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Public Policy

Authors: Szilagyi PG, Shenkman E, Brach C, et al.
Date: 2003.
Title: Children with special health care needs enrolled in SCHIP: patient characteristics and health care needs.
Publication: Pediatrics 112(6 Pt. 2):508-20.
Abstract: Available on PubMed®.
Availability: Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO17).

Authors: Shone LP, Dick AW, Brach C, et al.
Date: 2003.
Title: The role of race and ethnicity in SCHIP in four states: are these baseline disparities, and what do they mean for SCHIP?
Publication: Pediatrics 112(6):521-32.
Abstract: Available on PubMed®.
Availability: Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO16).

Authors: Brach C, Lewit EM, VanLandeghem K, et al.
Date: 2003
Title: Who's enrolled in SCHIP? Findings from the Child Health Insurance Research Initiative (CHIRI™).
Publication: Pediatrics 112(6):499-507.
Abstract: Available on PubMed®
Availability: Reprints of this article can be ordered from the AHRQ Publications Clearinghouse (1-800-358-9295, AHRQ Publication No. 04-RO15).

Authors: Dick AW, Allison RA, Haber SG, Brach C, Shenkman B
Title: Consequences of States' Policies for SCHIP Disenrollment.
Publication: Health Care Financing Review 23(3):65-88.
Date: 2002
Abstract: Policymakers are concerned about disenrollment from the State Children's Health Insurance Program (SCHIP). We describe disenrollment in Florida, Kansas, New York, and Oregon and assess the links between disenrollment and states' SCHIP policies. We find that SCHIP is used on a long-term basis (at least 2 years) for a significant group of new enrollees and as temporary coverage (fewer than 12 months) for many others. Recertification generates large disenrollments (about half of children still enrolled at the time), but as many as 25 percent return within 2 months. The increased disenrollment rate at recertification is completely eliminated by a policy of passive re-enrollment.
Availability: AHRQ Publication No. 02-R070 is available from the AHRQ Publications Clearinghouse.

Authors: Brach C, and Fraser I.
Title: Reducing Disparities through Cultural Competent Health Care: An Analysis of the Business Case.
Publication: Quality Management in Health Care 10(4):15-28.
Date: 2002
Abstract: The persistence of racial and ethnic disparities in health care access, quality, and outcomes has prompted considerable interest in increasing the cultural competence of health care, both as an end in its own right and as a potential means to reduce disparities. Health care organizations have financial incentives to become culturally competent, but limitations inherent in these incentives must be overcome if cultural competence is to become widespread.
Availability: AHRQ Publication No. 02-R081 is available from the AHRQ Publications Clearinghouse.

Authors: Jiang HJ, Begun JW.
Title: Dynamics of Change in Local Physician Supply: An Ecological Perspective.
Publication: Social Science and Medicine 54(10):1525-41.
Date: 2002
Abstract: An ecological framework was proposed that explains the growth of a physician population by four mechanisms—the intrinsic properties of this physician population; the local market's carrying capacity, determined by three environmental dimensions (munificence, concentration, diversity); competition within the same physician population; and interdependence between different physician populations. The study period is from 1985 to 1994, during which dramatic changes occurred in the health care sector—an unprecedented growth in managed care, increased hospital consolidation and organized physician practice. MSA level data were compiled from ARF, the AHA Annual Surveys of Hospitals, the AMA Census of Medical Groups, the InterStudy National HMO Census, and the U.S. County Business Patterns. Both changes in the number and percentage of physicians in a particular specialty population were examined. Variables measuring three environmental dimensions were found to have significant and differential effects on change in the size of different specialty populations. For instance, hospital consolidation and managed care penetration both showed significant positive effects on growth of the generalist population but suppressing effects on growth of the specialist population. MSAs with higher percentages of for-profit hospitals had significant increases in the percentage of specialists.

Authors: Basu J, Friedman B.
Title: Hospitalization of children for ambulatory care sensitive conditions: Determinants of patient flows in a large State.
Publication: Health Economics 10(1)67-78.
Date: 2001
Abstract: The study examines the influence of key policy variables such as types of insurance, and local supply of primary care, and patient characteristics such as race, and severity of illness, among others, on out-of-area use of hospitals by children with diagnoses defined as ambulatory care sensitive (ACS) conditions. Hospital discharge data for New York residents admitted to hospitals in New York, Pennsylvania, New Jersey or Connecticut in 1994 are used. Patient-level data are merged with the Area Resource file (ARF), and American Hospital Association (AHA) surveys. Hypotheses are developed from a model that links the choices of families residing in a local area, supply considerations of ambulatory care providers, HMOs and hospitals, determining the admissions to hospitals for ACS conditions in an out-of-area hospital. The study uses logistic regression to predict travel out of the local area for ACS admission. The study finds that HMOs do not especially take members outside the area when hospital care is needed. Inadequate primary care could cause significant patient flows. Severity of illness significantly affects flows out of the local area and children with nonwhite race tend to stay in. The implications of these findings might be that a greater availability of local primary care physicians could reduce the movement of children outside the county. This could be more effective in areas with more nonwhites and Medicaid patients because those are the areas associated with higher occurrence rates, and a higher likelihood of patients to stay locally. Future research will compare patient flows for ACS conditions with other conditions such as those treated with elective procedures, use other age groups, and examine the time trends for ACS conditions.

Authors: Brach C, Fraser I.
Title: Can cultural competency reduce ethnic and racial health disparities? A review and conceptual model.
Publication: Med Care Res Rev 57(Suppl 1):181-217.
Date: 2000
Abstract: This article investigates cultural competency's potential to reduce racial and ethnic health disparities through a review of both the cultural competency and disparities literatures and development of a conceptual model. It identifies nine major cultural competency techniques described in the literature (interpreter services, recruitment and retention policies, training, coordinating with traditional healers, use of indigenous community workers, culturally competent health promotion, including family/community members, immersion into another culture, and administrative and organizational accommodations). The authors model how cultural competency techniques could improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations that lead to good outcomes, thereby reducing disparities. The authors conclude that while there is substantial evidence to suggest that cultural competency should work, health systems have little evidence about which cultural competency techniques are in fact effective, and less evidence on when and how to implement them properly.

Authors: Brach C, Sanches L, Young D, et al.
Title: Wrestling with typology: Penetrating the "black box" of managed care by focusing on health care system characteristics.
Publication: Med Care Res Rev 57(Suppl 2):93-115.
Date: 2000.
Abstract: The health care system has undergone a fundamental transformation, undermining the usefulness of the typology of HMO, IPA, PPO, etc. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain (financial features, structure, care delivery and management policies, and products) and by key roles in the health care system (sponsor, plan, provider intermediary organization, and direct services provider). The matrix is a tool for researchers, administrators, clinicians, regulators and policy makers, and data collectors. It suggests a new set of players to be studied; emphasizes the relationships among the players; and provides a checklist of independent, control, and interactive variables to be included in analyses.
Availability: AHRQ Publication No. 01-R014 is available from the AHRQ Publications Clearinghouse.

Authors: Fraser I, McNamara P.
Title: Employers: Quality takers or quality makers?"
Publication: Med Care Res Rev 57(Suppl 2):33-52.
Date: 2000
Abstract: Available on PubMed®
Availability: AHRQ Publication No. 01-R012 is available from the AHRQ Publications Clearinghouse.

Authors: Gross P, Steiner C, Bass E, Powe N
Title: Relation between prepublication release of clinical trials results and the practice of carotid endarterectomy.
Publication: JAMA 284:2886-93.
Date: 2000.
Abstract: This article determined whether prepublication release of carotid endarterectomy trail results via National Institutes of Health Clinical Alerts were associated with a prompt change in patient care that was consistent with the new medical evidence. The study uses several years of data from seven States (NY, CA, PA, FL, CO, IL, and WI) that participate in the Healthcare Cost and Utilization Project. Findings include that the prepublication dissemination of Cost-effectiveness analysis trial results with clinical alerts was associated with prompt and substantial changes in medical practice. However, the results were extrapolated to patients and settings not directly supported by the trials.
Availability: AHCPR Publication No. 01-R017 is available from the AHRQ Publications Clearinghouse.

Authors: McNamara P, Caldwell B, Fraser I, et al.
Title: New contributions from the field of health services research
Publication: Med Care Res Rev 57(Suppl 2):5-8.
Date: 2000.
Abstract: Recent publication and wide press coverage of an Institute of Medicine (IOM) study documenting the extent and nature of patient safety problems broadened public understanding of a fundamental and discouraging finding from the field of health services research—the quality of care delivered in the United States varies greatly and cannot be presumed. The IOM report underscores another finding from health services research that offers some guidance for those seeking to improve quality: the safety and quality of patient care can be no better than the system within which it occurs. Improvements in quality require a comprehensive and purposive set of system solutions based on scientific evidence about what works and what doesn't. This introductory article summarizes seven articles included in a special supplement of Med Care Res Rev, which were drawn from centerpiece presentations at two recent national meetings of health plans and health services researchers (Building Bridges 1999, 2000). The family of timely and actionable articles provides insights on organizational and institutional approaches to quality, and inform our future research agenda related to quality by identifying evidence gaps, offering design suggestions, and implicitly identifying research priorities.

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 non-local 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 non local 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.

Authors: Palmer CS, Miller B, Halpern MT, Geiter L.
Title: A model of the cost-effectiveness of directly observed therapy for treatment of tuberculosis.
Publication: Journal of Public Health Management and Practice 4(3):1-13.
Date: 1998
Abstract: A hypothetical cohort of 25,000 TB patients and their contacts were followed in a 10-year decision model; rates of treatment default, infectiousness following partial treatment, relapse, hospitalization, and development of drug-resistant TB were considered. The incremental cost per additional case cured was $24,064 when all patients started treatment on directly observed therapy (DOT) compared with patient responsible therapy, indicating that outpatient DOT provides a cost-effective method of improving health outcomes for TB patients and their contacts while controlling direct costs.

Author: Fraser I, McNamara P, Lehman G, et al.
Title: The pursuit of quality by business coalitions: A national survey
Publication: Health Aff 18(6):158-65.
Date: 1999
Abstract: Available on PubMed®
Availability: AHRQ Publication No. 00-R003 is available from the AHRQ Publications Clearinghouse.

Authors: Brach C, Scallet L.
Title: Managed care challenges for children and family services.
Publication: In Humane Managed Care?, edited by Schamess G, and Lightburn A. Washington (DC): National Association of Social Workers Press.
Date: 1998
Abstract: This chapter highlights five challenges facing those dedicated to the welfare of children and their families who also want to make the most of the opportunity managed care presents: (1) The speed with which managed care is moving through the various systems that serve children and families. (2) The emphasis that has been placed on outcomes. (3) The participation of clients in the design and implementation of managed care policies and programs and the importance of ensuring client protection. (4) The need for the development of culturally competent systems of care. (5) The potpourri of legal considerations that accompany managed care initiatives.

Authors: Fraser I, Chait E, Brach C.
Title: Promoting choice: Lessons from managed Medicaid programs.
Publication: Health Aff 17(5):165-73.
Date: 1998
Abstract: By examining the experiences of seven States with mandatory managed Medicaid programs, this article seeks to draw some lessons and raise research, policy, and operational questions about enrollee choice of health plans. The article explores the strategies States adopt to inform and facilitate choice, and what methods they use to assign individuals who do not make a choice in the time allotted. Differences are identified in the enrollment and education process that might account for some of the variation among States' rates of enrollees who choose a plan. Use of enrollment brokers and restrictions on marketing is also discussed.
Availability: AHCPR Publication No. 98-R088 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.
Availability: AHCPR Publication No. 99-R030 is available from the AHRQ Publications Clearinghouse.

Authors: Friedman B, Steiner C, Scott J.
Title: Rationing of an expensive technology in the U.S.: Hospital intensive care in two States, 1992.
Publication: In Governments and Health Systems: Implications of Differing Involvements, edited by Chinitz JCD. Sussex, England: John Wiley and Sons, Ltd.
Date: 1997
Abstract: A discussion of public and payer policies and descriptive review of variations in use of ICU services for adult, non-emergency, non-surgical patients. Once admitted to a hospital, most people with public and private insurance are protected against the extra out-of-pocket expense for the ICU. Therefore, some amount of rationing can be desirable if patients demand service that has very low benefit relative to the high resource costs of production. Many payers do give physicians and hospitals incentives to provide less ICU care than patients and ideal agents would demand. The variations in use suggest that rationing is more a function of hospital characteristics and performance variables than of patient characteristics.

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.

Author: Brach C.
Title: Privatizing local mental health authorities and mental health services: Raising questions and considering options.
Publication: Boston (MA): Technical Assistance Collaborative, Inc.
Date: 1996
Abstract: This monograph, distributed to state and county mental health agencies, weighs the advantages and disadvantages of privatizing local mental health authorities and the relative merits to different organizational forms (quasi-public v. private non-profit corporation). The monograph also reviews considerations for privatizing the delivery of mental health services, and gives guidance on implementing either type of privatization strategy.
Availability: Select to access information on how to order this monograph on the Web site of the Technical Assistance Collaborative.

Authors: Brach C, Mauch D.
Title: Public sector responsibilities in managed care.
Publication: In Managed care: Challenges for children and family services, edited by L. Scallet, C. Brach and E. Steel. Baltimore, (MD): Annie E. Casey Foundation.
Date: 1996
Abstract: This report poses the question: "What responsibilities must remain with the public sector?" The response comes in three parts. First, the public sector's objectives in caring for vulnerable children and families are defined. Second, core functions of government that cannot be delegated are articulated. Third, strategies are offered for executing core functions and securing the public sector's objectives. Public sector officials who think through these issues and plan accordingly can remain in control while using the private sector effectively to accomplish public objectives.

Authors: Brach C, Scallet L.
Title: Trends.
Publication: In Managed care: Challenges for children and family services, edited by Scallet L, Brach C, Steel E. Baltimore (MD): Annie E. Casey Foundation.
Date: 1996
Abstract: This report was designed to educate the systems that serve children and families (e.g., child welfare, special education, juvenile justice) about managed care. Drawing upon knowledge from the sectors where managed care is relatively more advanced, such as the health and mental health sectors, the authors discuss the implications of the advancement of managed care techniques into child- and family-serving systems.

Author: Drissel A.
Title: Managed care and children and family services: A guide for State and local officials.
Publication: Baltimore (MD): Annie E. Casey Foundation. Edited by Brach C.
Date: 1996
Abstract: This guide is the final product of a project for the Annie E. Casey Foundation, Managed care: Implications for children and family services. A major goal of the project was to provide a bridge from the sectors where managed care is relatively more advanced, such as the health and mental health care systems, to those where managed care is beginning to make inroads.

Authors: Robinson G, Brach C.
Title: Managed mental health care and women: Implications of a changing delivery system.
Publication: Paper read at Changes in Mental Health Care: What Might They Mean for Women?
Date: October 2, 1996
Abstract: This article was written to serve as the basis of discussion for the Commonwealth Fund Commission on Women's Health's symposium, Changes in Mental Health Care: What Might They Mean for Women? The public mental health system is now undergoing a radical transformation with the advent of managed care. Over the past two decades Medicaid has grown into a dominant funding source for public mental health services. States, facing budgetary pressures, are increasingly shifting Medicaid programs into managed care.

Authors: Brown RE, Miller B, Taylor WR, Palmer CS, et al.
Title: Health care expenditures for tuberculosis in the United States.
Publication: Arch Intern Med 155:1595-1600.
Date: 1995
Abstract: This retrospective cost of illness study estimated 1991 direct expenditures for TB-related outpatient and inpatient diagnosis and treatment, screening, preventive therapy, contact investigations, surveillance, and outbreak investigations. The direct medical expenditures for TB in 1991 were estimated at $703.1 million. Treatment accounted for more than 86% of all TB-related expenditures; inpatient treatment accounted for 60% of the total. Prevention activities made up only 14% of all costs. Direct medical expenditures may be underestimated because of limitations in the database on hospital expenditures and health department cost-accounting systems and because of the lack of a national database on screening activities.

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.
Availability: AHCPR Publication No. 96-R030 is available from the AHRQ Publications Clearinghouse.

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