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CODS Final Grant Reports Available at NTIS

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Information on final reports is available here in two ways. Final reports are listed below in alphabetical order by the grantee's name. There is also a topic index to assist in finding final reports on a particular subject.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z


B

Principal Investigator: Mark C. Berger
Title: Employer Provided Health Insurance and Job Lock.
Publication Report Date: September 1996
Grant No.: HS 08188
Abstract: Job lock can occur when workers postpone job changes because they fear losing employer-provided health insurance. If this type of job lock is prevalent, then the overall quality of matches between workers and employers is reduced and workers are on average less productive. The authors use the 1987 and 1990 panels of the Survey of Income and Program Participation to examine whether job lock affects mobility of wages. They estimate mixed stock and flow hazard models of job tenure and standard wage equations that depend on employer-provided health insurance, health status, and the interaction of the two. This provides the authors with a difference in differences estimator of the effects of job lock. They find no statistically significant evidence that job lock affects job tenure or wages in either 1987 or 1990. As part of the examination of job lock, the authors have also studied the consequences of error in the measurement of health insurance status, the effects of dual husband-wife employer-provided health insurance coverage on labor market outcomes, and the use of mixed hazard models to estimate the length of time with health insurance coverage.
Availability: Copies can be ordered from NTIS, NTIS Order number: PB97-144794INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: John M. Brooks
Title: Factors Affecting the Bargaining Between Pharmacies and Insurers.
Publication Report Date: 1998
Grant No.: HS 09541
Abstract: The medical care marketplace has changed dramatically over the last decade. In the face of escalating costs, insurers have taken a more active role in bargaining with providers over the prices of medical care services. Unfortunately, there has been little previous research to help policy-makers understand the effects of these changes on provider reimbursements. The aim of this research is to fill this information gap by modeling the bargaining power of pharmacies in their price negotiations with insurers and investigating the extent that bargaining power varies with characteristics of the pharmacy, insurer, and pharmacy market. Empirical estimates were obtained using pharmacy/insurer transactions from Medstat's 1994 Marketscan Database.
The authors find statistically significant variation in pharmacy bargaining power across markets, insurers, and pharmacy types. With respect to market structure, pharmacy bargaining power was negatively related to pharmacies per capita and pharmacies per employer, and positively-related to pharmacy concentration at higher concentration levels.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB99-134892INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 or (703) 605-6000 for local calls.

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C

Principal Investigator: Douglas C. Coate
Title: Effects of Employee Enrollment in Health Maintenance Organizations on the Costs of Employer Sponsored Group Health Plans
Publication Report Date: November 1994
Grant No.: HS 07030
Abstract: The report analyzes the effects of employee enrollment in health maintenance organizations (HMOs) on the costs of employer sponsored group health plans. The empirical results suggest that group health plans in which all enrollment is in one plan design (traditional indemnity, preferred provider organization, or health maintenance organization) are less costly than plans which allow employee choice between different plan designs. HMOs are the least costly plan design in the no choice environment. In multiple choice group health plans, however, cost savings from employee enrollments in HMOs are not evident.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB95-174058INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Lisa L. Cubbins
Title: Employer-Based Health Insurance and Labor Market Changes.
Publication Report Date: September 1999
Grant No.: HS 09521
Abstract: Employer-based health insurance is one of the most important fringe benefits offered to workers as it affects to access to health care and their families' access as well. However, American workers are not equally likely to receive health benefits. This study considers trends in the receipt of health benefits by gender, race, ethnicity, and poverty status between 1987 and 1997. It also tests for the effects of worker resources (age and education) and economic location (job, occupation, firm, and industry characteristics), as well as group differences in these effects over time. Data from the Current Population Surveys are analyzed using bivariate probit regression, with separate analyses by marital status. The findings showed that the probability of receiving health benefits declined for unmarried individuals and marred men between 1987 and 1997. Gender, race, ethnicity, and poverty status each affect receipt of health benefits, though gender and race have unexpected effects. Worker resources and economic location characteristics influence the probability of receiving health benefits and do explain some of the status group differences. Overall, this study shows that status group variation in health benefits is closely tied to marital status and economic location.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB2000-101196INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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D

Principal Investigator: Cheryl L. Damberg
Title: Health Care Reform: Distributional Consequences of an Employer Mandate for Workers in Small Firms.
Publication Report Date: August 1994
Grant No.: HS 07536
Abstract: During the 1993-94 health care debate, small employers expressed concern about the financial burden a mandate would impose because a disproportional share of the uninsured are employed in small firms. Data from the 1987 National Medical Expenditure Survey are used to simulate the distributional effects of the 1993 Health Security Act. The results reveal why small employers were vehemently opposed to a mandate, even assuming that workers would bear the full incidence of the mandate. An employer mandate would have important effects on labor markets, leading to a deterioration in wages among small firms and changes in wage compensation for workers relative to staying out of the labor force. Workers in large firms, in contrast, would see wages increase as the cost of insurance to their employers declined. The combined effect would have likely induced labor to flow from small to large firms. The mandate would have also reduced wages (or other fringe benefits) to provide coverage that some workers already had through their spouse. This would have likely reduced labor force participation (roughly 250,0000 workers), especially among secondary workers and workers with weak attachments to the labor force. To avoid the loss of workers to large firms or out of the labor force, small firms would have been required to raise wages.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB95-256566INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Ravinder Dhawan
Title: Analysis of Health Care Reform: A Multi-Sector Approach.
Publication Report Date: 1994
Grant No.: HS 07520
Abstract: This study provides a comprehensive framework intended to account for how proposed changes in the health care system affect and are affected by other areas of the economy. Multi sector, general equilibrium methods are applied to analyze possible repercussions of: (1) changes in tax treatment of employer payment of health insurance premiums, and (2) new government- and employer- based incentives to encourage enrollment in managed care systems such as health maintenance organizations (HMOs). The model is designed to track the interactions and feedback among the sectors: households, fee-for-service providers, managed care providers, and private insurers, as well as, secondarily, employers and the government. Simulation results show the effects of the two policy changes on fee-for-service costs and insurance premiums; HMO premiums; distribution of the population between fee-for-service and HMO plans; profits of fee-for-service providers, insurers and the HMO; and a variety of measures concerning health care expenditures.
Availability: Copies can be ordered from the National Technical Information Service (NTIS), NTIS Order number: PB95-154266INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703 -605-6000).

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E

Principal Investigator: Randall P. Ellis
Title: Competition and Health Plan Premium Determination.
Publication Report Date: November 1997
Grant No.: HS 08159
Abstract: There are many ways in which employers can share the cost of health insurance premiums with their employees. This AHCPR funded project examined how health premium cost sharing affects the levels of health plan premiums. Telephone and faxed requests were used to obtain detailed health plan information about state employee health plans in 35 states, with each plan offered and each rate class (e.g., single versus family coverage) contributing a distinct observation. This data on 4,289 health plans was used to show that premium levels do seem to respond to changes in how premiums are calculated. increasing the share of premiums that employees pay for single and family coverage and increasing the number of plans offered both tend to reduce health plan premiums.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB98-131337INM at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703 -605-6000).

Principal Investigator: Jose Escarce
Title: Efficiency in Hospitals: Do HMOs ABuy Right@?
Publication Report Date: March 1999
Grant No.: HS 09194
Abstract: This study uses hospital discharge data for 1992-94 to assess differences between HMO and insured non-HMO patients in California and Florida with regard to the quality of the hospitals used for coronary artery bypass graft (CABG) surgery. The authors find that commercially insured HMO patients in California used higher quality hospitals than commercially insured non-HMO patients, controlling for patient distance to the hospitals. In contrasts, commercially insured HMO and non-HMO patients in Florida were similarly distributed across hospitals of different quality levels, whereas Medicare HMO patients in Florida used lower quality hospitals than patients in the standard Medicare program. The authors conclude that the association between HMO coverage and hospital quality may differ across geographic areas and patient populations, possibly related to the maturity and structure of managed care markets.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB99-146102INM at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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G

Principal Investigator: Esther Gal-Or
Title: Industrial Organization of Health Care Markets.
Publication Report Date: 1995
Grant No.: HS 08213
Abstract: The results of the project are included in three different studies. The first study demonstrates that the stochastic nature of the demand for medical services combined with the lumpiness of investment decisions may give rise to excessive investment when multiple hospitals select independently their levels of capacities. The second study shows that when a payer can dictate to the provider what type of treatment to administer to the patient it is possible to implement the 'first best' levels of investment in cost control efforts and in aggressiveness of treatment. Implementation of the 'first best' requires that the payer utilizes the prospective reimbursement rule accompanied with the removal of all malpractice liabilities from the provider. The third study considers a model of quality competition among health care providers and demonstrates that the equilibrium in the market is characterized by strict differentiation in the quality of care that is offered to consumers. The market outcome generates excessive investment in quality in comparison to the socially optimal outcome and, as a result, an excessive number of low income individuals who find health care unaffordable.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB95-264545INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Dana P. Goldman
Title: Managed Care as a Public Cost Containment Mechanism.
Publication Report Date: 1994
Grant No.: HS 07490
Abstract: Managed care is viewed by some advocates as a convenient way to control health care costs while providing increased access to preventive services in the public sector. This dissertation investigates this claim in detail using evidence from two managed care demonstrations in public insurance programs: the military health services system and Medicaid. An analysis of the DoD experience demonstrates that the generosity of benefits and lower prices expanded managed care participants' use of ambulatory services relative to their fee-for-service counterparts. Most of this expansion is due to increase in the number of users. An evaluation of the Medicaid reforms indicates that the HMO did not significantly reduce expenditures. This clearly vitiates the presumed effectiveness of reform strategies that rely on managed care to contain costs.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB95-170759INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Glenn G. Graham
Title: Demand Uncertainty, Reserve Margins, and Hospital Costs.
Publication Report Date: 1992
Grant No.: HS 06905
Abstract: The stochastic nature of illness causes the demand for hospital services to random. To accommodate this random demand, hospitals set aside capacity, or a reserve margin. This dissertation examines the causes and cost impact of hospital reserve margins. Hospital specific data are used to estimate two sets of models. In the first of these the determinants of hospital reserve margins are estimated using both ordinary least squares regressions and instrumental variables regressions. These determinants are classified into four major groups: price, relative capacity, quality, and other exogenous factors. Predicted values of the reserve margin taken from the first set of models are then used as regressors in translog cost functions when estimating the second set of models. These models give the variable cost impact of hospital reserve margins.
Availability: Copies can be ordered for the national NTIS, NTIS Order number: PB95-256574INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Michael Grossman
Title: Economic Analyses of Health Care Financing Authorities.
Publication Report Date: November 1996
Grant No.: HS 06095
Abstract: This project raises the fundamental question: Do differences in the market structure of the industry that issues tax-exempt hospital bonds across states lead to differences in the interest rates on the debt that state and local health care financing agencies issue on behalf of hospitals? The interest rate exclusive or inclusive of issuer fees falls as the number of issuers in the State rises or as the concentration of real par value among them (measured by four leading issuer concentration ratio or by the Herfindahl index) falls. If each issuer had approximately the same share in real per value, the interest rate inclusive of fee would fall by approximately 31 basis points (1 basis point equals 1/100 of 1 percent). Our analysis of underwriter selection indicates that the selection of an underwriter by competitive sealed bids rather than by negotiation lovers bond yields by at most 58 basis points. In other words, competition among issuers has the potential to offset at least half of the increase in yields that result from lack of competition among underwriters.
Availability: Copies can be ordered from the NTIS, NTIS Order Number: PB97-118863INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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H

Principal Investigator: Jack L. Hadley
Title: Effects of HMO Market Structure on Firm and Consumer Behavior in the Employment-Based Health Insurance Market.
Publication Report Date: April 1998
Grant Number: HS 09193
Abstract: This report presents the results of a number of multivariate statistical analyses that address the general question of how variations in HMO market structure affect particular aspects of the employment-based health insurance market. HMO market structure is measured by two variables defined for sample employers in metropolitan statistical areas (MSAs): HMO penetration (HMO enrollment as a percentage of total population) is a continuous measure of the prevalence of HMOs in the market: and HMO competition, which indicated whether the market has both high HMO penetration (30 percent or higher) and high HMO competition (in the first quartile of the Hirschman-Herindahl Index of HMO concentration). The particular dependent variables analyzed are: (1) the type of insurance plan offered by employers; (2) premiums charged to employers for managed care and fee-for-service plans; (3) premium sharing between employers and workers; (4) the use of internal financial incentives by employers to influence workers' selection of an insurance plan; and (5) the effects of such incentives and HMO market structure on the proportion of workers actually selecting a managed care plan.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB98-127758, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Mahmud Hassan
Title: Effects of Tax Exemptions on the Supply of Charity Care by Non-Profit Hospitals.
Publication Report Date: October 1994
Grant No.: HS 07266
Abstract: Non-profit hospitals are granted tax-exempt status with the expectations that they will advance public interest. The purpose of this research is to investigate the relationship between different forms of the tax subsidy and the hospital's discretionary supply of charity care. The empirical analysis is performed using data from the California's Annual Hospital Disclosure Reports over the fiscal years 1987-90. We limited our study to non-profit, short-term, general hospitals with continuous presence of data in all 4 years 1987-90. The final data set for our analysis contained information on 205 hospitals. We used a fixed effects two-stated least squares econometric model to estimate the relationship. The empirical results show that hospitals pass on 95 percent of the savings from the tax-exempt bond in the way of additional charity care. But only 2-4 percent of the savings from income tax and property taxes is given away in the form of additional charity care.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB95-141347INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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K

Principal Investigator: Jacob A. Klerman
Title: Employment Effects of Health Care Reform.
Publication Report Date: 1996
Grant No.: HS 08219
Abstract: This project explored the likely employment effects of legislation mandating that employers provide health insurance to their employees (such as the proposed Health Security Act). The project concludes that for most workers, employers would react to such legislation by lowering wages. For workers with wage near the minimum wages, such a reaction would be illegal and some disemployment is likely. Conventional estimates of the employment effects of the minimum wage suggest an employment effects of about 100,000 workers. Using minimum wage effects based on the methodology of Meyer and Wise, would yield large employment effects. Updating their estimates and including in the data an increase in the minimum wage suggests that the Meyer and Wise model is not capturing the nature of the effects of the minimum on employment and wages and that those estimates should not be used for policy purposes.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB97-109409INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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L

Principal Investigator: Kenneth M. Langa
Title: Medicaid Cost-Containment in the 1980's: Did It Encourage Interpayer Differences in Hospital Care.
Publication Report Date: August 1992
Grant No.: HS 06948
Abstract: This study tests whether Medicaid cost-containment policies implemented in California in 1983 encouraged increasing differences in the resources used to treat hospitalized Medicaid as compared to privately-insured (fee-for-service or HMO), patients. Hospital discharge abstracts for approximately 50,000 patients per year, admitted to 128 California hospitals in 1983, 1985, and 1988 were examined. Payer-specific measures of resource use (probability of receiving selected procedures, total number of procedures, and length-of-stay) were calculated for patients with one of three medical conditions: (1) ischemic heart disease; (2) gallbladder disorders; and (3) uterine disorders. The resource use results suggest that, within the cost-containment 'environment' of the 1980's, California hospitals became unwilling or unable to provide the same level of treatment to Medicaid patients as was provided to patients with private insurance.
Availability: Copies can be ordered for the NTIS, NTIS Order number: PB94-206430INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: John M. Lowe
Title: Gravity Model Analysis of Hospital Patient Flows.
Publication Report Date: February 1993
Grant No.: HS 06949
Abstract: The effects of inner city hospital closure and the introduction of selected hospital financing reforms on patient flows in an urban hospital market are evaluated using a generalized gravity model. Closure of inner city hospitals is shown to increase patient loads on nearby hospitals serving similar patient populations. ZIP Codes containing closed hospitals experience reduced access to hospitals. Excess capacity in the hospital market ameliorated the worst effects of these closures. Universal insurance coverage improves access to hospital services for poor patient populations compared to federalizing the Medicaid program. Hospitals at risk for closure benefit from both reforms. Inner city community hospitals may lose patients under both plans, with important implications for medical education. The gravity model provides excellent fits of patient flows by accounting for patient travel times, the 'match' in health insurance profile between patient's residential zones (ZIP Codes) and hospitals, and characteristics of medical school and community hospital markets.
Availability: Copies can be ordered for the NTIS, NTIS Order number: PB94-214376INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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M

Principal Investigator: Larry M. Manheim
Title: Regulation and DRG Effects on Hospital Mortality Rates.
Publication Report Date: 1994
Grant No.: HS 06161
Abstract: The cross-sectional and longitudinal research describes the effects of Government regulatory policy, hospital resource, environmental, and regional characteristics on 30-day, post-admission Medicare hospital mortality rates. Changes in Medicare hospital mortality rates for congestive heart failure patients were analyzed using mortality data collected in 1983/84 for a sample of multi-system hospitals and their competitors, and compared with 1987 data. Cross-sectional studies revealed substantial regional differences in risk-adjusted hospital mortality rates which were not explained by significant, but modest, relationships between hospital resources and local population and environmental predictors of hospital mortality rates. Longitudinal studies revealed no evidence that quality of care deteriorated for congestive heart failure patients treated in hospitals facing more severe financial pressure due to the introduction of Medicare prospective payment.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB95-106092INM, at their Web site (set link to the actual document, not just FedWorld) or by calling by NTIS sales desk at 1-800-53-6847 (703-605-6000).

Principal Investigator: Peter M. Milgrom
Title: Determinants of Dental Malpractice
Publication Report Date: 1995
Grant No.: HS 06554
Abstract: The purpose of the study was to examine the relative contribution of the legal environment, individual claims experience and liability insurance coverage, and the market on the structure and process of care of dental practice. A cross-sectional design was employed to estimate from a survey of 4,278 general dentists (77 percent response rate, 3,048 dentists) the prevalence of claims, and to investigate the prevalent severity distribution of resolved claims. In addition, a survey of insurance firms and state insurance commissioners was conducted. The final report prevalence and payment data as well as findings on the determinants of professional liability claims. The report contains copies of published papers and the instrumentation used in the study.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB96-116249INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Vincent Mor
Title: Longitudinal Study of AIDS Health Services Use and Costs.
Publication Report Date: April 1994
Grant No.: HS 06214
Abstract: The investigators assembled a longitudinal data set for individuals with HIV disease, conducted personal interviews with a nonrandom sample, and abstracted medical and billing record data to describe the pattern of health services utilization and costs incurred at different times. The highest costs were incurred during the period immediately preceding death and they were driven by the inpatient component of costs. After controlling for clinical status, neither race, risk group, nor education were predictive of hospitalization. Nonwhites and intravenous drug users incurred higher hospital costs than did gay white males, largely due to longer stays. We examined changes in unmet need for services over a one-year period and found that clients reported the greatest need for dental services; nearly 25% reported unmet need at both interviews. Clients preferred community-based care over institutional care. A majority of clients favored nonaggressive treatment and exhibited a preference for avoiding severe outcome states such as being on a respirator or severe pain.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB95-123055INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Michael A. Morrisey
Title: Managed Care and Hospital-Physician Integration.
Publication Report Date: December 1997
Grant No.: HS 09183
Abstract: It has long been suggested that the growth of managed care would lead to closer linkages between hospitals and physicians. The use of capitation in particular has been seen as changing the incentives facing providers and leading to integrated delivery systems that have removed conflicting incentives among providers. Such integration could be structural in the sense of the vertical merging of traditional hospital and physician firms into a common delivery organization. It can also be more informal in the sense of small linkages in management, sharing of information, development of clinical routines, that serve to tie hospitals and physicians more closely together. The specific aims of this study were: (1) to describe the different integrative structures and practices that hospitals and physicians have developed to cope with managed care, and (2) to estimate the impact of managed care on integrative structures and practices developed between hospitals and physicians.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB98-126519INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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N

Principal Investigator: John A. Nyman
Title: Prospective Case-Adjusted Payments: Profits and Access.
Publication Report Date: 1993
Grant No.: HS 07018
Abstract: In recent years, a number of States have adopted case-mix adjusted nursing home reimbursement systems for their Medicaid patients. In a case-mix reimbursement system, the relative reimbursement rates are based on an estimated case-mix index of costs. If the actual costs match the estimated costs of the case-mix index, then the reimbursement system is access neutral, meaning that each patient type is equally profitable and equally likely to gain access to the nursing home. Access neutrality was the original intent of the case-mix system: to eliminate the incentive that made nursing homes prefer light-care patients to heavy-care ones. If the actual costs differ from the estimated costs of the case-mix index, then certain patients will be more profitable than others. The profitable patients would not necessarily be the light-care patients, but instead those patients for whom the difference between actual costs and the reimbursement rate is the largest.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB94-198199INM, at their Web site (set link to the actual document, not just FedWorld) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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R

Principal Investigator: Kimberly Rask
Title: Do Public Hospitals Affect Private Insurance Choice. Public Insurance as Substitutes for Private Insurance: New Evidence about Public Hospitals.
Publication Report Date: 1996
Grant No.: HS 08110
Abstract: Public hospitals have been important providers of health care for Medicaid enrollees and the uninsured. In this paper, public hospitals are modeled as public subsidy to health care providers for providing care to the uninsured. However, a possible cost of this type of provision is that by offering an alternative to the private insurance market, the proximity of free or subsidized care may decrease the incentive to purchase private health insurance. Individual-level data for respondents under age 65 was obtained from the 1987 National Medical Expenditure Survey (NMES). The sample was divided into three groups: those with household incomes below the poverty level (n=2,836), between 100-400% (n=13,113), and greater than 400% of the poverty level (n=7,793). Multinomial legit regressions are estimated for the low and middle income groups where the dependent variable (insurance) can take one of three values: private insurance, Medicaid, or no insurance, while a binomial probit (private insurance or no insurance) is estimated for the high income group. For people below the poverty level and those with high incomes, public hospitals proximity is not related to insurance coverage. Those in the middle income group, however, are shown to be less likely to be privately insured if a public hospital is in their county. For the low-income group, the presence of a public hospital was associated with a lower likelihood of Medicaid coverage. The accessibility of public hospitals to care for the poor may give individuals an incentive to forego private insurance and rely instead upon public provision of medical care.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB97-131817INM, at their Web site (set link to the actual document, not just FedWorld) or by calling NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: James C. Robinson
Title: Adverse Selection and Risk Rating in Insurance Markets.
Date of Final Report: April 1995
Grant No.: HS 06580
Abstract: The study used demographic, personnel, fee-for-service (FFS) claims, and HMO utilization data from a large private firm to evaluate risk selection among competing health plans and to develop a method for adjusting capitation payments to compensate for selection. The FFS plan and large group-model HMO experienced enrollee risk similar to the employee population as a whole. The smaller and newer network and independent practice HMOs exhibited both very favorable and very adverse risk selection. The study develops a method for evaluating the ability of risk-adjustment models to predict expenditures for employees groups enrolled in different health plans, as distinct from the conventional emphasis on predicting risk for individual employees. The four-equation statistical model explains 61% of the variance in per capita expenditures across groups with different risk levels.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB94-182011INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=821177426+3+0+0&waisaction=retrieve), or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Louise B. Russell
Title: Risk and Risk Factor Modeling Project.
Publication Report Date: July 1995
Grant No.: HS 07002
Abstract: This project produced a comprehensive model, the Risk and Risk Factor Model, of the risks of death, hospitalization, and nursing home admission as functions of a common set of biomedical and behavioral risk factors. The relationship on which the model is based were estimated with data from a nationally representative sample of noninstitutionalized U.S. adults, the Epidemiologic Follow-up Study (NHEFS) of the National Health and Nutrition Examination Survey (NHANES I). The model can be used to project the health efforts of risk factor modification over a 20-year period in a common framework that assures that comparisons across interventions are valid. It is thus particularly appropriate for studies of the effectiveness and cost-effectiveness of preventive interventions.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB2000-108004INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=823767566+4+0+0&waisaction=retrieve) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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S

Principal Investigator: Karen Seccombe
Title: Medical Insurance among the Working Poor: 1977-1987.
Publication Report Date: February 1996
Grant No.: HS 07444
Abstract: Using data from the National Medical Expenditures Survey (NMES) and the National Medical Care Expenditures Survey (NMES), this research examines the extent, sources, and changes in health insurance coverage over time for individuals and families. The problems faced by the working poor were of particular interest. The results of this research suggests that the working poor are a critically neglected group with respect to health insurance coverage. They are less likely than non-poor groups to receive insurance from an employer, and they are more likely to be completely uninsured. This is true for both individuals and for families. Moreover, the working poor experienced significant declines in coverage during the 1980s which were not experienced by non-poor groups.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB95-212684INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=830907784+0+0+0&waisaction=retrieve) or by calling the NTIS sales desk at 1-800-553-6847 73-605-6000).

Principal Investigator: John B. Silvers
Title: Economics of Hospital Capital Expenditure
Publication Report Date: July 1996
Grant No.: HS 07115
Abstract: This study of hospital capital expenditure decisions investigated financial and strategic reasons for observed hospital capital investment decisions. Survey data from hospital chief financial officers (CFO) is analyzed in conjunction with Medicare Cost Report data. A pure finance model (driven by cash flow) is first tested for 4,097 hospitals for 1991. One additional dollar of cash flow is associated with $0.16 additional capital investment and $1.60 less expenditure on payroll. This supports a bias toward spending available cash flow on capital versus labor. However, these equations reveal a high degree of simultaneity: an additional dollar of payroll produces $0.12 in capital investment and an additional dollar of capital investment is associated with $7.30 increase payroll.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB97-112627INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=844089173+0+0+0&waisaction=retrieve) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: John B. Silvers
Title: Variation in Inpatient Cost and Net Corporate Value by DRG
Publication Report Date: 1992
Grant No.: HS 06158
Abstract: For the employed population, the time lost from work during illness represents a real, but indirect, economic cost to the firm that must be absorbed in addition to any related direct health care expenditures paid. The research shows that less than one-third of these work days lost around a hospitalization are explained by the actual days in the hospital. Furthermore, the value of this lost time is only marginally related to the dollars spent directly on health care although this indirect loss increases total cost by another 56%. The main conclusion is that a combination of other factors altogether are more important in returning employees to work than the actual care delivered. Therefore, changing the way personal and worksite characteristics relate to lost work around a hospitalization should have a large dollar impact on indirect cost substantially complementing efforts to reduce the other two thirds of total health care costs incurred for direct services.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB94-203650INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=833337830+1+0+0&waisaction=retrieve) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

Principal Investigator: Frank A. Sloan
Title: Impact of Reforms on Access to Insurance and Health.
Publication Report Date: March 1997
Grant No.: HS 08614
Abstract: This study examined the impact of state initiatives to improve access to health insurance coverage on the number of the uninsured and distribution of coverage. Using pooled data from the 1989-95 Current Population Surveys to analyzed coverage for the entire population and data from the Health and Retirement Survey to analyze coverage for individuals age 51-64, a fixed effects probit model based on a time-series of cross-sections was used for analysis. Six groups of state policies were evaluated: (1) Medicaid, (2) low cost plans, (3) subsidized coverage, (4) risk pooling, (5) open enrollment/continuity of coverage rules and (6) community rating. Both analyses showed few reforms resulted in increased coverage. Those which succeeded include Medicaid eligibility expansions, employer tax credits, and selected open enrollment/ continuity of coverage rules—including guaranteed issue for small groups, guaranteed renewal for individual policies and, for single adults, limitations on pre-existing conditions waiting periods for individual coverage.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB97-144786INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=848589352+8+0+0&waisaction=retrieve) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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Principal Investigator: John M. Tilford
Title: Access to Medical Care and the Demand for Medical Care.
Publication Report Date: April 1994
Grant No.: HS 07554
Abstract: This study investigates elderly health care demand, especially with respect to coinsurance and time, using new method to estimate the effect of time. Health care demand was estimated using the 1987 National Medical Expenditure Survey (NMES) data base. The NMES provides data on willingness to pay for a reduction in doctor's office waiting time which was used to measure the value of time in obtaining health care. The standard measure of the value of time, the wage rate, was hypothesized to produce biased estimates of time price elasticities. Elderly coinsurance elasticities were estimated to be approximately -0-10. Time price elasticities ranged from -0.01 to -0.02. Time prices created with the wage rate produced biased estimates of time price elasticities. Finally, differential use of health care, possibly induced by differences in health insurance coverage, has implications for health status. People consistently identified as not having ownership of medigap supplemental insurance policies, namely males and blacks, were less likely to use acute and other care, which includes well care, and were more likely to use chronic care and to be in poor health.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB94-203718INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=8539810834+0+0+0&waisaction=retrieve) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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Principal Investigator: Daniel J. Zabinski
Title: Reform of the Tax Preference for Employer-Provided Health Insurance: An Econometric Analysis.
Publication Report Date: September 1993
Grant No.: HS 07545
Abstract: The current tax code in the United States allows workers to exclude compensation in the form of employer-provided health insurance from their taxable income. One effect of this tax preference is that it lowers the price of a unit of health insurance, so employer-provided health insurance is implicitly subsidized. The report specifies and estimates a model of the health insurance market and uses the estimated model to produce estimates of the effects of the tax preference and several alternatives to it. In this model, each household experiences a level of illness. Prior to this illness, the household chooses a health insurance contract. After this illness, they choose everything else they consume to maximize their utility subject to a budget constraint. This optimization problem is used to derive an expected utility function that depends on the features of a health insurance contract. Households maximize this expected utility by choosing from the contracts offered by competitive insurance firms facing adverse selection. This problem is used to derive choices for health insurance that depend on the model parameters. The parameters are estimated, and the estimated model is used to produce estimates of the effects of the tax preference. We find that the tax preference has larger cash-equivalent values for rich households than for poor households. The tax preference also has a more significant effect on the health care coverage chosen by rich households than by poor households.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB94-203700INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=8637911120+0+0+0&waisaction=retrieve) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000)

Principal Investigator: Jack Zwanziger
Title: Effect of Selective Contracting on Physician Pricing.
Publication Report Date: October 1997
Grant No.: HS 07068
Abstract: The principal objectives of the project was a comparison of the rates of growth of the physician fees negotiated by HMOs and the fees paid by indemnity insurance plans. In order to accomplish this four large data sets had to be combined: the survey of negotiated fees, the 'usual, customary and reasonable' fees paid by indemnity plans, census data and managed care penetration data. The first three data sets were created and cleaned in the expected time frame, by the end of month nine in the project, but the managed care data proved to be far more intractable. Managed care plans responding to the SMG survey (the vendors of the managed care plan data) often had inconsistent or ambiguous ways of defining their service areas. As a result, these data required extensive cleaning where data from each plan was examined manually. This cleaning took place over an 18 month period during which the principal investigator reduced expenditures on the project so as to retain the resources that would be needed to complete it when the managed care penetration data would be completed. As a result, approximately $12,000 in direct costs were lost, the amount the principal investigator had intended to use to complete the analysis. The principal investigator is continuing the study at a slower rate using the author's own resources.
Availability: Copies can be ordered from the NTIS, NTIS Order number: PB98-116676INM, at their Web site (Set link to: site, http://neptune.fedworld.gov/cgi-bin/waisgate?waisdocid=915431411+0+0+0&waisaction=retrieve) or by calling the NTIS sales desk at 1-800-553-6847 (703-605-6000).

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Current as of May 2001


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