The health insurance picture in 1993: some rare good news

Lessons from the Clinton plan: incremental market reform, not sweeping government control

The Clinton health reform attempt in the mid-1990s and the U.S. experience since then suggest some clear lessons for the next U.S. president. Public confidence in a major reform proposal must be won, and congressional support must be garnered, even if the election is a landslide. Insisting on universal coverage as a precondition may undercut the ability to enact other policies needed to improve the health system. Excessive regulation and price controls are likely to exacerbate underlying problems. The next president should take full advantage of market incentives to promote a high-value health system.

Health care costs: on the rise again

Since 1999, health care costs have been growing faster than national income. This rapid growth has occurred as the ability of private and public purchasers to reduce service utilization and bargain for lower prices has fallen, insurers have recouped lost profits through higher premiums, and new technologies have driven up costs throughout the sector. Private insurance market responses to these rising costs may lead to reductions in the number of people with insurance and to increased fragmentation of the insurance market. Over time, technological change in medicine both increases costs and improves the quality of care. The challenge for public policy is to maintain insurance and some degree of equity in the face of these rising costs.

Trends in out-of-pocket spending by insured American workers, 1990-1997

This paper examines trends in out-of-pocket spending for insured workers from 1990 to 1997. Data are from the Consumer Expenditure Survey conducted by the U.S. Bureau of Labor Statistics. The survey collects detailed quarterly data on all consumer spending from logs kept each year by more than 10,000 households with job-based health insurance. During the study period, total out-of-pocket spending in constant dollars remained unchanged. Spending for medical expenses, drugs, and supplies declined by 23 percent, but this decline was offset by rising employee contributions for health insurance premiums. The shift to managed care, whose benefit structure requires less cost sharing, may have played a role in reducing out-of-pocket spending.

Would you like suspenders to go with that belt? An analysis of optimal combinations of cost sharing and managed care

When and why would it be efficient for a managed care insurance plan using managerial limits to add patient cost sharing? This paper uses a diagrammatic model to indicate that the use of patient point-of-service cost sharing can cause the managerial limits or guidelines to be less restrictive in limiting high value care for cases of severe illness. The model shows that cost-sharing is more likely to improve efficiency the greater the variation in illness severity and the smaller the degree of moral hazard. The model is extended to the case in which provider cost sharing is also used.

Managed care, medical technology, and health care cost growth: a review of the evidence

Although managed care plans reduce health care expenditures at any point in time, less is known about whether such plans control health care cost growth. Because use of new medical technology is an important determinant of cost growth, the impact of managed care on utilization of medical technology will largely determine whether managed care can reduce expenditure growth to sustainable levels. This article reviews the literature relating medical technology to cost growth and the literature examining the impact of managed care on either cost growth or on the diffusion of medical technology. Studies that examine plan-level data often reach different conclusions than studies that examine market-level data. The evidence suggests that managed care, as currently practiced, may reduce the rate of cost growth. However, managed care is unlikely to prevent the share of gross domestic product spent on health care from rising unless the cost-increasing nature of new technology changes.

Employer-sponsored health insurance for chiropractic services

The use of chiropractors has increased substantially in recent years, and there is growing scientific evidence on the effectiveness of chiropractic treatment for common low back ailments. Despite the increased acceptance of chiropractic care, little is known about the prevalence of chiropractic coverage in employer health plans and the nature of such benefits when they are provided. This article reports on the extent and composition of chiropractic insurance among workers with employer-sponsored health insurance in 1993. The prevalence of the benefits in employer plans was examined, as was the extent to which plans are in compliance with state mandated benefits in this area. The authors also examined what the actual benefits consist of and how they compare with those for physician office visits and physical therapy.

Improving the delivery of clinical preventive services to women in managed care organizations: a case study analysis

BACKGROUND

In February-October 1996 a case study analysis was conducted to examine the key features of prevention programs for women in six managed care plans and one group medical practice. These programs, which use either data-based or office-based strategies, are considered by experts in the field to be exemplary.

METHODS

Prevention programs for the case study were identified through a literature review and discussions with knowledgeable individuals about prevention programs and managed care. Information was collected about breast and cervical cancer prevention programs through written materials and telephone interviews with staff. Given limited and noncomparable information, relative program effectiveness was not assessed.

CASE STUDIES

The case study programs use many types of data to support prevention strategies such as patient reminders and performance feedback to providers. Successful programs require substantial resources and planning; are population based; gain the support of providers and patients early; have clear, established systems for collecting and using data; and have a monitoring and evaluation component. The challenges that remain for managed care plans are balancing the need for prevention programs with limited resources, using imperfect data to support interventions, developing effective strategies for reaching high-risk populations, and working with large networks of providers.

DISCUSSION

Managed care plans have great potential to use their information systems and organizational structure to support prevention efforts. The extent to which these opportunities are realized depends on managed care plans' progress in developing their broader information management systems and on purchasers' demands for these types of programs.

Testing the HMO competitive strategy: an analysis of its impact on medical resources

Competitive approaches to health care reform, including managed competition, are hypothesized to reduce health care expenditures and the resources devoted to medical care. Empirical evidence has been limited. The short- and long-run effects of an experiment closely resembling managed competition are analyzed. We examine effects on hospitals, technology diffusion, physicians, and health insurance premiums. The strategy reduces capital in hospitals, has minor effects on physicians and technology, and has only initial effects on average premiums.

Growing diversification in HMOs, 1988-1994

Based on data from annual surveys conducted by the American Association of Health Plans, this article shows growing product diversification among the nation's HMOs. Between 1988 and 1994 the percentage of HMOs offering point-of-service (POS) plans increased from roughly 20 percent to 74 percent, and the percentage offering PPO plans rose from about 25 percent to 58 percent. Today, most HMOs view themselvesas managed care organizations (MCOs) offering an array of health plans and products, not as traditional, close-ended HMOs. Future analysis of the health care industry should regard the MCO rather than the HMO as the unit of analysis. One potential developing problem is the growth of self-insured HMO plans. If current trends continue, self-insured HMO plans could erode the insurance function in the HMO market, as occurred in the indemnity market in the 1980s.

Trends in hospitalizations for abnormal uterine bleeding in the United States: 1980-1992

We examined trends in hospital discharges, length of hospital stay, and procedures performed for abnormal uterine bleeding from 1980 through 1992. We used data from the National Hospital Discharge Survey. Discharges involving patients with reproductive tract cancers or pregnancy-related diagnoses were excluded. The overall discharge rate for abnormal uterine bleeding decreased 66% during the study period, from 56 discharges per 10,000 women in 1980 to 19 per 10,000 in 1992. The discharge rate declined significantly for hospitalizations during which hysterectomy was not performed and remained relatively stable for hospitalizations with hysterectomy. Discharge rates decreased among all age and race groups and in all geographic regions. The percentages of discharges following hysterectomy steadily increased from 25% in 1980 to 72% in 1992. The average length of stay decreased significantly only for discharges for stays during which hysterectomy was performed, from 7.6 days in 1980 to 3.7 days in 1992. During the study period, abnormal uterine bleeding contributed to more than 5 million hospitalizations, 2 million hysterectomies, and 20 million hospital days. Our findings are consistent with a decreased likelihood of hospitalization for abnormal uterine bleeding if hysterectomy was not performed and shorter hospital stays for women undergoing hysterectomy for bleeding. These findings highlight the impact of abnormal uterine bleeding on the U.S. health care system.

Creation of a specialized nutrition support outcomes research consortium: if not now, when?

BACKGROUND

There is a compelling need to determine the benefits of sophisticated, costly, and potentially hazardous nutrition support interventions. The clinical efficacy and cost effectiveness of specialized nutrition support must be quantitatively defined. Creation of a national outcomes research consortium to study the use of specialized nutrition support can meet these objectives.

METHODS

Nutrition support and outcomes research literature were reviewed to develop a model for the application of outcomes research methods to clinical, professional, administrative, and financial problems currently challenging the discipline of nutrition support.

RESULTS

A multi-institutional nutrition support outcomes research consortium involving creation of a large, practice-based data base is proposed. Relevant clinical, administrative, methodologic, and implementation issues are discussed.

CONCLUSIONS

A multi-institutional nutrition support outcomes research consortium offers the means to collect rigorous data that can be used to improve patient outcomes, improve the cost-effectiveness of nutrition support, establish a firm scientific basis for the discipline of nutrition support, and assist nutrition support clinicians in the cost-cutting climate that currently characterizes health care in the United States. Given the timeliness of these objectives and the human, professional, and financial costs of not achieving them in a timely fashion, it is fair to ask of a nutrition support outcomes research consortium, "If not now, when?"

Financial performance of safety-net hospitals in a changing health care environment

Safety-net hospitals serving the poor and indigent in inner-cities have received inadequate research attention regarding the determinants of their financial performance in the changing health care environment. We analyze how the 1990-92 financial performance of 275 such hospitals is related to exogenous and endogenous factors such as payer mix, service mix, staffing and ownership. Models of hospital financial performance are developed using operating margin, cost per discharge and revenue per discharge as measures of performance. Stepwise regression is used to test the model with data from the American Hospital Association (AHA) and Health Care Investment Analysts (HCIA). Results suggest that: 1) The profitability of inner-city hospitals appears positively related with technical complexity of care; 2) High interest and low operating surplus may constrain the addition of technically sophisticated services to enhance profitability; 3) There is some evidence that new governmental programs, e.g. Medicaid managed care and Medicaid Diagnosis Related Groups (DRGs), may not have improved operating margins, though Medicaid DRGs appear to have contained costs. Follow-up research is needed on this issue; 4) Given external fiscal realities, internal management strategies for inner-city hospitals require research, e.g. developing appropriate managed care systems and timely expansion of sub-acute services and; 5) Services such as AIDS treatment and community health education represent opportunities to respond to community needs, especially since unit cost of such services will decline with high volume.

Trends in health insurance coverage in California, 1989-1993

California's uninsurance rate of 22.7 percent is higher than the national average. The state's rate of employment-based insurance coverage--below the national average--is declining because of rising health insurance premiums, falling family incomes, and the changing structure of the economy and the labor market. Growing Medicaid coverage, fostered by expanded eligibility and falling incomes, has prevented rapid growth in the state's uninsured population. Anticipated cutbacks in federal Medicaid funding, however, would increase California's uninsurance rate. Continuing cutbacks in health services for the uninsured would reduce their access to health care and increase stress on many private health services.

A national survey of the arrangements managed-care plans make with physicians

BACKGROUND

Despite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians.

METHODS

In 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independent-practice-association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs).

RESULTS

Respondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians' previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physicians was typical in the HMOs but rare in the PPOs. Fifty-six percent of the network or IPA HMOs used capitation as the predominant method of paying primary care physicians, as compared with 34 percent of the group or staff HMOs and 7 percent of the PPOs. More than half the HMOs reported adjusting payments according to utilization or cost patterns, patient complaints, and measures of the quality of care. Ninety-two percent of the network or IPA HMOs and 61 percent of the group or staff HMOs required their patients to select a primary care physician, who was responsible for most referrals to specialists. About three quarters of the HMOs and 31 percent of the PPOs reported using studies of the outcomes of medical care as part of their quality-improvement programs.

CONCLUSIONS

Managed-care plans, particularly HMOs, have complex systems for selecting, paying, and monitoring their physicians. Hybrid forms are common, and the differences between group or staff HMOs and network or IPA HMOs are less extensive than is commonly assumed.

Private employment-based health insurance in ten states

This Data Watch reports key findings from the 1993 Robert Wood Johnson Foundation Employer Health Insurance Survey, through which more than 20,000 employers in ten states were interviewed. Our report contrasts the behavior of four size classes of small businesses (fewer than fifty workers) with that of all other businesses. We examine offer rates by business size; characteristics of employers and workers in business offering and not offering insurance; premiums, benefits, and medical underwriting; the extent of choice among plans; and self-insurance. We discuss the implications of our findings for health policy.

Small employers and the health insurance market

In 1993 half of all small businesses (fewer than fifty workers) sponsored a health plan for their employees, up from 41 percent in 1989. While not as deep, the benefits offered by small firms are nearly as broad as benefits offered by large firms, and they have expanded since 1989. Small businesses pay more for coverage, however. Although coverage restrictions based on health status and preexisting conditions are a significant concern of small firms, actual limits of this type in the small-group market are modest. Firms not offering insurance report that they have wide access to coverage, and many would sponsor a plan if only prices were lower.

Is health spending slowing down?

We analyze trends in real per capita health care spending. Using a different and, we believe, more appropriate adjustment for trends in general inflation than the Health Care Financing Administration (HCFA) analysts use, we reach a different conclusion: The purported slowdown in health care spending in the 1990s is modest at best through 1993. Other measures of health care spending, such as the medical care Consumer Price Index, private health care premiums, and hospital cost growth, are unreliable measures of overall health care spending.