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Friedman, Bernard

Authors: Basu J, Friedman B, and Burstin H.
Title: Primary Care, HMO Enrollment and Hospitalization for ACS Conditions: A New Approach.
Publication: Med Care 40(12) 1260-69.
Date: 2002
Abstract: The study tests the association of primary care availability, HMO enrollment, and other person and location variables with potentially preventable hospitalization for adults in New York State, comparing preventable admissions to other types of admissions. The study population is all hospital stays of New York residents in the age group 20-64 hospitalized either in New York or in three contiguous states: New Jersey, Pennsylvania, or Connecticut using 1995 statewide discharge files from the Healthcare Cost and Utilization Project (HCUP) maintained by the Agency for Healthcare Research and Quality. A multinomial logit model uses the individual discharge as the unit of analysis. ACS admissions are compared with "marker" admissions (urgent but non-ACS), and "referral sensitive" surgeries (more discretionary), controlling for severity of illness. Higher primary care density was associated with a lower likelihood of ACS admission, compared with marker admissions, and without increasing referral-sensitive admissions. The study also supports the hypothesis of ACS admissions being less likely for private HMO enrollees than for other insured adults. This result was not found for Medicaid HMO enrollees, even by comparison to other Medicaid enrollees. A key policy-relevant result is the negative association of primary care physicians per capita with the likelihood of ACS admissions, without an offsetting association with resource costs via referral-sensitive admissions. This type of analysis could be strengthened in several ways for a defined population when better data on individual patients and several time periods are used.
Topics: Prevention, Access.

Authors: Friedman B., Devers K., Steiner C., Fox, S.
Title: The Use of Expensive Health Technologies in the Era of Managed Care: The Remarkable Case of Neonatal Intensive Care.
Publication: Journal of Health Politics, Policy and Law 27(3)441-64
Date: 2002.
Abstract: The use of neonatal intensive care (NIC) continued to rise rapidly in the 1990s despite the concerns of observers about cost-effectiveness of NIC in some cases and better outcomes in facilities with high volume and capabilities. The study tested the effects of insurance type, competition among hospitals, and market pressure from managed care plans on the supply and cost of NIC. Key findings are that the decision of a hospital to offer NIC was associated with teaching status, the proportion of infants in the market area with high documented risk, and the market concentration of major competitors. The market share of managed care plans, and the concentration of enrollment, was not associated with NIC being offered or the standardized charges. Whether a particular patient was admitted to a NICU depended on patient risk factors, whether a NICU was present, but not on payer group. The results are consistent with the hypothesis that young insured parents (with the advice of their obstetricians) prefer hospitals with NIC, and also are relatively profitable enrollees for health plans.
Topics: Children, Cost, Hospitals, Markets.

Authors: Friedman B, De La Mare J, Andrews R, McKenzie D.
Title: Estimating Hospital Cost for Discharged Patients—Practical Options in an Era of Data Restrictions.
Publication: Journal of Healthcare Finance 29(1):1-13.
Date: 2002.
Abstract: Analysts often estimate the cost of hospital services by applying cost/charge ratios from Federal or State data sources to the charges provided on hospital discharge records. Recently, a number of sources of discharge data are not permitting release of hospital identities. This study compares several sources of cost/charge data for use in the restricted environment. Accounting data from four State systems and from files of the federal Health Care Financing Administration (HCFA) are employed. In one analysis hospitals are grouped by selected characteristics. Cost/charge varies by state and characteristics. Some HCFA and State measures track each other closely. A wider analysis of hospital-specific data for 51 states offers a separate test and extension of the initial results. The study supports a practical policy option of releasing grouped cost/charge ratios attached to discharge records when identity must be masked.
Topics: Cost, Hospitals.

Authors: Friedman B., Basu J.
Title: Health Insurance, Primary Care, and Preventable Hospitalization of Children in a Large State.
Publication: American Journal of Managed Care 7(5):473-81.
Date: 2001
Abstract: The study analyzes variations of the admission rate to hospitals of children with ambulatory care-sensitive (ACS) conditions, testing the relationship to insurance coverage, HMO enrollment, availability of primary care, severity of illness, distance to hospital, and a number of other factors. Hypotheses are derived from basic considerations of demand and use of primary care and preventive services, and then tested with a weighted linear regression model of the ACS admission rate for children residing in each county of New York. The principal data are all hospital discharges for New York resident children admitted to hospitals in New York, Pennsylvania, New Jersey, or Connecticut in 1994. The data and methodology are noteworthy for including out-of-area hospital admissions. One key result is a substantial negative association of the ACS rate with private HMO coverage. There are also sizable negative effects of the availability of primary care services in physician offices and distance traveled. Large differences related to racial and ethnic composition of the population are found, independent of other determinants. There was a positive association with the proportion of admissions for all conditions covered by Medicaid or self-pay. Severity of illness and use of emergency departments were controlled. There was no independent effect of a location in New York City. The results are consistent with smaller-scale studies, suggesting that improved health insurance for children could reduce hospital admissions. Contracting with HMOs also appears to be attractive. Independently, programs to increase the availability of primary and preventive services could substantially reduce ACS admissions. Some disparities remain that deserve more detailed attention at a local level.
Topics: Children, Managed Care, Prevention.

Author: 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.
Topics: Children, Cost, Hospital, Managed Care, Public Policy.

Author: Friedman B.
Title: Excess capacity: Commentary on the evolution of analysis and policy.
Publication: Health Services Research 33(6):1669-82.
Date: 1999
Abstract: This article is a response to "Excess capacity: Markets, regulations, and values," written by Professor Carolyn Madden. Dr. Friedman formulates more carefully and augments Professor Madden's assessment of divergent viewpoints on the issues of excess bed capacity and costs in hospitals, as well as questions the evidence for her conclusions about changes in dominant conceptual frameworks.
Topics: Cost, Hospitals, Markets.
Availability: AHCPR Publication No. 99-R046 is available from the AHRQ Publications Clearinghouse.

Author: Friedman B, Jee J, Steiner C, et al.
Title: Tracking the State Children's Health Insurance Program with hospital data: National baselines, State variations, and some cautions.
Publication: Med Care Res Rev 56(4):440-55.
Date: 1999
Abstract: State and Federal agencies are concerned with the impact of the State Children's Health Insurance Program (SCHIP) on the health care of enrolled children. As part of a broad program evaluation, and at relatively low cost, analysts can track data on hospital admissions for ambulatory care sensitive (ACS) conditions. This article uses hospital data for 19 States to calculate baseline ACS rates and to discuss trends and cross-state variations just prior to the start of SCHIP. A few cautions and limitations are discussed. An unexpected result in the explorations was a substantial increase in the rate of ACS admissions for self-pay and Medicaid-enrolled children during the period of 1990-95. During that same period, the admission rate for other insured children fell by more than a third. The comparisons across States are meant to be illustrative; they do reveal a relationship between the rate of asthma admissions and the proportion of self-pay plus Medicaid-enrolled cases.
Topics: Children, Hospitals, Insurance, Medicaid, Prevention.
Availability: AHRQ Publication No. 00-R009 is available from the AHRQ Publications Clearinghouse.

Author: Friedman B, Steiner C.
Title: Does managed care affect the supply and use of ICU services?
Publication: Inquiry 1999 Spring;(36):68-77.
Date: 1999
Abstract: In two States that differ greatly in hospital ownership and history of regulation, we find that the services per ICU user are less for managed care patients than for other privately insured. In Massachusetts, the differences across payers disappear for hospitals where the total supply of ICU is low in relation to expected demand. In both States, admission to ICU is not significantly different between managed care and other privately insured.
Topics: Cost, Hospitals, Markets.
Availability: AHCPR Publication No. 99-R071 is available from the AHRQ Publications Clearinghouse.

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.

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.
Topics: Cost, Hospitals, Medical Decisionmaking, Public Policy.

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