==================================HSR02================================== 2. Medicaid and Medicare vs. health insurance and their role in health care delivery. 1 UI - 87061345 TI - A proposal for financing health care of the elderly. AB - The American Medical Association House of Delegates has adopted a proposal for financing health care of the elderly, developed by the Board of Trustees, the Council on Medical Service, and the Council on Legislation. The proposal would replace the present Medicare program with a system of vouchers to older persons to purchase private health insurance policies or plans providing specified adequate benefits including catastrophic coverage. Vouchers would be financed by a new tax on adjusted gross income during working years that would replace the present employee health insurance payroll tax, and by continuation of the employer health insurance payroll tax. Tax rates would be at a level sufficient both to meet obligations to current Medicare beneficiaries and, over a 30-year period, to achieve prefunding of benefits. All tax contributions after that date would be preserved for the future use of those taxed, and could be invested during earning years, rather than being paid out immediately for present beneficiaries. The proposal would place health care for the elderly on a fiscally sound basis, provide increased cost sharing for those who are financially well off, and provide the protection against catastrophic health care expense lacking under the current Medicare program. MH - Aged ; American Medical Association ; Comparative Study ; Costs and Cost Analysis ; *Financing, Government ; Health Insurance for Aged and Disabled, Title 18/ECONOMICS ; Health Services for the Aged/*ECONOMICS ; Human ; Insurance, Health/ECONOMICS ; United States SO - JAMA 1986 Dec 26;256(24):3379-82 2 UI - 87060652 AU - Lang WP ; Weintraub JA TI - Comparison of Medicaid and non-Medicaid dental providers. AB - A statewide mail survey of a stratified sample of 640 Michigan general dentists was conducted in 1983, with a response rate of 41 percent, n = 261. An analysis was performed to compare Medicaid and non-Medicaid providers. About half of all respondents reported that they were not seeing any Medicaid patients (Group 1); 29 percent reported that less than 10 percent of their patients were Medicaid-eligible (Group 2), and 22 percent reported that 10 percent or more of their patients were Medicaid-eligible (Group 3). Significant differences existed among the three groups for age of respondent, length of time in practice, and number of new patients seen each month. Respondents with greater percentages of Medicaid patients in their practices were more likely to be in group practice. Stratification of respondents by location suggested that rural providers were more likely than urban respondents to have some Medicaid patients in their practices. Over 40 percent of respondents from all groups reported themselves as being not busy enough. In 1984, more than one million persons in Michigan were eligible for Medicaid dental benefits, but only one-fourth of these individuals were recipients of dental care. Factors that may limit dentists' participation in the Medicaid program, despite the presence of a large eligible population and self-reported lack of business, are discussed. MH - Comparative Study ; General Practice, Dental/ECONOMICS ; *Insurance, Dental ; *Medical Assistance, Title 19 ; Michigan ; Support, U.S. Gov't, P.H.S. SO - J Public Health Dent 1986 Fall;46(4):207-11 3 UI - 87022990 AU - Prowant BF ; Kappel DF ; Campbell A TI - A comparison of inpatient and outpatient Medicare allowable charges for continuous ambulatory peritoneal and center hemodialysis patients: a single-center study. AB - Medicare allowable charges were compared between 21 continuous ambulatory peritoneal dialysis (CAPD) and 25 center hemodialysis (CHD) patients for the 12-month period from Sept 1982 through Aug 1983 to determine if savings from CAPD therapy were offset by higher hospitalization charges. All adult patients on a single therapy for the 12-month period who were not dialyzed or hospitalized at other institutions were included. The CAPD and CHD patient groups did not differ significantly by age, sex, or incidence of systemic disease. However, the CHD group had significantly more black patients. The primary renal disease, the incidence of diabetes mellitus, and other systemic diseases did not differ between the groups. The number of hospital admissions was similar between the two groups. However, the CHD patients tended to have a higher number of hospital days than the CAPD group (17.5 v 12.4). Although the total hospital charges tended to be higher for CHD ($16,145) than CAPD patients ($9,872), this difference was not significant. Outpatient dialysis charges were significantly less expensive for CAPD ($16,470) than CHD ($28,233). Emergency department charges were also significantly less for the CAPD group. Charges for patients with and without systemic disease were analyzed separately. In both subgroups, all charges were less for CAPD therapy; however, this difference was significant only for outpatient dialysis charges. Total charges for the 12-month period were significantly less for the CAPD group ($26,453) than for CHD ($45,586). This demonstrates that hospitalization charges did not offset the savings of home dialysis in these patients. MH - Ambulatory Care Facilities/*ECONOMICS ; Comparative Study ; *Fees and Charges ; Female ; Health Insurance for Aged and Disabled, Title 18/ *ECONOMICS ; Hemodialysis Units, Hospital/*ECONOMICS ; Hemodialysis/ *ECONOMICS ; Hospital Units/*ECONOMICS ; Human ; Insurance, Health, Reimbursement ; Length of Stay ; Male ; Middle Age ; Missouri ; Patient Admission ; Peritoneal Dialysis, Continuous Ambulatory/*ECONOMICS ; United States SO - Am J Kidney Dis 1986 Oct;8(4):248-52 4 UI - 87013433 AU - Coffey RM ; Goldfarb MG TI - DRGs and disease staging for reimbursing Medicare patients. AB - Beginning October 1, 1983, Medicare began reimbursing many hospitals on the basis of a set of fixed fees tied to Diagnosis-Related Groups (DRGs). Using 1979-1981 Maryland data for Medicare patients, this paper compares the DRG system with the Disease Staging patient classification system in terms of structure, explanation of resource consumption (length of stay) of hospital patients, and impact on reimbursement by type of hospital. The two systems are conceptually and empirically different in classifying patients. Further, Disease Staging and DRGs perform similarly in explaining length-of-stay variation among Maryland patients. However, the two systems generate substantially different reimbursements by type of hospital. Surprisingly, large hospitals (including urban, not-for-profit, teaching hospitals) fare better under a DRG-based reimbursement system than under Disease Staging, a severity-of-illness system that excludes procedures as a basis of classification. These results imply that reimbursement policy based on Disease Staging would create disincentives to perform surgery compared with the current DRGs. MH - Comparative Study ; *Diagnostic Related Groups ; Health Insurance for Aged and Disabled, Title 18/*ECONOMICS ; Hospitalization/*ECONOMICS ; Hospitals, Teaching/ECONOMICS ; Human ; Length of Stay ; Maryland ; Ownership ; Prospective Payment System/*METHODS ; *Severity of Illness Index ; Support, U.S. Gov't, P.H.S. SO - Med Care 1986 Sep;24(9):814-29 5 UI - 87013427 AU - Guendelman S ; Schwalbe J TI - Medical care utilization by Hispanic children. How does it differ from black and white peers? AB - Factors associated with the utilization of medical care by Hispanic, black Non-Hispanic, and white Non-Hispanic children were analyzed using multivariate regression techniques on a Health Interview Survey sample. The findings indicate that Medicaid coverage was the sharpest enhancer of entry into care for Hispanics and blacks, contributing significantly to the amount of physician visits. While financial factors seemed more influential determinants of physician contacts for minorities, perceived health needs appeared to be important contributors to entry into health care for white children. Such differences reveal that important racial-ethnic disparities persist with respect to physician utilization among children. Improved insurance coverage for Hispanics, particularly children of Mexican origin, is suggested as an important intervention to facilitate access for this population. MH - Adolescence ; Age Factors ; *Blacks ; Child ; Child, Preschool ; Comparative Study ; Cuba/ETHNOLOGY ; Family Characteristics ; Health Services Accessibility ; *Hispanic Americans ; Human ; Infant ; Medical Assistance, Title 19/UTILIZATION ; Mexico/ETHNOLOGY ; Office Visits/ *UTILIZATION ; Peer Group ; Personal Health Services/*UTILIZATION ; Physicians ; Puerto Rico/ETHNOLOGY ; Socioeconomic Factors ; Statistics ; United States ; *Whites SO - Med Care 1986 Oct;24(10):925-40 6 UI - 86266146 AU - Levey LA ; MacDowell NM ; Levey S TI - Health care of poverty and nonpoverty children in Iowa. AB - Responses to a survey of 637 Iowa children under age six years from Aid to Families with Dependent Children (AFDC) households was conducted through telephone interviews with parents and compared to a second sample of children in 760 randomly sampled households. Utilization of health services for children in the AFDC sample was similar to that of nonpoverty children and superior to that of other poverty children. Irrespective of Medicaid coverage, poverty children's health care differed from that of nonpoverty children in the following ways: less well care from a private practice or pediatrician, seeing the same health professional at each well visit less often, receiving immunizations at the same place as source of well care, examination by a physician at the most recent well visit, sick care at the same place as well care. MH - Child Health Services/*UTILIZATION ; Child, Preschool ; Comparative Study ; Health Surveys ; Human ; Infant ; Insurance, Health ; Iowa ; Medical Assistance, Title 19 ; *Poverty ; Support, Non-U.S. Gov't SO - Am J Public Health 1986 Aug;76(8):1000-3 7 UI - 86255760 AU - Kreling DH ; Kirk KW TI - Estimating pharmacy level prescription drug acquisition costs for third-party reimbursement. AB - Accurate payment for the acquisition costs of drug products dispensed is an important consideration in a third-party prescription drug program. Two alternative methods of estimating these costs among pharmacies were derived and compared. First, pharmacists were surveyed to determine the purchase discounts offered to them by wholesalers. A 10.00% modal and 11.35% mean discount resulted for 73 responding pharmacists. Second, cost-plus percents derived from gross profit margins of wholesalers were calculated and applied to wholesaler product costs to estimate pharmacy level acquisition costs. Cost-plus percents derived from National Median and Southwestern Region wholesaler figures were 9.27% and 10.10%, respectively. A comparison showed the two methods of estimating acquisition costs would result in similar acquisition cost estimates. Adopting a cost-plus estimating approach is recommended because it avoids potential pricing manipulations by wholesalers and manufacturers that would negate improvements in drug product reimbursement accuracy. MH - Comparative Study ; Costs and Cost Analysis ; Insurance, Health, Reimbursement/*ECONOMICS ; Insurance, Pharmaceutical Services/*ECONOMICS ; Medical Assistance, Title 19/*ECONOMICS ; Pharmacies/ECONOMICS ; Prescriptions, Drug/*ECONOMICS ; Support, Non-U.S. Gov't ; Texas SO - Med Care 1986 Jul;24(7):590-600 8 UI - 86233929 AU - Andersen RM ; Giachello AL ; Aday LA TI - Access of Hispanics to health care and cuts in services: a state-of-the-art overview. AB - The most current research literature on the access of Hispanics to medical care is reviewed, and data from a 1982 national survey by Louis Harris and Associates on access to health care are presented to document current levels of access to health care of the Hispanic population. Through telephone interviews, 4,800 families were contacted, yielding a total sample of 6,610 persons. According to the survey's data, the ability of Hispanics to obtain health services is hampered by relatively low incomes, lack of health insurance coverage, and ties to a particular physician. However, Hispanics do not differ significantly from whites in their use of hospitals, physicians, or outpatient departments and emergency rooms. Hispanics are less satisfied than whites on a host of measures describing the most recent medical visit. These levels of dissatisfaction with the visit are similar to those of blacks. The recession and public care service cutbacks did not appear to result in a substantial reduction in the volume of medical care received by Hispanics and blacks. Still, the services available to minorities are viewed by them as less effective in meeting their needs in comparison with how whites view the services they receive. Further, the 1982 survey reveals particular difficulties and barriers for Hispanics in obtaining needed medical services. More than one-fifth of the Hispanic families had one or more significant problems in obtaining needed services. MH - Adolescence ; Adult ; Aged ; Blacks ; Child ; Child, Preschool ; Comparative Study ; Consumer Satisfaction ; Data Collection ; Dental Care ; Female ; Health Services/UTILIZATION ; *Health Services Accessibility ; *Hispanic Americans ; Human ; Infant ; Infant, Newborn ; Insurance, Health ; Male ; Medical Assistance, Title 19 ; Middle Age ; Pregnancy ; Review ; Socioeconomic Factors ; Support, Non-U.S. Gov't ; United States ; Whites SO - Public Health Rep 1986 May-Jun;101(3):238-52 9 UI - 86230381 AU - Schlesinger M TI - On the limits of expanding health care reform: chronic care in prepaid settings. AB - Health Maintenance Organizations have become a favored vehicle for reform of the American health care system, while controlling costs and assuring quality. But for populations with a high prevalence of chronic disease--the elderly or the mentally ill--HMOs may fall short of meeting needs. Three stages of reform are proposed for adapting the principle of prepayment to better serve enrollees with chronic illness. MH - Aged ; *Chronic Disease/ECONOMICS/THERAPY ; Comparative Study ; Costs and Cost Analysis ; Fees, Medical ; Health Insurance for Aged and Disabled, Title 18/ECONOMICS ; Health Maintenance Organizations/ECONOMICS/*TRENDS/ UTILIZATION ; Human ; Institutionalization/ECONOMICS/TRENDS ; Long Term Care/ECONOMICS ; Medical Assistance, Title 19/ECONOMICS ; Mental Disorders/ECONOMICS/THERAPY ; Policy Making ; United States SO - Milbank Q 1986;64(2):189-215 10 UI - 86229341 AU - Shaughnessy PW ; Schlenker RE ; Polesovsky MB TI - Medicaid and non-Medicaid case mix differences in Colorado nursing homes. AB - Profiles of case mix and related variables were compared for 1,064 Medicaid and 459 non-Medicaid residents of 65 freestanding nursing homes in Colorado in 1980. The results point to substantial case-mix differences, with Medicaid residents typically characterized by fewer and less intense long-term care problems as well as greater independence in functioning (ADLs). Policy impacts of these findings in Colorado have included a legislatively mandated home and community-based care program as well as a more stringent preadmission certification program for Medicaid clients. The method of comparing Medicaid and non-Medicaid case mix in nursing homes appears to have policy relevance for other states as well. Research implications in the areas of measuring severity of long-term care problems and measuring residents' functional abilities apart from services received are also suggested. MH - Activities of Daily Living ; Aged ; Colorado ; Comparative Study ; *Diagnostic Related Groups ; Human ; Length of Stay ; Long Term Care ; *Medical Assistance, Title 19 ; Middle Age ; Nursing Homes/*UTILIZATION ; Reimbursement Mechanisms ; Sampling Studies ; Support, U.S. Gov't, Non-P.H.S. SO - Med Care 1986 Jun;24(6):482-95 11 UI - 86223204 AU - Sloan FA ; Valvona J TI - Prospective payment for hospital capital by Medicare: issues and options. AB - After this year, Medicare will no longer reimburse capital-related expenses. Instead, a new approach may be implemented. Should the new capital payment scheme be prospective? Should Medicare continue to recognize return on equity? What will be the relationship between Medicare payment and health care planning? These and other questions should be asked since the answers will directly affect the health care setting. MH - Aged ; *Capital Expenditures ; Comparative Study ; Costs and Cost Analysis ; Depreciation ; *Economics ; Equipment and Supplies, Hospital/ ECONOMICS ; Health Insurance for Aged and Disabled, Title 18/*ECONOMICS ; Human ; Ownership/ECONOMICS ; Prospective Payment System/*METHODS ; Reimbursement Mechanisms/*METHODS ; Reimbursement, Incentive ; Support, U.S. Gov't, Non-P.H.S. ; United States SO - Health Care Manage Rev 1986 Spring;11(2):25-33 12 UI - 86203111 AU - Kovar MG TI - Expenditures for the medical care of elderly people living in the community in 1980. AB - Policy debates about financing medical care for the elderly are often clouded by evidence drawn from averages based on aggregate data. The National Medical Care Utilization and Expenditure Survey enables examination of the circumstances of the 95 percent of the elderly who are not institutionalized. A significant portion of out-of-pocket charges falls on the poor; public expenditures are highly concentrated for the relatively few elderly in their last year of life. Medicare and Medicaid have successfully lessened the burden on families. MH - Aged ; Community Health Services/*ECONOMICS ; Comparative Study ; *Expenditures, Health ; Female ; Financing, Personal ; Health Insurance for Aged and Disabled, Title 18/ECONOMICS ; Health Services for the Aged/ *ECONOMICS ; Hospitalization/ECONOMICS ; Human ; Income ; Institutionalization/ECONOMICS ; Male ; Time Factors ; United States SO - Milbank Q 1986;64(1):100-32 13 UI - 86166792 AU - Rosko MD ; Broyles RW TI - The impact of the New Jersey all-payer DRG system. AB - Two prospective payment systems that operated concurrently in New Jersey during 1980-1982 created a natural experiment and a unique opportunity to compare the effectiveness of the two systems in restraining cost increases. Our results indicate that during that period, annual increases in the cost per case were significantly less in hospitals that were subject to the all-payer DRG system than in those institutions that were paid under the Standard Hospital Accounting and Rate Evaluation (SHARE) program. We also found that, relative to the SHARE program, the DRG system appears to have increased admission rates and reduced length of stay. MH - Blue Cross/ECONOMICS ; Comparative Study ; Cost Control/METHODS ; Diagnostic Related Groups/*ECONOMICS ; *Economics, Hospital ; Human ; Length of Stay/ECONOMICS ; Medical Assistance, Title 19/ECONOMICS ; New Jersey ; Patient Admission/ECONOMICS ; *Prospective Payment System ; *Reimbursement Mechanisms ; Reimbursement, Incentive ; Statistics SO - Inquiry 1986 Spring;23(1):67-75 14 UI - 86166787 AU - Cohen J ; Holahan J TI - An evaluation of current approaches to nursing home capital reimbursement. AB - One of the more controversial issues in reimbursement policy is how to set the capital cost component of facilities rates. In this article we examine in detail the various approaches used by states to reimburse nursing homes for capital costs. We conclude that newer approaches that recognize the increasing value of nursing home assets over time, commonly called fair rental systems, are preferable to the methodologies that have been used historically in both the Medicare and the Medicaid programs to set capital rates. When properly designed, fair rental systems should provide more rational incentives and less encouragement of property manipulation than do more traditional systems, with little or no increase in state costs. MH - Capital Financing/*METHODS ; Comparative Study ; Cost Control ; Costs and Cost Analysis ; Depreciation ; Financial Management/*METHODS ; Health Insurance for Aged and Disabled, Title 18 ; Investments ; Maryland ; Medical Assistance, Title 19 ; Nursing Homes/*ECONOMICS ; *Reimbursement Mechanisms ; Support, Non-U.S. Gov't ; United States ; West Virginia SO - Inquiry 1986 Spring;23(1):23-39 15 UI - 86143923 AU - Dimick AR ; Potts LH ; Charles ED JR ; Wayne J ; Reed IM TI - The cost of burn care and implications for the future on quality of care. AB - The high cost of health care has become a nationwide concern and there are several national initiatives under way to reduce the rate of increase of these costs. Among the most recent initiatives has been the introduction of Medicare reimbursement based upon Diagnostic Related Groups (DRGs). This paper presents a retrospective analysis of the costs of care of burned patients admitted to the University of Alabama at Birmingham Burn Center and a profile of the financial impact of DRGs. Costs for burned patients were twice as high as for the average patient in the hospital and increased at a faster rate. Since 1977 the proportion of indigent patients and patients with very poor third-party coverage has greatly increased and those with good or excellent third-party coverage has decreased. If the care for Medicare patients had been reimbursed on the bases of DRG rates in 1982, payments would have exceeded costs by $2,981 but would have been $88,399 less than charges. In 1983, if the care for Medicare patients had been reimbursed on the bases of DRG rates, the payment would have been $409,629 less than costs and $634,583 less than charges. This very unfavorable reimbursement is because DRG reimbursement is essentially a flat rate and for long lengths of stay costs are much greater than reimbursements. Specific policies on methods to correct this discrepancy are suggested. MH - Burn Units/*ECONOMICS/STANDARDS ; Burns/*ECONOMICS/THERAPY ; Comparative Study ; Costs and Cost Analysis ; Diagnostic Related Groups ; Fees and Charges ; Health Insurance for Aged and Disabled, Title 18 ; Human ; Insurance, Health, Reimbursement ; Intensive Care Units/*ECONOMICS ; Length of Stay ; *Quality of Health Care ; Retrospective Studies SO - J Trauma 1986 Mar;26(3):260-6 16 UI - 86112394 AU - Greer DS ; Mor V ; Morris JN ; Sherwood S ; Kidder D ; Birnbaum H TI - An alternative in terminal care: results of the National Hospice Study. AB - Hospice is a program of supportive services for terminally ill patients and their families, provided either at home or in designated inpatient settings, which is purported to improve patient and family quality of life at lower cost than conventional terminal care. The National Hospice Study was a multi-site, quasi-experimental study to compare the experiences of terminal cancer patients and their families in hospices with those of similar patients and families receiving conventional terminal care. The results indicate that, although care is different in hospices, e.g. lesser utilization of aggressive interventional therapy and diagnostic testing, patients' quality of life is similar in the hospice and conventional care systems with the exception of pain and symptom control, which may be better in the inpatient hospice setting. Hospice patients are more likely to die at home and their families are satisfied with that outcome. Otherwise, no consistent superiority of family outcome was associated with the hospice approach. The cost of hospice care is less than that of conventional terminal care for patients in hospices without inpatient facilities, but the cost of hospice appears to be equivalent to conventional care for patients in hospices having beds. MH - Adult ; Aged ; Cancer Care Facilities ; Comparative Study ; Costs and Cost Analysis ; Female ; Health Insurance for Aged and Disabled, Title 18/ ECONOMICS ; Health Services Research ; Home Care Services ; *Hospices/ CLASSIFICATION/ECONOMICS/ORGANIZATION & ADMIN. ; Hospitalization ; Human ; Insurance, Health, Reimbursement/ECONOMICS ; Male ; Middle Age ; Models, Theoretical ; Neoplasms/PHYSIOPATHOLOGY/PSYCHOLOGY/THERAPY ; Outcome and Process Assessment (Health Care) ; Pain/OCCURRENCE ; Quality of Life ; Support, Non-U.S. Gov't ; Support, U.S. Gov't, Non-P.H.S. ; *Terminal Care/ECONOMICS/ORGANIZATION & ADMIN. ; United States SO - J Chronic Dis 1986;39(1):9-26 17 UI - 86107382 AU - Thomas F ; Larsen K ; Clemmer TP ; Burke JP ; Orme JF Jr ; Napoli M ; Christison E TI - Impact of prospective payments on a tertiary care center receiving large numbers of critically ill patients by aeromedical transport. AB - To determine the economic impact of federal prospective payments and the potential effect if private insurance payers were to implement similar prospective payments, we examined payments under Medicare diagnosis-related grouping (DRG) reimbursement policies for 105 Medicare and 357 non-Medicare patients admitted to a tertiary care center via air transport. Among the 105 Medicare patients, the average length of stay was 11.4 days and the mortality rate was 24%. Hospital charges exceeded DRG reimbursement for 74% of Medicare patients. A comparison of previous Medicare payment policies to current federal DRG reimbursement resulted in a revenue loss to the hospital of $667,229 ($6335 per patient). For the 357 non-Medicare patients, the average length of stay was 10.8 days, the mortality rate was 10%, and hospital charges exceeded Medicare DRG reimbursement for 78% of the patients. Implementation of DRG-like payments by non-Medicare insurers would create a hospital revenue loss of $2,493,048 ($6983 per patient). We conclude that unless current and planned prospective payment policies are modified, the use of aeromedical transport services to recruit large numbers of critically ill patients to tertiary care centers is economically prohibitive. MH - Aircraft ; Comparative Study ; Critical Care/*ECONOMICS ; Diagnostic Related Groups ; Health Insurance for Aged and Disabled, Title 18/ *ECONOMICS ; Hospitalization/*ECONOMICS ; Human ; Length of Stay ; Mortality ; Prospective Payment System/*ECONOMICS ; Reimbursement Mechanisms/*ECONOMICS ; Transportation of Patients/*ECONOMICS ; Utah SO - Crit Care Med 1986 Mar;14(3):227-30