Biomedical subjects
A F Coburn
Publications and source records attributed to A F Coburn.
Effects of changing Medicaid fees on physician participation and enrollee access.
This paper assesses the effects of Medicaid fee changes on physician participation, enrollee access, and shifts in the site of ambulatory care using several natural experiments in Maine and Michigan. We use Medicaid claims and enrollment data to measure these outcomes. The reimbursement changes included substantial percentage changes in fees, however the value of the Medicaid fee improvements relative to the private market eroded very rapidly in the months following the interventions. Although the fee increases did not improve the outcome measures, they might have prevented conditions from worsening.
Rural models for integrating primary care and mental health services.
This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models--diversification, linkage, referral and enhancement--which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.
Satisfaction with practice in a rural state: perceptions of nurse practitioners and nurse midwives.
Data from nurse practitioners and certified nurse midwives are used to explore contributions to primary care in a rural state and how regulatory restrictiveness and other factors affect satisfaction with practice (N = 151). Satisfaction is high, especially with home communities and professional aspects of work, including collaboration with physicians. However, many feel limited by regulations and are less satisfied, especially those with a master's degree and those in organizational versus office practice sites. Reducing restrictive regulations, reevaluating practice structures, and providing for full scope of practice and other incentives consistent with rising educational levels can increase access to care.
Urban-rural differences in employer-based health insurance coverage of workers.
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State-sponsored programs for the uninsured: is there adverse selection?
Risk contracting by states for coverage of previously uninsured populations has been hampered by uncertainty regarding likely claims experience. This study reports on the utilization experience of two state programs offering subsidized coverage in commercial managed care organizations to low-income and previously uninsured people. Program participants used services similarly to people enrolled through large employer benefit plans. There was no evidence of pent-up demand or an unusual level of chronic illness. Similarly, there was little evidence of underutilization, although dissatisfaction and reported barriers to service were more frequent among nonwhite enrollees.
Managerial responses to Medicaid prospective payment in the nursing home sector.
The United States must soon address long-term care policy. Policymakers have sought cost containment through reimbursement policies that contain incentives for efficiency. Nursing facility administrators were surveyed twice following a significant change in Maine's Medicaid reimbursement policy to determine the effects of the change on their managerial practices. The administrators responded to some of the policy changes as profit maximizers, including instituting cost controls and benefiting from incentives. In other areas, such as staffing, staff pay, and accepting heavy care patients, the administrators did not seem to behave entirely as expected. Insights from organizational theory are useful for explaining some of the other behaviors. As long-term care reform is undertaken, a policy framework should include aspects of the internal environment of nursing facilities, such as administrator goals and organizational structure and mission.
Legislative and policy strategies for supporting rural health network development: lessons from the 103rd Congress.
There was considerable support in most major health reform bills considered by the 103rd Congress for the development of rural integrated service networks. The demise of comprehensive health reform, together with the pace of current market-driven changes in the health care system, suggests the need to assess the impact of specific policy strategies considered in the last Congress on rural integrated service network development. Toward this end, this article evaluates the rural health policy strategies of the major bills in relation to three essential preconditions for the development of rural integrated service networks: (1) the need for a more stable financial base for rural providers; (2) the need for administrative, service and clinical capacity to mount a successful network; and finally, (3) the need for appropriate market areas to ensure fair competition among networks and plans. Key policy strategies for supporting rural network development include reform of insurance and payment policies, expansion of targeted support and technical assistance to the underserved, limited-capacity rural areas, and policies governing purchasing groups or alliances that will ensure appropriate treatment of rural providers and networks.
An expert panel approach to assessing the rural implications of health care reform: the case of the Health Security Act.
The policy arena is hungry for objective information regarding the potential effects of comprehensive national and state health care reform. Such information reduces the dependence of policy-makers on information generated solely by advocacy groups and serves as a checkpoint for such information. Unfortunately, the academic community is often unable to mobilize its resources quickly enough to help meet this information need. This article describes one model for overcoming this difficulty. When the time frame is especially short, academic expertise can be brought together in the form of an expert panel. However, for such an approach to be effective, it must be carefully configured and orchestrated. Critical ingredients include much preparatory groundwork, a well-defined framework and methodology for conducting the policy analysis, and a professional facilitator. The Rural Policy Research Institute used such an approach to analyze President Clinton's Health Security Act shortly after the initial blueprint was released (but before the legislative language was released). The consensus of the expert panel was that the Health Security Act would, on balance, represent an improvement over today's rural reality. However, a number of troubling aspects were noted. First, the Act's emphasis on primary care and nonphysician providers is a double-edged sword. While these are precisely the types of providers needed in rural areas, the short-run effect may be to create increased competition for such providers from urban areas.(ABSTRACT TRUNCATED AT 250 WORDS)
Effect of prospective reimbursement on nursing home costs.
OBJECTIVE: This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. DATA SOURCES/STUDY SETTING: The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. STUDY DESIGN: This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. PRINCIPAL FINDINGS: Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. CONCLUSIONS: Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems.
The effects of variations in AFDC and Medicaid eligibility on prenatal care use.
Despite substantial evidence linking improved pregnancy outcomes with receipt of prenatal care and recent improvements in prenatal care utilization, specific subpopulations continue to receive less than adequate care. The study reported here examined the effects on prenatal care utilization of differences among states in AFDC and Medicaid eligibility policies. The study was based on information obtained from birth certificates and a mailed questionnaire to stratified random samples of all women experiencing live births during specified periods in four states. States were selected to provide comparisons between two states with liberal AFDC and Medicaid eligibility standards--Wisconsin and Colorado--and two states--Maine and Texas--which had more restrictive standards at the time data were collected. Study findings generally indicate that more liberal AFDC/Medicaid eligibility standards improve the adequacy of prenatal care among low income women. They also suggest, however, that the often lengthy eligibility process may actually pose barriers to care.
Developing consumer-centered quality assurance strategies for home care. A case management model.
Despite a growing interest in home care quality assurance, models for effective quality assurance systems are in short supply. This article describes such a model, developed after a literature review; interviews with business leaders and with home care consumers and their families; and focus groups with consumers, case managers, and home health nurses. The Consumer-Centered, Negotiated Model for Home Care Quality integrates quality assurance into the case management process, focusing on the entire plan of care, not simply individual services. In this model, quality assurance is a regular and ongoing process, utilizing standards that are consumer-oriented, specific, and measurable.
Impact of the Maine Medicaid waiver for the mentally retarded.
To evaluate the impact of Maine's Medicaid waiver for the mentally retarded, baseline and 1-year followup data were obtained for 191 waiver clients and a comparison population of 115 persons excluded from the program because of enrollment limits. Program effectiveness was evaluated through measures of changes in clients' personal and community living skills. Medicaid and other data were used to establish individual and aggregate costs. It was found that the waiver program is a cost-effective alternative to intermediate care placements but that client screening is necessary to limit the enrollment of clients not at risk of institutional placement.
The impact of Medicaid reimbursement policy on subacute care in hospitals.
Concerns about the increasing cost of hospital care have directed policy attention to inappropriate hospital use and, in particular, to hospital patients awaiting long-term care (LTC) placement. In 1982, pursuant to changes in federal Medicare and Medicaid law, Maine implemented changes in Medicaid reimbursement policy for subacute patients designed to reduce hospital backups and corresponding Medicaid expenditures for unnecessary hospital care. This article evaluates the impact of this change in Medicaid hospital payment policy on the volume of subacute patient days and the length of subacute stays (LOS) in Maine. Although declines in Medicaid expenditures, total subacute days, and LOS of patients awaiting LTC placement were observed in the 1st year of the policy, study findings do not show a statistically significant impact of the policy on the length of patients' subacute stays. Patient diagnosis of mental and nervous system disorders and nursing home occupancy rates in the hospital service area were both significant predictors of subacute LOS. Study findings indicate that efforts to reduce hospital backups must address specific barriers to timely LTC placement, including shortages of institutional and noninstitutional LTC services, and the lack of financial incentives for LTC providers to accept heavier care patients.
The impact of prospective reimbursement on nursing home efficiency.
Data Envelopment Analysis (DEA) was used to estimate the relative efficiencies of nursing homes in Maine for 2 years before the introduction of a prospective payment system and for 2 years afterward. A multiple regression was performed in which the DEA-estimated efficiency was the dependent variable and a number of facility characteristics and study year were the independent variables. Study findings indicate that nursing home efficiency scores fell after the introduction of prospective reimbursement; that is, generally speaking, more inputs were being used per unit of output in the period after the introduction of prospective reimbursement than in the period preceding it. This may be the result of poor management, degraded quality of inputs, improved quality of outputs, or some other unobserved trend during this same period. The study also concludes that higher occupancy rates are associated with lower efficiencies and that patients in restraints produce severe negative effects on efficiency. In addition, it appears that a sudden increase in administrative hours in the final study year played a role in that year's lower average efficiency scores, but also that all input levels generally rose while output levels remained virtually constant.
Predictors of prenatal care utilization.
Despite substantial evidence linking improved pregnancy outcomes with receipt of prenatal care and recent improvements in prenatal care utilization, specific subpopulations continue to receive inadequate or less than adequate care. The study reported here examined the predictive power of a set of variables describing the type of financial coverage available to the mother, attributes of the mother, father and family and characteristics of the health care system. A stratified random sample of mothers was generated from state birth certificate files and surveyed through the use of a mailed questionnaire. Stratification was designed to assure adequate representation of subgroups expected to receive less adequate prenatal care. The study findings indicate that there were deficiencies in prenatal care utilization and that these deficiencies were concentrated in specific areas and subpopulations within the state. While the majority of women in the study started prenatal care in the recommended first trimester, most did not maintain the recommended schedule of visits with their care provider. The following conditions were found to reduce the likelihood of receiving adequate care after controlling for service need: younger women (particularly adolescents); less educated (particularly those without a high school education); low income; longer travel time; Medicaid recipient; and rural resident. In addition, it was found that where one lives is a significant predictor of the adequacy of prenatal care even after controlling for all of the above variables. The authors conclude that it is important in assessing potential policy and program options for reducing differentials in prenatal care use to distinguish between economic and noneconomic barriers to utilization. Receipt of Medicaid does not assure adequate prenatal care use.(ABSTRACT TRUNCATED AT 250 WORDS)
By design or default: U.S. health policy in the twenty-first century.
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The health of the chronically mentally ill: a review of the literature.
This paper reviews three areas of research on the health of the chronically mentally ill: epidemiological studies on this population, studies exploring the clinical interface of physical and psychiatric disorder, and studies illuminating barriers to adequate health care for this population. Its purpose is to increase our understanding of the unique health problems facing the chronically mentally ill so that appropriate interventions can be developed. The review suggests that greater attention to this area should result in improved physical health as well as improved psychiatric intervention. The implications for policy, practice, and research are discussed.