. 327
no. 752 Prospective Reimbursement
Fundamentals 328
Through
Budget
Review.
New
Jersey,
Island and Western Pennsylvania, abs. no. 754 Public Insurance in Private Medical Markets. Some Problems Health Insurance. abs. no. 764 Realities of Rural Primary Care. abs. no. 776 Reimbursement for Physicians' Services. abs. no. 793 Repeated
Hospitah'zation
for the Same
Diseuse.
A Multiplier
Rhode
of National
of National
of Second
Opinion
Programs
for Elective
Surgery.
of
abs. no.
Grayi_ of America. abs. no. 339 Health and Retirement. Policy _nd Research Issues. abs. no. 352 Health Care Poticy in a Changing Environment. abs. no. 376 Health in the Future. In the Pink or in the Red. abs. no. 387 Health in the United States. Chartbook. abs. no. 388 Health
Insurance
Bibliography.
abs. no. 390
Health Costs. abs. no. 798 Role of the Private Sector in National Health Insurance. abs. no. 820 Social Medicine. The Advance of Orgamized Health Ser_ces in America.
Health Insurance Coverage for Alcohol_Drug Ado_'ction Treatment for Virginia State Employee_ A Feasibility Evaluation, abs. no. 391 Health Status and Use of Meo_'cal Services. Evidence on the Poor, the _91ack,
abs. no. 834 Spy in the House
and the Rural Elderly. abs. no. 422 H_dth Status, Medical Care Utilization, and Outcome.
State
of Medicine.
Health Legislation Catastrophic Health
State Regulation abs. no. 857
abs. no. 850
Report Vol, 8 No. 3. State Comprehensive Insurance Legislation. abs. no. 853
of Health
Services
Utilization.
Lessons
From
and
Miel_'gan.
An Annotated
Bibli-
ography of Empirical Studies. Volume Labs. no. 423 Health Status, Med$cal Care Ut_Tization, and Outcome. An Annotated
Bibli-
ography of Empirical Studies. Volume 2. abs. no. 424 Health Status, Medical Care Utih'zation, and Outcome. An Annotated
Bibli-
Strategies for Controlh'ng the Cost of State Medical Assistance Programs. abs. no. 861 Systems Approach to Health Insurance Pokey Information. A Preliminary Taxonomy of Health Insurance Issues, Program Options, Problems and Solutions. abs. no. 885 Technology in Hospitals. MedYcal Advances and Their Diffusion. abs. no.
ography of Empirical Stuch'es. Volume 3. abs. no. 425 Health Status, Med_'cal Care Utilization, and Outcome. An Annotated Bibh" ography of Empirical Studies. Volume 4, abs. no. 426 Health Status, Socioeconomic Status, and Utilization of Outpatient Services for Members of a Prepaid Group Practice. abs. no. 427 Health. What Is It Worth. Measures of Health Benefits. abs. no. 429
893 Three World Systems of Me_'cal Why Do HMOs Seem to Provide
How Much C_n Business Expect to Earn From Smoking Cessation. 469 Illness Prevention _nd Medical Insurance. abs. no. 474
no. 941 Working With the Insurer. Trends
in health
Alcohol
Care. Trends More Health
and Prospects, abs. no. 904 Maintenance Services. abs.
Impact of Social and Eeonomic no. 486
abs. no. 948
lmprn_n8 Health in America. 1977.80. abs. no. 495
status
and Health.
Changes
abs. no. 12
Income
Brown Lung Disability. Costs, Compensation ploratory Policy Study. abs. no. 53 Build Study I979. abs. no. 54
and
Controversy.
An
Ex-
on Financial
U.S. Pubh'c
Health
abs. no.
Security
Systems.
abs.
Service
Highlights
of
and Illness. abs. no. 497
Injuries at Work Are Fewer Among Older Employees. Insurance Cost Sa_ngs Due to an Adequate Alcoholism no. 510
abs. no. 508 Health Benefit. abs.
Catalog of Public Use Data Tapes from the National Center for Health Statistics. abs. no. 71 Catastrophic Illness Expense. ImpHcations for National Health Po_'cy in the United States. abs. no. 73 Catastrophic Illness in an HALO. abs. no. 74
Interim Report to Congress on Occupational Diseases. abs. no. 517 MedJeal Risks. Patterns of MortMity and Sur_val. abs. no. 563 Med_'cal Self-Care Programs. abs. no. 564 Mental Disorder and Primary Medical Care. An Analytical Review of the Literature. abs. no. 584
Comparative National Policies on Health Care. Conceptualization and Measurement of Health
Occupational Injuries and Illnesses abs. no. 654
abs. no. 93 for Adults in the Health
lnsurunce Study. Volume VIII, Overview. abs. no. 110 Conditions for Change in the Health Care System. abs. no. 111 Conference on Health Promotion and Disease Prevention, Febru_y 1978. Volume If. Conference Summ_uies. abs. no. 114 Cost of Catastrophic Illness. abs. no. 159 Cost of Disease 160
and Illness in the United
States
16-18,
in the Year 2000. abs. no.
Determining Health Needs. abs. no. 203 DisabzTity. From Social Problem to Federal Progrum. abs. no. 211 Disability Insurance. Program Issues and.Research, abs. no. 213 Disab_Tity Insurance. Trends Since World War II. abs. no. 214
in the United States
by Industry,
1978.
Overview of Health Insurance Study Pubh'cations. abs. no. 666 Perspectives on Health Promotion and Disease Prevention in the UL,ited States. abs. no. 680 Poverty and Health. Economic Causes and Consequences of Health Problearns, abs. no. 712 Prevemtion. Rhetoric Proposed Framework
and Reality. abs. no. 719 for Health and Health Care Policies.
Prospective Medicine. abs. no. 749 Repeated Hospitah'zation for the Same Disease. Health Costs. abs. no. 798 Social Nature of Chronic Dise_e and Disability.
abs. no. 748
A Multiplier
of National
abs. tto. 835
VII..55
Social Structure
and
the Diffusion
of Medical
Innovations
in the United
Health
Care Issues for _)Tdustry. abs. no. 373
States, Great BHtain, Sweden and France. abs. no. 838 Source Book of Health Insurance Data, 1979-1980. abs. no. 847 Status of Children, Youth and Families, 1979. abs. no. 858
Health Promotion Programs in Occupational Settings. abs. no. 417 Health Services and Health Hazards. The Employee's Need to Know. no. 419
abs.
Thirty- To-One Paradox. abs. no. 903
Health Services, no. 420
abs.
Health
Needs
of the Aged
and Medical
Solutions.
Welfare Status, Illness and Subjective Health DetYnition. abs. no. 934 Workers' Compensation and Work-Related Illnesses and Diseases. abs. no. 945 Vlsion/hearlng services Dental and Vision Care BenetYts in Health Effects Impact
of Advertising Lessons From of National Health Insurance
Correction Medicaid Volantary
Services.
Insurance
Plans. abs. no. 189
Optometry. abs. no. 249 on the Use and Spen_'n 8 for Sight
abs. no. 483
and Cash Welfare
Recipients.
Study.
abs. no. 546
initiatives
Centers,
Hospital Cost Containment. How Business Can Implore How Business Can Promote lies. abs. no. 463 How Business 464
and Decision-Making
a Competitive
How Business Can Use :_pec#Tc Techniques abs. no. 465 How Much 469
Interacts
Can Business
How to Improve
Health
Mechanisms.
Selected Notes for Future Policy. abs. no. 449 Health Planning and Regulation. abs. no. 462 Good Health for Employees and Their Fami-
Can Stimulate
How Business An Empirical
Power
With the Health Expect
Health
Care System.
to Control
Health
Care System.
Care Costs.
abs. no. 466
to Earn From Smoking
and Contain
abs. no.
Cessation.
abs. no.
Costs, abs. no. 472
Background Papers on Industry's Changing Role in Health Care Delivery. abs. no. 46 Business Perspective on Industry and Health Care. abs. no. 55 Carter Administration, Congress and Health Policy. A National Leadership Conference. abs. no. 67 Ch'mbal Et_cacy Assessment Program. abs. no. 8006
Idea Whose Time Has Come. Less Health Insurance. abs. no. 473 Industry and HMOs. A Natural Alliance. abs. no. 500 Industry Roles in Health Care. abs. no. 501 Industry's Voice in Health Policy. abs. no. 502 Insurance Cost Savings Due to an Adequate Alcoholism Health BeheSt. no. 510
Complex Puzzle of Rasing Health Together. abs. no. 107
Joint
Care Costs.
Can the Private
Sector Fit it
Con(h'tions Containing
for Change in the Health Care System. Health BenelYt Costs. The Self-Insurance
abs. no. 111 Option. abs. no. 130
Controlling abs. no. Controlling Controlling no. 142
Health Care Costs. Strengthening the Private Sector's Hand. 135 Rising Hospital Costs. abs. no. 139 the Costs of Retirement Income and Medical Care Plans. abs.
Health no. 524
Cost Containment
Lifetime Health-Monitoring Med_'cine. abs. no. 532
Program.
Program.
Hospital
A Practical
Utilization Approach
Report.
abs. abs.
to Preventive
Mail-Order Medicine. An Analysis of the Sears Roebuck Foundation's Community Medical Assistance Program. abs. no. 535 Major Issues in the Finar_cing and Management of HeMth Care. abs. no. 536 Medical Benetlt Cost Containment in the U.S.A. abs. no. 552 Medical Malpractice Suits. abs. no. 561
Corporate Role in Containing Health Care Costs. abs. no. 145 Cost Containment Education Efforts in United States Medical Schools. alas. no. 150
Mental Wellness Programs for Employees. Multilevel Care. A Veterans Administration Control. abs. no. 596
Cost Containment Through Risk-Shmffng by Primary Care Physicians. A tlistory of the Development of United Healthcare. abs. no. 155 Cost-Benet_t Study of a Hypertension Screening and Treatment Program at the Work Setting. abs. no. 165 Council on Wage and Price Stability Report on Rising Health Care Costs.
National HeMth Care Strategy Series Update. alas. no. 8028 National Health Insurance. 96th Congress second session, Volume 2. abs. no. 631 Payer, Provider, Consumer. Industry Confronts Health Care Costs. abs. no. 670
alas. no. 172 Crisis in Health Care. abs. no. 173
Personnel Leadership in Action. Doing Containment. abs. no. 679
Cutting Cost Without no. 178 Day
Cutting
the Quality
Hospitalization as a Cost-Effective Pilot Study. abs. no. 179
Design Digest
of Care. Shattuck Alternative
Lecture.
to Inpatient
abs.
Care. A
for a Corporate Health Care _lonitoring System. abs. no. 199 of Hospital Cost Containment Projects, Tlu'rd Edition. abs. no. 208
Economics Economics Employer
of Cost Containment. abs. no. 236 of Industrial Health. History, Theory, Practice. abs. no. 237 AcqtuNition of Health Care Facilities. A Possible Outcome of
Escalating Premiums. abs. no. 261 Evaluation of Alternative Payment Strategies Approach. abs. no. 280
for Hospitals.
Evaluanbn of Market Mechanisms of Cost Control. Fee-For-Service Health Maintenance Organizations,
A Conceptual
abs. no. 283 abs. no. 307
Group Insurance Cost Containment Strategies. abs. no. 342 Health. A Victim or Cause of ImTation. abs. no. 348 Health Care Cost Containment. abs. no. 8018 Health Care Cost Containment. Challenge to Industry. abs. no. 357 Health Care Costs. private Initiatives for Containment. abs. no. 364 Health Care Guidance. Commercial Health Insurance and National Health Policy. abs. no. 369 Health Care in the American Economy. Number 3. abs. no. 370
VII-56
abs. no. 587 Initiative in Health
Something
About
Care Cost
Health
Care Cost
Prevention. Rhetoric and Reah'ty. abs. no. 719 Private Cost Containment. abs. no. 727 Private Sector Perspective 733
on the Problems
of Health
Program for Elective SluZical Second Opinion. Surgical gram Participants, 1976-197Z alas. no. 742 Promoting Health. Consumer Education and National Quality Health Care. The Role of Continuing Medical 769 Regulation of Health Report on Coalitions RetIu'nking Employee
Care Costs.
abs. no.
Experience
of pro-
Policy. abs. no. 744 Education, abs. no.
Care in the United States. abs. no. 787 to Contain Me_'cal Care Costs. abs. no. 800 Benelfts Assumptions. abs. no. 808
Rasing Health Costs. Public and Private Responses. abs. no. 813 Second Surgical Opinions. What Have We Learned. abs. no. 823 Setting National Priorities. Agenda for the 1980"s. abs. no. 830 South Carolina Voluntary Effort Report 1980-81. abs. no. 8040 South Carolina Voluntary Effort, 1980-81. abs. no. 848 Steps to Control lntIation in Health Care Costs. abs. no. 860 Systems Development. Trends, Issues and Implications. abs. no. 886 Taking Action To Contain Health Care Costs. Part I. abs. no. 887 Taking Action to Contmh Health Care Costs. Part If. abs. no. 888 Vertically Linked Healt_ Organizations. abs. no. 929
Health Care Programs
Women's Health no. 944
,_Iovement.
Workers compensation Analysis of Workers"
Feminist
Compensation
Alternatives
to Medical
Control. abs.
Laws. abs. no. 39
Brown Lung Disabih'ty. Costs, Compensation and Controversy, An Exploratory Policy Study. abs. no. 53 Diagnosis and the Dole. The Function of lllness in American Distn'butive Politics. abs. no. 206 Disability Insurance. Program Issues and Research. abs. no. 213 Disability Policies and Government Programs. abs. no. 215 Econon_'cs of Industrial HeMth. History, Theory, Practice. abs. no. 237 Health Services and Health Hazards. The Employee's Need to Know. abs. no. 4i9 How Cheap is a Life. abs. no. 467 InjurTes at Work Are Fewer Among Older Employees. abs. no. 508 Interim Report to Congress on Occupational Diseases. abs. no. 517 Providing More Information on Work Injury and Illness. abs. no. 757 Social Security Programs Throughout the World, 1977. abs. no. 837 Social Welfare Expenditures Under Public Programs, Fiscal Year 1977. abs. no. 840 Use of Tax Subsicfl'es for the Cost of Compliance With Safety and Health Regulations. abs. no. 923 Workers" Compensa_on and Work-Related Illnesses and Diseases. abs. no. 945 Workers" Compensation no. 946
Insurance.
Recent
Workers'
Research
Studies.
Compensation
Trends in Employer
Costs, abs.
abs. no. 8045
VII-57
