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Declining payments for emergency department care, 1996-1998

ANNALS OF EMERGENCY MEDICINE 2003年第3期41卷 299-308页

作者： Tsai, AC Tamayo-Sarver, JH Cydulka, RK Baker, DW Case Western Reserve Univ Dept Epidemiol & Biostat Sch Med Cleveland OH 44106 USA Metrohlth Med Ctr Dept Emergency Med Cleveland OH USA Northwestern Univ Feinberg Sch Med Div Gen Internal Med Dept Med Chicago IL 60611 USA

Study objective: We describe recent trends in payments from different payer classes and assess their relative importance to the financial solvency of emergency departments. Methods: We used Medical Expenditure Panel Survey data from 1996 and 1998. The unit of analysis was the ED visit. Primary outcome measures were ED charges and payments. The independent variable of interest was payer class, and therefore, we limited our analysis to those either uninsured or covered by Medicare, Medicaid, or private insurance. Results: From 1996 to 1998, a declining percentage of total charges were paid, from 60.3% to 53.0% (difference -7.3%;95% confidence interval [Cl] -11.3% to -3.5%). Although the percentage of total charges paid by Medicaid, Medicare, and the uninsured remained constant, the percentage of total charges paid by the privately insured declined from 75.1% to 63.4% (difference -11.7%;95% Cl -16.6% to -6.7%). Overall, adjusted mean ED charge increased from $695 to $798 (difference $103;95% Cl $61 to $146). Two payer classes experienced statistically significant increases in adjusted mean charge: the uninsured, from $544 to $740 (difference $196;95% Cl $62 to $330), and the privately insured, from $658 to $813 (difference $151;95% Cl $103 to $199). Although the adjusted mean payment rate for the uninsured remained stable, the adjusted mean payment rate for the privately insured declined from 77.7% to 65.7% (difference -12.0%;95% Cl -13.4% to -10.7%). Conclusion: The ability of EDs to provide emergency care to all regardless of ability to pay is increasingly threatened by declining overall payment rates. Cost shifting to fund care for the uninsured is an increasingly untenable financing strategy.

关键词：急诊室医院/经济学急诊室医院/发展趋势卫生经费支出/统计学和数值数据保险范围/经济学保险范围/统计学和数值数据 Medicaid/经济学 Medicaid/统计学和数值数据未参加医疗保险者/统计学和数值数据 Medicare/经济学 Medicare/统计学和数值数据美国/流行病学人类

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Heart failure disease management in an indigent population

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AMERICAN HEART JOURNAL 2001年第2期141卷 254-258页

作者： O'Connell, AM Crawford, MH Abrams, J Univ New Mexico Sch Med Albuquerque NM 87131 USA

Background Multidisciplinary disease management programs (MDMP) have demonstrated reduced hospitalizations in motivated pretransplant heart failure populations, but little is known about their effectiveness in largely indigent patients who are not transplant candidates. Methods and Results We studied 35 patients with heart failure with left ventricular election fraction (EF) less than or equal to 45% enrolled in an MDMP who were either indigent or funded by Medicaid/Medicare. This nonrandomized sample consisted of 14 patients identified because they had hospital readmission rates of greater than or equal to2 per year (group A) and 21 patients referred by their primary care physicians because they were difficult to manege (group B). Group A patients were New York Heart Association (NYHA) class III or IV, aged 25 to 87 years (mean 57 +/- 17 SD) and had an EF of 15% to 45% (29% +/- 11%). Group B patients were NYHA class II or III, aged 35 to 86 (57 +/- 16) years and had an EF of 20% to 45% (28% +/- 10%): Data were compared for the year before enrollment in the MDMP and the year afterward. In group A hospital admissions decreased from 33 to 3, a 91% reduction, and NYHA class improved to class II-III (P < .001). In group B hospital admissions decreased from 9 to 0, and NYHA class improved to class I-II (P < .001). When hospital and clinic charges were assessed for both groups, the net savings were $162,000 per year or $4600 per patient. Conclusions A multidisciplinary heart failure program can improve functional status and reduce hospitalization and net costs compared with conventional care in indigent non-transplant candidate patients.

关键词：成本及成本分析医院费用住院/经济学住院/统计学和数值数据医疗费用无力承担/经济学未参加医疗保险者/统计学和数值数据回顾性研究美国成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Effects of Payment Changes on Urgent/Emergent Admissions in Rural and Urban Communities

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The Journal of Rural Health 1993年第2期9卷 120-128页

作者： Ahern, Melissa Department of Health Services Administration Florida International University North Miami Florida 33181 AC I Room 222 North Miami Campus United States

Abstract: Reimbursement changes during the 1980s, particularly Medicare diagnosis‐related group (DRG) reform and the growth of managed care, have squeezed hospital revenues available for cross‐subsidizing care for uninsured patients and patients for whom marginal costs exceed marginal revenues. This study uses logistic regression with time and residence interactions to explore the impact of payment changes on rural versus urban patients' admission status (urgent versus nonurgent). Findings show that uninsured rural patients had a significantly higher probability in 1987 than they did in 1983 of being admitted to hospitals in an urgent/emergent condition. Findings also show incrementally higher probabilities for Medicare and Medicaid rural patients in 1987. Results are consistent with the view that cross‐subsidization is no longer effective for covering uninsured rural care and that more direct subsidies may be necessary. Copyright © 1993, Wiley Blackwell. All rights reserved

关键词：加利福尼亚数据收集急症女(雌)性卫生服务易得程度/经济学卫生服务易得程度/统计学和数值数据卫生服务研究医院乡村/经济学医院乡村/统计学和数值数据医院乡村/发展趋势医院乡村/利用医院市区/经济学医院市区/统计学和数值数据医院市区/发展趋势医院市区/利用人类住院病人/分类保险健康补偿/统计学和数值数据保险健康补偿/发展趋势 Logistic模型男(雄)性未参加医疗保险者/统计学和数值数据病人入院/经济学病人入院/统计学和数值数据病人入院/发展趋势

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Models to promote medical health care delivery for indigent families: computerized tracking to case management.

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Journal of health & social policy 1990年第1期2卷 21-34页

作者： Kavanagh, K.T. Tate, N.P. Boling Center for Developmental Disabilities University of Tennessee Memphis.

Poor patient/parental medical compliance is one of the most important health care issues of today. Multiple interrelated factors contribute to this problem. Of prime importance is patient/parental maturity and knowledge. Reversal of this process is undoubtably harder than prevention. The cost effectiveness of various methods of intervention is discussed in relation to a large mid-south indigent population. Computerized patient tracking is cost efficient and effectively promotes compliance in a percentage of patients. Its additional utility is the identification and triage of patients, most in need of intervention, to existing social service personnel for family-centered case management. Family-centered case management holds the best hope of reversing the many factors adversely affecting patient compliance. However, this method is costly and requires a low ratio of clients to caseworkers in order to be effective. Community-centered patient management is less costly to implement and is very useful in tightly woven communities resistant to outside intervention. However, this method often has a high client to caseworker ratio and has less utility in dealing with complex medical problems.

关键词：病案系统计算机化未参加医疗保险者/统计学和数值数据密西西比病人医疗护理计划/方法病人依从贫困区提醒者系统社会工作/人力社会工作/组织和管理社会经济因素田纳西人类

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Covering uninsured children and their parents: Estimated costs and number of newly insured

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MEDICAL CARE RESEARCH AND REVIEW 1999年第2期56卷 197-214页

作者： Thorpe, KE Florence, CS Tulane Univ Sch Publ Hlth & Trop Med New Orleans LA 70118 USA

The Child Health Insurance Program (CHIP) supplies $20.4 billion over 5 years and nearly $50 billion over 10 years to extend health insurance to uninsured children with family incomes up to 200 percent of poverty. This article analyzes the March 1997 Current Population Survey estimating the number of children likely to be eligible for CHIP or currently eligible for Medicaid. Of the 8.6 million parents of uninsured children,four out of five were uninsured at the time of the survey. Expanding coverage to parents as well as children could make program participation more attractive and simplify the enrollment process. If 75 percent of uninsured parents of CHIP eligible children participated, 1.7 million parents could be insured, costing federal and state governments 3.4 billion. Another 3.4 million parents would be insured by expanding Medicaid to cover uninsured parents of Medical-eligible children.

关键词： Medicaid/立法和法学 Medicaid/统计学和数值数据未参加医疗保险者/统计学和数值数据美国

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Urban and Rural Differences in Health Insurance and Access to Care

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The Journal of Rural Health 1994年第2期10卷 98-108页

作者： Hartley, David Quam, Lois Lurie, Nicole Rural Health Research Center University of Washington Department of Geography Seattle Washington United States Institute for Health Services Research Department of Internal Medicine University of Minnesota in Minneapolis Minneapolis Minnesota United States

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub‐samples of 400 group‐insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies. Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P<0.01). These differences were confirmed by multivariate analysis. Rural residents with group insurance have higher out‐of‐pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment‐based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers. Copyright © 1994, Wiley Blackwell. All rights reserved

关键词：卡方分布绝对免赔额与共同保险/统计学和数值数据地理学卫生服务易得程度/经济学卫生服务易得程度/统计学和数值数据保险赔偿费/统计学和数值数据保险健康/统计学和数值数据采访最小二乘法分析 Logistic模型未参加医疗保险者/统计学和数值数据明尼苏达多元分析农村卫生/统计学和数值数据城市卫生/统计学和数值数据成年人人类

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Vulnerable populations and health insurance

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MEDICAL CARE RESEARCH AND REVIEW 2000年第1期57卷 110-134页

作者： Shi, LY Johns Hopkins Univ Sch Publ Hlth & Hyg Dept Hlth Policy & Management Baltimore MD 21205 USA

This study provided a national profile of health insurance of certain vulnerable populations including children, racial/ethnic minorities, low-income families, non-metropolitan statistical area (MSA) residents, and those with poor health status. The study shows an increase in the proportion of uninsured nonelderly population. While public insurance helped reduce the employment- and health-related disparities in private coverage, it has not overcome other disparities related to vulnerable characteristics including race/ethnicity, wages, education, and area of residence. Comparison between health maintenance organization (HMO) and fee-for-service insurance indicates that younger although not much healthier people, racial/ethnic minorities, MSA residents, and those residing in the West and Northeast regions were more likely to have HMO coverage. To reduce significant disparities in health insurance coverage, policy makers will have to consider expanding public insurance coverage, targeting vulnerable groups, partiallarly those with multiple vulnerable characteristics rather than merely the economically distressed. Expecting managed care to achieve cost containment for services provided to vulnerable populations may be unrealistic.

关键词：费用控制按诊疗收费计划/统计学和数值数据卫生服务研究健康状况保险健康/统计学和数值数据 Logistic模型管理医疗规划/统计学和数值数据未参加医疗保险者/统计学和数值数据少数民族/统计学和数值数据模型经济计量学贫困/统计学和数值数据问卷调查美国青少年成年人老年人儿童女(雌)性人类男(雄)性中年人

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Health Insurance Coverage in U.S. Urban and Rural Areas

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The Journal of Rural Health 1993年第3期9卷 204-214页

作者： Frenzen, Paul D. Economic Research Service U.S. Department of Agriculture Washington District of Columbia 20005 1301 New York Ave Room 340 United States

Abstract: This study examines the health insurance coverage of the nonelderly population in U.S. urban and rural areas in 1989, using data from the March 1990 Current Population Survey conducted by the Bureau of the Census. Access to coverage was assessed by classifying all persons by family employment status and income. Rural residents had less access to coverage than urban residents but were only slightly less likely to be insured. In comparison to urban residents, fewer rural residents obtained coverage through employment, and more purchased private coverage outside the work place. The differences in coverage by family employment status and income were generally much greater than the differences by place of residence. Copyright © 1993, Wiley Blackwell. All rights reserved

关键词：数据收集就业/统计学和数值数据家庭卫生保健福利计划雇员/统计学和数值数据卫生政策/经济学卫生服务易得程度/经济学卫生服务易得程度/统计学和数值数据收入/统计学和数值数据保险健康/经济学保险健康/统计学和数值数据 Medicaid/统计学和数值数据未参加医疗保险者/统计学和数值数据农村人口/统计学和数值数据美国市区人口/统计学和数值数据成年人人类中年人

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ASSESSING THE VALUE OF MEDICAID PRESCREENING IN A COUNTY PUBLIC-HEALTH UNIT

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EVALUATION & THE HEALTH PROFESSIONS 1991年第4期14卷 412-421页

作者： SEROW, EG UNIV S FLORIDA COLL PUBL HLTHDEPT COMMUNITY & FAMILY HLTHTAMPAFL 33620 USA

The purpose of this study was to determine if already-existing staff in a rural health department could effectively increase access of their clients to Medicaid. All "sliding fee" patients seeking services were asked a series of questions to determine their categorical eligibility for Medicaid. Those identified as potentially eligible were formally referred for complete financial eligibility determination, and outcomes of those referrals were examined to determine the number of patients newly insured. The study revealed that the majority of poor clients being served in the health department were categorically ineligible for Medicaid and that the majority of potentially eligible patients declined to complete the application process. The process cost the health department twice as much in staff time as it could possibly have recouped in Medicaid reimbursements.

关键词：未参加医疗保险者/统计学和数值数据公共卫生管理/经济学美国

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A Descriptive Analysis of Health Insurance Coverage Among Farm Families in Minnesota

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The Journal of Rural Health 1992年第3期8卷 178-184页

作者： Kralewski, John E. Liu, Yuanli Shapiro, Janet China Studying Health Services Research Policy and Administration School of Public Health University of Minnesota United States Division of Health Services Research Policy of the School of Public Health University of Minnesota United States

This paper reports the findings of a study of health insurance coverage and access to health services among farm families in Minnesota. The study included 1,482 families actively engaged in farming during 1989. While less than 10 percent of the population were uninsured during this period, the majority had limited coverage with high deductible and coinsurance provisions. Moreover, they were paying an estimated 15 to 20 percent more for their plans than a similar plan would have cost in the Minneapolis‐St. Paul, MN, area. With the exception of cost, satisfaction with health services was found to be very high, and there were few indications of access problems. Copyright © 1992, Wiley Blackwell. All rights reserved

关键词：农业/经济学用户满意/统计学和数值数据成本及成本分析/统计学和数值数据数据收集卫生服务易得程度/统计学和数值数据保险健康/经济学保险健康/统计学和数值数据未参加医疗保险者/统计学和数值数据明尼苏达农村卫生/统计学和数值数据人类

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