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Hellinger, Fred

Authors: Fleishman J, Hellinger F.
Title: Trends in HIV-Related Inpatient Admissions and Deaths: A Seven-State Study.
Publication: Journal of Acquired Immune Deficiency Syndromes 28(1):73-80.
Date: 2001
Abstract: Reports of declining HIV-related inpatient utilization since the introduction of combination antiretroviral therapy have typically been based on data from a single institution or locality. This study examines trends in HIV-related inpatient admission rates from 1993 through 1997, using a negative binomial analysis of comprehensive data from seven states. We used comprehensive hospital discharge data from seven states, from the State Inpatient Database of the Healthcare Costs and Utilization Project. HIV-related inpatient admission rates rose between 1993 and 1995, but then showed sharp and steady declines starting in late 1995. This general pattern was observed for all seven states, and did not differ by patients' gender or race/ethnicity. Admission rates were highest for black males and lowest for white females. The rate at which HIV-related admissions ended in the death of the patient also declined steadily after 1995. The inpatient death rate for women was lower than that for men, but racial/ethnic differences in death rates were not significant. These results confirm and extend previous reports of reduced HIV-related inpatient utilization subsequent to the advent of combination antiretroviral therapy.
Topics: Chronic Conditions, Cost, Hospitals.

Authors: Hellinger F, Fleishman J.
Title: Location, Race, and Hospital Care for AIDS Patients: An Analysis of Ten States.
Publication: Inquiry 38:319-30.
Date: Fall 2001
Abstract: This study is the first statewide comparison of hospital utilization and inpatient mortality rates for persons with Acquired Immune Deficiency Syndrome (AIDS). Data from 120,772 hospital discharge abstracts for all AIDS-related admissions in 10 states (California, Colorado, Florida, Iowa, Kansas, Maryland, New Jersey, New York, Pennsylvania, and South Carolina) in 1996 were combined with data on the number and the racial and ethnic characteristics of all persons living with AIDS (PLWAs) in each state. These data were used to derive population-based estimates of the utilization of hospital services per PLWA and of inpatient mortality rates in each state. Multivariate analyses examined sources of variation in inpatient length of stay and inpatient mortality. The primary finding of this study is that hospital utilization rates and inpatient mortality rates for persons with AIDS vary substantially across states and among racial and ethnic groups within states even after adjusting for severity of illness. Blacks and Hispanics had longer hospital stays and were more likely to die in the hospital than whites. State-level policies, such as home and community-based waiver programs and enhanced HIV reimbursement rates, significantly affected hospital use.
Topics: Chronic Conditions, Cost, Hospitals.

Authors: Hellinger F., Young G.
Title: Adjusting the Balance of Power: An Analysis of Physician Antitrust Exemption Legislation.
Publication: JAMA 286(1):83-8.
Date: 2001
Abstract: Under current antitrust law, physicians are largely prohibited from joining together to collectively negotiate. However, such activities may be approved by State laws under the so-called State action immunity doctrine and by Federal legislation under an explicit antitrust exemption. In 1999, Texas became the first State to pass legislation attempting to exempt physicians who collectively negotiate fees with health plans. Last year, similar legislation was introduced in the US Congress, in 18 State legislatures, and in the District of Columbia. This legislation was passed only in the District of Columbia, where its implementation was blocked by the city's financial control board. Nonetheless, legislation permitting physicians to collectively negotiate fees with managed care plans already has been introduced in 10 State legislatures this year, and there is continued interest in introducing similar legislation in the U.S. Congress. This analysis examines the basic features of this legislation and its potential impact on the balance of power between physicians and managed care plans.

Authors: Wong H., Hellinger F.
Title: Conducting Research on the Medicare Market: The Need for Better Data and Methods.
Publication: Health Services Research 36(1 Part 2):291-308.
Date: 2001
Abstract: This study highlights data limitations, the need to improve data collection, the need to develop better analytic methods, and the need to use alternative data sources to conduct research related to the Medicare program. These objectives are achieved by reviewing existing studies on risk selection in Medicare HMOs, examining their data limitations, and introducing a new approach that circumvents many of these shortcomings. Data for 1995-97 for five States (Arizona, Florida, Massachusetts, New York, and Pennsylvania) from the HCUP State Inpatient Databases (SID), maintained by AHRQ and the Health Care Financing Administration's Medicare Managed Care Market Penetration Data Files and Medicare Provider Analysis and Review Files are used in this study. The authors analyzed hospital utilization rates for Medicare beneficiaries in the traditional fee-for-service Medicare and Medicare HMO sectors and examine the relationship between these rates and the Medicare HMO penetration rates. Medicare HMOs were found to have lower hospital utilization rates than their fee-for-service counterparts, differences in utilization rates vary across States, and that HMO penetration rates are inversely related to the rough measure of favorable selection. The authors conclude that substantial growth in Medicare HMO enrollment and the implementation of a new risk-adjusted payment system have led to an increasing need for research on the Medicare program. Improved data collection, better methods, new creative approaches, and alternative data sources are needed to address these issues in a timely and suitable manner.
Topics: Cost, Managed Care, Markets, Medicare.

Authors: Hellinger FJ, Fleishman JA.
Title: Estimating the national cost of treating people with HIV disease: Patient, payer, and provider data.
Publication: Journal of Acquired Immune Deficiency Syndrome 24(2):182-8.
Date: 2000
Abstract: Existing estimates of the national cost of treating all people with HIV disease use data from a sample of people with HIV disease to extrapolate the cost of treating all people with HIV disease (patient-based approach). This study derives estimates using two novel approaches (i.e., payer-based and provider-based) and compares these with existing estimates. The data sources include the Health Insurance Association of American and the American Council of Life Insurance 1996 HIV survey, the 1996 State Inpatient Databases (SID) maintained by AHRQ, and the IMS America Ltd. survey of independent and chain drugstores. The authors found that the cost of treating all people with HIV disease in 1996 was between $6.7 and $7.8 billion, and the average annual cost of treating a person with HIV disease was between $20,000 and $24,700. They concluded that analysts should derive estimates of the cost of treating people with HIV disease by using several different approaches.
Topics: Chronic Conditions, Cost, Methods.
Availability: AHRQ Publication No. 00-R058 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger FJ, Wong HS.
Title: Selection bias in HMOs: A review of the evidence.
Publication: Med Care Res Rev 57(4):405-39
Date: 2000
Abstract: Many studies have compared the characteristics of persons who join HMOs with those of persons who join fee-for-service plans, and several studies have reviewed findings regarding selection bias in HMOs. This article extends the findings of previous reviews by including information from studies published through 1999. This is important because of the rapid diffusion of HMOs in all markets and recent changes in the way public programs are organizing and paying for care from HMOs. This article also examines recent changes in how HMOs are paid. This is important because recent changes in payment methodologies may reduce, or eliminate, overpayments to HMOs resulting from selection bias. For example, changes in Medicare's risk adjustment system implemented in January 2000 unquestionably mitigate the impact of favorable selection on HMO payments.
Topics: Cost, Managed Care, Medicare.
Availability: AHRQ Publication No. 01-R026 is available from the AHRQ Publications Clearinghouse.

Author: Young GJ, Desai KR, Hellinger FJ.
Title: Community control and pricing patterns of nonprofit hospitals: An antitrust analysis.
Publication: Journal of Health Politics, Policy, and Law 25(6):1051-81.
Date: 2000
Abstract: The traditional control of nonprofit hospitals by the communities they serve has been offered as a justification for restraining antitrust enforcement of mergers involving nonprofit hospitals. Community control is arguably a constraint on a nonprofit hospital's inclination to exercise market power in the form of higher prices. However, community control is likely to be attenuated for hospitals that through merger or acquisition become members of hospital systems, particularly those that operate on a regional or multi-regional basis. In this paper, the authors report findings from a study in which they used a panel data set to examine empirically the relationship between market concentration and price growth for three types of nonprofit hospitals: independent (or stand alone) facility, member of local hospital system, and member of nonlocal hospital system. Study results indicated that (1) all three types of nonprofit hospitals exercised market power in the form of higher prices and (2) hospitals that were members of nonlocal systems were more aggressive in exercising market power than were either independent or local system hospitals. The results have important implications for antitrust enforcement policy.
Topics: Cost, Hospitals, Markets, Public Policy.

Authors: Friedman B, Devers K, Hellinger F, et al.
Title: Carve outs and related models of contracting for speciality care: Framework and highlights of a workshop.
Publication: American Journal of Managed Care 4(Special Issue).
Date: 1998
Abstract: This article provides an overview of papers presented at a workshop sponsored by AHCPR in January, 1998. The papers, published in this special issue of the American Journal of Managed Care, focus on one set of strategies: the use of carve outs and related models of contracting for specialty care. The defining common feature of these contracts is that they engage providers and management entities different from those otherwise available to care for the same patients within a health plan. The other common feature of these arrangements is that they receive significant attention in the marketplace and almost no attention from research. The purpose of the workshop and this special issue of the American Journal of Managed Care is to identify what is known and not known about these arrangements and develop an agenda for future research.
Topics: Cost, Managed Care, Medicaid, Mental Health.
Availability: AHCPR Publication No. 98-R080 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger F.
Title: Antitrust enforcement in the health care industry: The expanding scope of State activity.
Publication: Health Services Research 33(5):1477-94.
Date: 1998
Abstract: This study examines State laws that attempt to immunize mergers and other cooperative agreements among health care providers from federal antitrust prosecution. These laws are referred to as State health care antitrust exemption laws (SHAELs), and since 1992, 20 States have passed such laws. This study also examines the increasing activity of many State attorney general's offices involving collaborative activities among health-related organizations. In particular, the study reviews instances where merging hospitals have obtained State antitrust consent decrees that entail ongoing oversight responsibilities.
Topics: Cost, Hospitals, Markets, Public Policy.
Availability: AHCPR Publication No. 99-R030 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger F.
Title: Cost and financing of care for persons with HIV disease: An overview.
Publication: Health Care Financing Review 19(3):5-18.
Date: 1998
Abstract: This article explores the impact of new combination drug therapies on the cost and financing of human immunodeficiency virus (HIV) disease. Evidence indicates that the proportion of costs attributable to drugs has increased significantly since the diffusion of new combination drug therapies, and that the proportion of costs attributable to hospital inpatient care has decreased. The absence of timely data is the major difficulty in analyzing the impact of recent changes. Only two studies have examined costs since the diffusion of new combination drug therapies, and there are no recent studies of the insurance status of persons with HIV disease.
Topics: Chronic Conditions, Cost, Research Agenda.

Author: Hellinger F.
Title: The effect of managed care on quality: A review of new evidence.
Publication: Archives of Internal Medicine 158:833-41.
Date: 1998
Abstract: This article reviews recent evidence about the relationship between managed care and quality. With one exception, the studies reviewed represent observation periods that extend through 1990 or a more recent year. The review has led to the conclusion that managed care has not decreased the overall effectiveness of care. However, evidence suggests that managed care may adversely affect the health of some vulnerable subpopulations. Evidence also suggests that enrollees in managed care plans are less satisfied with their care and have more problems accessing specialized services. In addition, younger, wealthier, and healthier persons were more satisfied with their health plans than older, poorer, and sicker persons, even after adjusting for the type of health plan. The findings of the studies reviewed do not provide definitive results about the effect of managed care on quality. Indeed, relatively few studies include data from the 1990s, and little is known about the newer types of health maintenance organizations that invest heavily in information systems and rely on financial incentives to alter practice patterns. Furthermore, managed care is not a uniform method that is applied identically by all health plans, and research studying the different dimensions of managed care also is needed.
Topics: Cost, Managed Care, Medicare.
Availability: AHCPR Publication No. 98-R056 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger F.
Title: Regulating the financial incentives facing physicians in managed care plans.
Publication: American Journal of Managed Care 4(5):663-74.
Date: 1998
Abstract: Recent accounts of enrollees in managed care plans being denied access to potentially lifesaving services have heightened public anxiety about the impact of managed care on the accessibility and appropriateness of care, This anxiety has been translated into legislative action. The present review focuses on an area of managed care operations that has received considerable attention in State legislatures and in Congress during the past 2 years: the financial relationship between managed care health plans and physicians. Twelve States now mandate that managed care plans disclose information about their financial relationship with physicians, and 11 States regulate the method used by managed care health plans to compensate physicians. Most laws that regulate methods of compensation prohibit health plans from providing physicians an inducement to reduce or limit the delivery of "medically necessary" services. Moreover, in 1996 the Health Care Financing Administration (HCFA) finalized its regulations governing the financial incentives facing physicians in plans that treat Medicaid or Medicare patients, and these regulations went into effect on January 1, 1997. These regulations are also examined in this study.
Topics: Cost, Managed Care, Medicaid, Medicare.
Availability: AHCPR Publication No. 98-R064 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger F.
Title: The expanding scope of State legislation.
Publication: JAMA 276(13):1065-70.
Date: 1997
Abstract: This study examines three types of State laws that regulate managed care plans: (1) Laws that limit the ability of managed care plans to direct the flow of patients to specific (e.g., direct access laws, any-willing-provider laws, and freedom-of-choice laws). (2) Laws that prohibit contracts between managed care plans and providers that establish exclusive relationships (i.e., contracts that do not permit providers to sign contracts with other managed care plans). (3) Laws that mandate minimum lengths of hospital stay for deliveries. Arguments advocating and resisting these laws are examined along with information about their impact on the cost and quality of care.
Topics: Cost, Managed Care, Markets, Public Policy.
Availability: AHCPR Publication No. 97-R025 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger F.
Title: The impact of financial incentives on physician behavior: A review of the evidence.
Publication: Med Care Res Rev 53(3):294-314.
Date: 1996
Abstract: This study examines the relationship between the financial incentives confronting physicians in managed care plans and the utilization of services. The primary conclusion of this review is that the financial incentives confronting physicians are a key element in explaining the lower utilization rates of enrollees in managed care plans.
Topics: Cost, Managed Care, Medical Decisionmaking.
Availability: AHCPR Publication No. 98-R028 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger F.
Title: Any-willing-provider and freedom-of-choice laws: An economic assessment.
Publication: Health Aff 14(4):297-302.
Date: 1995
Abstract: In recent years the prerogative of managed care plans to selectively contract with health care providers to establish networks of preferred providers has been circumscribed in many States through the enactment of any-willing-provider and freedom-of-choice laws. This study considers arguments for and against these laws, and reviews evidence on their impact.
Topics: Cost, Managed Care, Markets, Public Policy.
Availability: AHCPR Publication No. 96-R030 is available from the AHRQ Publications Clearinghouse.

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