Painful medicine: managed care and the fate of America's major teaching hospitals

Healthcare spending in the United States has risen steadily throughout the post-World War II period as the American healthcare system has been transformed from cottage industry to big business. The increasing rate of social investment in healthcare also transformed America's major teaching hospitals. As a case in point, the University of Iowa Hospitals and Clinics saw annual operating revenues rise from $1 million in 1945 to more than $350 million in 1995, which was accompanied by an extraordinary expansion in its physical facilities and in its multifaceted operations. In the 1970s and even more so in the 1980s, however, the unceasing climb in healthcare spending fueled concern among policy experts, politicians, employers, and insurers alike. In turn, the search for effective cost controls led to the current managed care revolution. While the end of that revolution is not yet in sight, managed care has, it appears, effected significant cost savings, but at no small cost to America's major teaching hospitals and their social missions of teaching, research, and patient care. Whether those missions can survive--and, if so, in what form--in a healthcare system dominated by the managed care ethos is an increasingly important concern.

Is lower income associated with greater biopsychosocial morbidity? Implications for physicians working with underserved patients

BACKGROUND

Previous studies have established a powerful relationship between socioeconomic position and health. However, there has been little attention given to the association between income, biopsychosocial morbidity, and decline in health over time among primary care patients.

METHODS

Data were collected using a survey mailed to patients receiving care at a family medicine center and through a follow-up survey mailed 2 years later. The independent association between various biopsychosocial measures and family income was assessed through stepwise linear regression. After controlling for baseline health status, the effect of family income on health status at follow-up was assessed.

RESULTS

Data were available from 922 active family medicine patients who responded to the initial survey and from 655 who responded to the follow-up survey. In bivariate analyses, lower family income was significantly associated with poorer health status, greater psychological distress, more family dysfunction, less social support, more behavioral risk factors, higher rates of obesity and uncontrolled blood pressure, poorer physical and mental health status, and more medical diagnoses. In a multivariate analysis, age, sex, marital status, race, social network, family criticism, smoking, fat consumption, and health status were independently associated with family income. After controlling for covariates, including baseline health status, family income was a significant predictor of health status at follow-up.

CONCLUSIONS

Family income is associated with biopsychosocial morbidity and health decline. Physicians who care for poorer patients will likely be confronted by challenging and complex biopsychosocial problems.

Measuring charitable contributions: implications for the nonprofit hospital's tax-exempt status

Since 1985, some nonprofit hospitals have tried to measure the magnitude of their charitable contributions in order to protect themselves from challenges to their nonprofit tax-exempt status. Using a sample of 562 Catholic nonprofit hospitals, this research shows that these charitable contributions may be defined and measured in several different ways, each having methodological advantages and disadvantages. The data indicate that charity care contributions vary widely, are unequally distributed across the sample of hospitals, and are influenced by the characteristics of the people in the local community and not by the characteristics of the health care delivery system. These findings suggest that legislators may be correct when questioning the rationale for the tax-exemption accorded to virtually all nonprofit hospitals. Further, it suggests that nonprofit hospital administrators can protect the tax-exempt status of their hospital by emphasizing the charitable contributions it makes by absorbing the unreimbursed costs from Medicare and Medicaid.

Indigence and access to health care in sub-Saharan Africa

Access to health care services for the poor and indigent is hampered by current policies of health care financing in sub-Saharan Africa. This paper reviews the issue as it is discussed in the international literature. No real strategies seem to exist for covering the health care of the indigent. Frequently, definitions of poverty and indigence are imprecise, the assessment of indigence is difficult for conceptual and technical reasons, and, therefore, the actual extent of indigence in Africa is not well known. Explicit policies rarely exist, and systematic evaluation of experiences is scarce. Results in terms of adequately identifying the indigent, and of mechanisms to improve indigents' access to health care, are rather deceiving. Policies to reduce poverty, and improve indigents' access to health care, seem to pursue strategies of depoliticizing the issue of social injustice and inequities. The problem is treated in a 'technical' manner, identifying and implementing 'operational' measures of social assistance. This approach, however, cannot resolve the problem of social exclusion, and, consequently, the problem of excluding large parts of African populations from modern health care. Therefore, this approach has to be integrated into a more 'political' approach which is interested in the process of impoverishment, and which addresses the macro-economic and social causes of poverty and inequity.

Perspectives of nursing executives regarding ethical-economic issues

The authors grapple with the very real issue of how to allocate scarce health care resources while trying to hold down costs, especially in the face of changing federal and managed care reimbursement realities. Nurse executives (NEs) were surveyed in an attempt to discover their perspectives on a number of related ethical-economic issues. The NEs' responses to the entire "ethical-economic" survey were contrasted with answers offered to the same tool earlier by staff RNs. Among the questions raised was the impact of cost controls on staffing patterns. Not surprisingly, the staff nurses reported perceiving that budget cuts had a greater negative impact on staff positions and the quality of patient care than the nurse executives reported. Both groups were in favor of taxpayers covering a greater part of the cost of medically indigent care. When asked if they would be willing to pay higher taxes themselves, slightly less than half of the nurse executives answered in the affirmative while only 17% of the staff nurses indicated a similar willingness.

The effect of user charges and socio-demographic environment on paediatric trauma hospitalisation in Helsinki in 1989-1994

Although many studies have shown an association between socio-economic environment and childhood injury mortality rates, little research has focused on the association between injuries which require hospitalisation and the child's socio-economic environment. All municipal emergency care was free of charge before the beginning of 1991, from then on a moderate patient charge was introduced by the City of Helsinki. An earlier report from a completely different social environment suggest that even a moderate user charge might create systematic discrimination against indigent families. We studied the childhood injury hospitalisation rates during 1989-1994 in Helsinki and analysed the association between rates of hospitalisation and local socio-economic and demographic factors. We also examined the effect of introduction of emergency room user charges on the rate of hospitalisation. Data from 1607 injuries from Helsinki City Hospital and 769 injuries from Helsinki University Central Hospital from years 1989 through 1994 were used. Annual rates of child hospitalisation were calculated at city level. Local socio-economic and demographic variables were derived from the Helsinki Bureau of Statistics. The possible association between the explanatory variables and hospitalisation rates at Helsinki City Hospital was calculated using annual data from the 33 health districts in Helsinki. The overall rate of hospitalisation for injuries declined but not statistically significantly. No association between socio-economic and demographic variables and hospitalisation rates was found. The moderate user charge had no effect on hospitalisation rates, proving that, in this setting, the demand for care was rather inelastic in paediatric injuries severe enough to require hospitalisation.

Shifting the costs of indigent care back to county governments

Despite a decade of steadily rising prosperity, Texans are losing health care benefits at an alarming rate. As many as 41 million people in this country, or 15% of the population, lack health care coverage of any kind. Most of these people are under age 65 and are gainfully employed, but their employers don't provide coverage and/or don't pay them enough to afford it themselves. Most have minimum wage jobs and are ineligible for Medicaid. These individuals plant the gardens, work in fine restaurants, clean expensive houses, and generally benefit the communities in which they reside. Texas law suggests that county governments and property owners should pick up the tab for the medically indigent. However, as the uninsured numbers grow, county governments are finding ways to extricate their taxpayers and the institutions they support from the obligatory role as payer of "last resort" for these people. While reimbursement from government programs, managed care, and commercial insurers is putting tremendous financial pressure on health care providers, the county systems simply are not assuming their financial, legal, or ethical responsibilities for those outside the protective cover of these programs. In my experience, health care for the medically indigent has become "charity care" at the profit and nonprofit hospitals in the state. The strain is palpable in the emergency rooms, where by law the medical crises of the poor must be treated. This de facto safety net is fraying, and our political leaders need to make the painful decision to raise sufficient tax revenues to remove the weight.

Providers create coordinated care system to help cover Birmingham's uninsured

Providers strive to manage the uninsured themselves. Providers in Birmingham, AL, have partnered with a public hospital to better manage patients with no insurance coverage, and in the process have spread the cost of uncompensated care. See how Cooper Green Hospital leads the way.

The pride of the Yankees. A Maine hospital's willingness to barter gives new life to an old idea

Many people in rural Maine are long on pride but short on health insurance. Thanks to an innovative barter program at Franklin Memorial Hospital, they can keep their pride, get the care they need, and offer their talents to the hospital in exchange for services. It's a win-win situation for everyone.

What if socioeconomics made no difference?: access to a cadaver kidney transplant as an example

OBJECTIVES

Several studies have noted the impact of socioeconomic factors on access to expensive medical care, but none of those studies controlled for self-reported health and functional status or attitudes about treatment alternatives when analyses were completed. Because these factors may be correlated with socioeconomic status, the failure to control for them may have led to bias in other studies. The authors merged data from secondary sources with telephone survey data from a national sample of 456 end-stage renal disease patients to show how estimates of the effects of socioeconomic factors change when self-reported health and functional status and attitudes about treatment are incorporated into statistical models. The authors also showed how kidney transplant rates would change if socioeconomic factors no longer influences organ allocation decisions.

METHODS

Weibull proportional hazard analyses were used to show relationships between socioeconomic measures and waiting list entry and kidney transplant rates, before versus after accounting for self-reported health and functional status, attitudes about treatment, and other variables. Simulation analyses were used to estimate the number of waiting list spots and transplant operations that would move from economically advantaged to disadvantaged persons if socioeconomics no longer influenced organ allocation decisions.

RESULTS

Incorporating information about health and functional status, attitudes about treatment, and other factors into the hazard models often reduced the estimated impact of socioeconomic measures on the odds of (1) being on a waiting list for a cadaver kidney transplant and (2) receiving a transplant. Simulations showed that 30 to 65 waiting list spots or transplant operations per 1,000 patients would shift from economically advantaged to disadvantaged persons if socioeconomics no longer influenced organ allocation decisions.

CONCLUSIONS

Successful efforts to level the playing field would result in substantial redistributions of kidney transplants from economically advantaged to disadvantaged persons.

Charitable care and the nonprofit paradigm

Nonprofit hospitals have begun to focus once again on serving the health needs of their communities. Governmental needs for additional revenue and for-profit hospitals' contention that tax exemptions give nonprofit hospitals an unfair competitive advantage have resulted in changes in laws and regulations and have caused a change in the role of nonprofit hospitals. As local governments become more responsive to the health needs of their communities, they are requiring nonprofit hospitals to become more responsive as well. Laws, regulations, and court decisions have begun to require nonprofit hospitals to provide charity care and services at levels equal to the amount of their exempt taxes. In response, nonprofit hospitals are developing community benefit programs and public health services.

Oral health systems in Europe. Part I: Finance and entitlement to care

OBJECTIVE

To describe and compare the oral health systems in 18 European countries.

BASIC RESEARCH DESIGN

Semi-structured, in-depth validation interviews were carried out with key informants from the main national dental associations of EU and associated countries. The interviews were structured around the responses to a previously completed questionnaire, the topics and terminology of which had been agreed in advance with the collaborating associations. The resulting descriptions of dental practice and the dental workforce in each country were returned for further validation and correction by the collaborating associations. Ultimate editorial control over the review of each country's oral health system rested with the authors.

RESULTS AND CONCLUSIONS

Oral health care is mainly financed by government-regulated or compulsory social insurance in seven of the 18 countries examined here: Austria, Belgium, France, Germany, Luxembourg, The Netherlands and Switzerland. Providing universal or near-universal coverage by membership of insurance institutions, these systems provide oral health care for about 180 million people across Europe, and almost half of all EU citizens. In the Nordic countries and the UK entitlement to care is typically based upon residence or citizenship, and apart from in Norway and Iceland is provided within a tax-funded and government-organised health service. In southern Europe, Norway, Ireland and Iceland oral health care is largely financed directly by the patient, with occasional support through private insurance. Some publicly-funded and organised services do exist in these countries but generally only for specific population groups (e.g. children, unemployed), or in particular regions.

Longitudinal analysis of dental services provided to urban low-income (Medicaid) preschool children seeking initial dental care

This retrospective longitudinal study analyzed profile and cost of dental services provided to urban low-income (Medicaid) preschool children seeking initial dental care. Clinical and sociodemographic data for Medicaid children, ages five years and under at the time of their first dental visit, were obtained from the dental records of an urban community health center clinic located in a fluoridated area. The sample consisted predominantly of minority children (males = 54; females = 43) who were initially seen during a continuous six-month period in 1991. The children were then observed for a period of one year from the date of first service. At the initial dental visit, the children had a mean age of 3.7 years and dmft of 4.4 with two-thirds of them exhibiting dental caries. The children made an average of 2.3 visits with more than two-fifths of them receiving at least one treatment service during the year. Children four years of age and older at the initial visit, had greater caries prevalence, higher mean dmft, made more dental visits and incurred greater annual expenditure. Greater proportion of females and older children (> or = 4 years) received restorations and extractions. It is concluded that treatment for dental caries is a significant dental service provided to urban low-income (Medicaid) preschool children seeking initial dental care. The results of this study suggest that preschool programs should target these children and promote an initial dental visit before four years of age particularly among females.

Free high-tech health care in India

The Sri Sathya Sai Institute of Higher Medical Sciences in Andhra Pradesh can claim to have achieved the impossible--namely, the provision of high-tech medical services completely free of charge. Adherence to the five human values (truth, righteousness, peace, love and non-violence) and complete dedication to serve people without self-interest are the key elements for this success. This example may serve as a model for creating similar hospitals in the service of mankind.

California's county hospitals and the University of California graduate medical education system. Current issues and future directions

California's county hospitals train 45% of the state's graduate medical residents, including 33% of residents in the University of California system. This paper describes the interrelationships of California's county hospitals and the University of California (UC) graduate medical education (GME) programs, highlighting key challenges facing both systems. The mission of California's county health care systems is to serve all who need health care services regardless of ability to pay. Locating UC GME programs in county hospitals helps serve the public missions of both institutions. Such partnerships enhance the GME experience of UC residents, provide key primary care training opportunities, and ensure continued health care access for indigent and uninsured populations. Only through affiliation with university training programs have county hospitals been able to run the cost-effective, quality programs that constitute an acceptable safety net for the poor. Financial stress, however, has led county hospitals and UC's GME programs to advocate for reform in both GME financing and indigent care funding. County hospitals must participate in constructing strategies for GME reform to assure that GME funding mechanisms provide for equitable compensation of county hospitals' essential role. Joint advocacy will also be essential in achieving significant indigent care policy reform.

Annual update of the HHS poverty guidelines--HHS. Notice

This notice provides an update of the HHS poverty guidelines to account for last (calendar) year's increase in prices as measured by the Consumer Price Index.

The transformation of a local health department

In 1993, the health department serving the city of Amarillo, Texas, and surrounding communities was merged with the city's tax-supported Hospital District, which operated a public hospital and clinics providing medical care to poor people. Three years later, the public hospital and clinics were sold to a for-profit corporation, privatizing most medical services for the poor. The proceeds from this sale created a community trust fund for the provision of indigent care and eliminated Hospital District taxes. The city government reassumed operation of the Health Department, which redefined itself primarily in terms of public health functions not involving the provision of personal health services. These functions included communicable disease control, monitoring the health status of the community, identification of public health problems, and health promotion. The new Health Department, with a smaller budget and fewer staff members, is now funded by the for-profit corporation that purchased the public hospital, the community trust fund, and grants from the state health department.

[Health insurance in Africa: a straw for the health care system]

Health Care Systems Clutch at a Straw: The health care systems of sub-Saharan Africa are facing a global crisis which is severely challenging their survival. Currently, alternatives to the traditional financing of health care by government grants and/or "fee for service" are sought. Otherwise the vast majority of poor rural inhabitants of these countries will lose access to Western medicine at the end of this century, making appropriate medical care a privilege of a small number of rich urbans. One approach to solving this crisis is the introduction of a health insurance system. However, the culture of African people must also be considered if one attempts to design and implement an insurance scheme. This paper reflects some of the problems of health insurance in an African context. Since the author contributed to the design of a "Community Based Health Insurance" of the Evangelical Lutheran Church in Tansania, this scheme is used here as an example.

Free clinics

The simplicity and joy of practicing medicine in free clinics has been discovered by numerous Iowa physicians. They tell of the need to practice pure medicine for Iowans who truly need free medical care. They also share how to start a free clinic, step by step. It's simple, they say, with a little help from colleagues and the community.

Medicaid managed care and community providers: new partnerships

Growing enrollment in managed care plans among Medicaid recipients represents a new market for these plans but presents challenges to those providers that traditionally have served this population. To continue serving Medicaid patients, community-based providers must develop contracts or other types of partnerships with Medicaid-contracting health plans. This paper reviews the challenges to such collaboration and discusses the practical issues that plans and community-based providers must resolve to develop productive working relationships. Keys to successful collaboration are identified. Ways in which federal and state governments can help the collaborative process are suggested.

The VA health care system: an unrecognized national safety net

The dominance of local health care markets in conjunction with variable public funding results in a national patchwork of "safety nets" and beneficiaries in the United States rather than a uniform system. This DataWatch describes how the recently reorganized Department of Veterans Affairs serves as a coordinated, national safety-net provider and characterizes the veterans who are not supported by the market-based system.

The politics and economics of mental health 'parity' laws

The enactment of the Domenici-Wellstone amendment in September 1996, which calls for the elimination of certain limits on coverage for mental health care under private insurance, is being hailed as a major step forward in the quest for "parity" in mental health coverage. Parity legislation is being introduced in a number of state legislatures and is finding new enthusiasm in Congress. In this paper we consider the efficiency rationale for these laws and examine their likely impact in the era of managed care. We conclude that although such successes represent important political events, they may offer only small gains in the efficiency and fairness of insurance markets.