Biomedical subjects

Edward C Norton

Publications and source records attributed to Edward C Norton.

At least 19 recordsLinked to original sources

PubMed2006

Medicare payment changes and nursing home quality: effects on long-stay residents.

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.

Aged↗

PubMed2006

Mechanisms through which drug, sex partner, and friendship network characteristics relate to risky needle use among high risk youth and young adults.

Drug injector social networks are a primary social space in which risky needle use behaviors associated with HIV transmission occur, but the mechanisms through which these social networks influence risky needle use are unclear. This study investigated two mechanisms, social support and social regulation, through which injection drug users' social networks might relate to risky needle use behaviors. We investigated how these mechanisms work in three types of social networks, namely, drug user, sex partner, and friendship networks. Data are from a study of HIV risk and protective behaviors of youth and young adults, ages 14-43, in the United States who were injection drug users and/or the sexual partners of users (N = 277). The three types of networks were constructed based on information respondents provided about their drug use partners, sexual partners, and friends. The networks were characterized by structural (i.e., size and density) and interactional (i.e., multiplexity and closeness) characteristics. We conducted tests for mediation using ordered probit models and multiple linear regression. In the drug networks, social regulation partially meditated the relationship between multiplexity and risky needle use (p<.10). In the sex partner networks, emotional support partially mediated the relationship between network size and risky needle use (p<.001), fully mediated the relationship between network closeness and risky needle use (p<.001), and partially mediated the relationship between multiplexity and risky needle use (p<.01). Mediators were not identified in the friendship networks. The findings demonstrate that network mechanisms explaining risky needle use differ for drug user and sex partner networks in ways consistent with the functional nature of each type of network tie.

Adolescent↗

PubMed2006

Transitions between the public mental health system and jail for persons with severe mental illness: a Markov analysis.

Proposed changes to the mental health care system are usually debated in terms of either health benefits or costs savings. However, because of the extensive intersection between the mental health system and the criminal justice system, changes in the organization and financing of mental health services may change the jail detention rate. We analyze jail incarcerations for felonies and non-felonies following the start of a public managed mental health care program in King County, Washington (including Seattle). We analyze unique data that tracks individuals in and out of the public mental health, Medicaid, and criminal justice systems for 1993-1998. In this manuscript we examine individuals with severe mental illness who were enrolled in the Washington state Medicaid program. The final sample size has monthly observations on 6766 unique individuals aged 18-64. We estimate Markov models of the monthly transition probabilities among living in the community with no public mental health treatment, receiving inpatient or outpatient mental health or substance abuse services, or being in jail for either a felony or non-felony charge. The transition probabilities are adjusted for demographics and policy changes that occurred during our study period. There is little evidence of any change in the jail detention rate for severely mentally ill users of the county mental health system in contrast with other SMI individuals following the public managed care program.

Acute Disease↗

PubMed2006

OBRA 1987 and the quality of nursing home care.

Because minimum government standards for quality regulate only part of the market failure, they may have unintended effects. We present a general theory of how government regulation of quality of care may affect different market segments, and test the hypotheses for the nursing home market. OBRA 1987 was a sweeping government reform to improve the quality of nursing home care. We study how the effect of OBRA on the quality of nursing home care, measured by resident outcomes, varied with nursing home profitability. Using a semi-parametric method to control for the endogenous effects of regulation, we found that this landmark legislation had a negative effect on the quality of care in less profitable nursing homes, but improved the quality in more profitable nursing homes during the initial period after OBRA. But, this legislation had no statistically significant effect in the later period when the regulation was weakly enforced.

Aged↗

PubMed2006

Medicare prospective payment and quality of care for long-stay nursing facility residents.

BACKGROUND: The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities and also cut per-diem rates. Previous studies have found effects on facility-wide staffing but not on quality for short-stay residents. Because facilities may combine revenue streams to be used where needed, spillover effects on quality of care for long-stay residents are possible. OBJECTIVE: We sought to investigate effects of financial pressures from Medicare payment changes on quality of care for long-stay residents. METHODS: We investigated the effect of Medicare's Prospective Payment System for skilled nursing facilities on incidence of urinary tract infections and pressure sores among long-stay residents while controlling for resident severity. We conducted panel data analysis of nursing home residents in Ohio, Kansas, Maine, Mississippi, and South Dakota using Minimum Data Set data from 1995 to 2000. Each facility's Medicare dependence was used to separate effects of the policy from underlying industry trends. RESULTS: The probability of developing a urinary tract infection or pressure sore increased significantly among long-stay residents after Medicare's prospective payment system was implemented. Effects were roughly proportional to the percent of residents in a facility covered by Medicare. CONCLUSIONS: Although Medicare prospective payment and rate cuts were directly applicable only to Medicare (largely short-stay) residents in skilled nursing facilities, the resulting financial pressures lowered the quality of care experienced by long-stay residents, as measured by the likelihood of adverse outcomes. The observed quality decreases were likely due to decreases in nurse staffing prompted by the payment reductions.

Humans↗

PubMed2005

Equal division of estates and the exchange motive.

Although the bequest motive is one of the most important theoretical extensions of the life-cycle hypothesis, few empirical studies have measured determinants of unequal estate division. We estimated whether several proxies that are consistent with exchange and altruism lead to unequal estate division using data from a longitudinal survey of deceased elderly persons linked to probate court records. Equal division was the rule-between 70 and 83% of estates were divided equally, depending on the strictness of the definition of equal division. Several measures of exchange were not significant predictors of unequal division. Two factors that are consistent with both exchange and altruism- writing the last will and testament within five years of death and having more children-predict unequal estate division. The models control for selection, because many decedents do not file a record in probate court.

Aged↗

PubMed2004

Time to include time to death? The future of health care expenditure predictions.

Government projections of future health care expenditures--a great concern given the aging baby-boom generation--are based on econometric regressions that control explicitly for age but do not control for end-of-life expenditures. Because expenditures increase dramatically on average at the end of life, predictions of future cost distributions based on regressions that omit time to death as an explanatory variable will be biased upward (or, more explicitly, the coefficients on age will be biased upward) if technology or other social factors continue to prolong life. Although health care expenditure predictions for a current sample will not be biased, predictions for future cohorts with greater longevity will be biased upwards, and the magnitude of the bias will increase as the expected longevity increases. We explore the empirical implications of incorporating time to death in longitudinal models of health expenditures for the purpose of predicting future expenditures. Predictions from a simple model that excludes time to death and uses current life tables are 9% higher than from an expanded model controlling for time to death. The bias increases to 15% when using projected life tables for 2020. The predicted differences between the models are sufficient to justify reassessment of the value of inclusion of time to death in models for predicting health care expenditures.

Aged↗

PubMed2004

Effect of drive-through delivery laws on postpartum length of stay and hospital charges.

Postpartum hospital length of stay fell rapidly during the 1980s and 1990s, perhaps due to increased managed care penetration. In response, 32 states enacted early postpartum discharge laws between 1995 and 1997, and a federal law took effect in 1998. We analyze how these laws changed length of stay and hospital charges, using a national discharge database. Difference-in-differences models show that the laws increased both length of stay and hospital charges, but the magnitude of this effect is much smaller than has been estimated in previously reported case studies. Furthermore, we find that effects vary by law details, that ERISA diluted the law effects, and that law effects partially spilled over to unregulated Medicaid births.

Employee Retirement Income Security Act↗

PubMed2004

Informal care and health care use of older adults.

Informal care by adult children is a common form of long-term care for older adults and can reduce medical expenditures if it substitutes for formal care. We address how informal care by all children affects formal care, which is critically important given demographic trends and the many policies proposed to promote informal care. We examine the 1998 Health and Retirement Survey (HRS) and 1995 Asset and Health Dynamics Among the Oldest-Old Panel Survey (AHEAD) using two-part utilization models. Instrumental variables (IV) estimation controls for the simultaneity of informal and formal care. Informal care reduces home health care use and delays nursing home entry.

Aged↗

PubMed2004

Effects of Medicare payment changes on nursing home staffing and deficiencies.

OBJECTIVE: To investigate the effects of Medicare's Prospective Payment System (PPS) for skilled nursing facilities (SNFs) and associated rate changes on quality of care as represented by staffing ratios and regulatory deficiencies. DATA SOURCES: Online Survey, Certification and Reporting (OSCAR) data from 1996-2000 were linked with Area Resource File (ARF) and Medicare Cost Report data to form a panel dataset. STUDY DESIGN: A difference-in-differences model was used to assess effects of the PPS and the BBRA (Balanced Budget Refinement Act) on staffing and deficiencies, a design that allows the separation of the effects of the policies from general trends. Ordinary least squares and negative binomial models were used. DATA COLLECTION METHODS: The OSCAR and Medicare Cost Report data are self-reported by nursing facilities; ARF data are publicly available. Data were linked by provider ID and county. PRINCIPAL FINDINGS: We find that professional staffing decreased and regulatory deficiencies increased with PPS, and that both effects were mitigated with the BBRA rate increases. The effects appear to increase with the percent of Medicare residents in the facility except, in some cases, at the highest percentage of Medicare. The findings on staffing are statistically significant. The effects on deficiencies, though exhibiting consistent signs and magnitudes with the staffing results, are largely insignificant. CONCLUSIONS: Medicare's PPS system and associated rate cuts for SNFs have had a negative effect on staffing and regulatory compliance. Further research is necessary to determine whether these changes are associated with worse outcomes. Findings from this investigation could help guide policy modifications that support the provision of quality nursing home care.

Aged↗

PubMed2004

Influenza and pneumococcal vaccination demand responses to changes in infectious disease mortality.

OBJECTIVE: To test the hypothesis that individuals are more likely to receive a vaccination against influenza or pneumonia as the perceived disease threat increases. DATA SOURCES: This study uses two different national datasets. Individual-level information about the vaccination rates of 38,768 elderly persons are from the Behavioral Risk Factor Surveillance System, 1993-1998. Information on the combined influenza and pneumonia state mortality rates are measured from the Compressed Mortality File. STUDY DESIGN: Using both cross-sectional and state fixed-effects panel data estimators, we model an individual's probability of having an influenza or pneumococcal vaccination as a function of the lagged state mortality rate. Multiyear lags are specified in order to estimate the duration of the effect of disease mortality on individual vaccination behavior. PRINCIPAL FINDINGS: Results support our hypothesis that influenza vaccination behavior responds positively to disease mortality, even after a one-year lag. We further find that cross-sectional estimators used in previous work yield downward-biased estimates, although even for our preferred panel data models, the estimated effects are small. CONCLUSIONS: The findings indicate that behavioral demand responses can help to limit infectious disease epidemics, and suggest further research on how public awareness campaigns can mediate this disease threat responsiveness behavior.

Aged↗

PubMed2004

Cost shifting to jails after a change to managed mental health care.

OBJECTIVE: To determine whether managed mental health care for Medicaid enrollees in King County, Washington, has led to indirect cost-shifting to substitute treatments, such as jails and state mental hospitals that are free goods to providers. DATA SOURCES: Complete service records for 47,300 adults who used at least one of the following systems from 1993 to 1998: King County jail system, Medicaid, or the King County mental health system. Data were also obtained from the Washington State Hospital System. STUDY DESIGN: A quasi-experimental analysis that compares the difference in outcomes between the pre- and post-managed care periods for Medicaid enrollees compared to non-Medicaid enrollees. The outcomes-jail costs, state hospital costs, and county outpatient mental health costs-were estimated with two-part difference-in-differences models. The regressions control for person-level fixed effects on up to 66 months of data per person. DATA COLLECTION METHODS: Administrative data were collected from the jail, Medicaid, and mental health systems, then merged and cleaned. Additional data on costs were obtained in interviews. PRINCIPAL FINDINGS: There is a striking increase in the probability of jail use for persons on Medicaid following the introduction of managed care. There was a significant decrease in expenditures in the county mental health system for outpatient care. CONCLUSIONS: Managed care led to indirect cost-shifting, probably through poor access to services, which may have led to an increased probability of jail detention.

Adult↗

PubMed2004

The effects of the Women, Infants, and Children's Supplemental Food Program on dentally related Medicaid expenditures.

OBJECTIVE: This study estimates the effects of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on dentally related Medicaid expenditures for young children. METHODS: We used a five-year cohort study design to compare dentally related Medicaid expenditures for children enrolled in WIC versus those not enrolled for each year of life up to age 5 years. There were 49,795 children born in North Carolina in 1992 who met the inclusion criteria for the study. Their birth records were linked to Medicaid enrollment and claims files, WIC master files, and the Area Resource File. Our analysis strategy included a logit and OLS two-part model with CPI dollar adjustments. RESULTS: Children who participated in WIC at ages 1 and 2 years had significantly less dentally related expenditures than those who did not participate. WIC participation at age 3 years did not have a significant effect. Fewer WIC children received dental care under general anesthesia than non-WIC children. CONCLUSIONS: The WIC program has the potential for decreasing dentally related costs to the Medicaid program, while increasing use of dental services.

Adult↗

PubMed2004

Effects of WIC participation on children's use of oral health services.

OBJECTIVES: We estimated the effects of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on dental services use by Medicaid children in North Carolina. METHODS: We used linked Medicaid claims and enrollment files, WIC files, and the area resource file to compare dental services use for children enrolled in WIC with those not enrolled. We used multivariate models that controlled for child clustering and employed 2-step methodology to control for selection bias. RESULTS: Children who participated in WIC had an increased probability of having a dental visit, were more likely to use preventive and restorative services, and were less likely to use emergency services. CONCLUSIONS: Children's WIC participation improved access to dental care services that should lead to improved oral health.

Aid to Families with Dependent Children↗

PubMed2003

How measures of perception from survey data lead to inconsistent regression results: evidence from adolescent and peer substance use.

In studies of peer group behavior, the direct measure of peer group behavior is often not available, and so is replaced by perceptions from survey respondents. This study shows that regression estimators are inconsistent when the correctly measured independent variable of group behavior is replaced with perceived measures from survey respondents. The inconsistency is due to three sources: projection of own behavior onto the group, rescaling the marginal effect of the group, and simple random measurement error. We discuss why each effect may cause inconsistency, derive formulas for the probability limit to quantify their effects, and illustrate with three examples of adolescent smoking and drinking.

Adolescent↗

PubMed2003

Longevity and health care expenditures: the real reasons older people spend more.

OBJECTIVES: In this study, we investigated the relative contributions of both age and time to death to health care expenditures for elderly Medicare beneficiaries. We also analyzed differences in expenditure patterns by age and time to death for various service types and payers. METHODS: We conducted graphical analysis of person-month level data on 25,994 elderly persons from the 1992-1998 Medicare Current Beneficiary Survey Cost and Use files. RESULTS: Monthly health care expenditures for elderly people increase substantially with age primarily because mortality rates increase with age and health care expenditures increase with closeness to death. Time to death is the main reason for higher inpatient care expenditures, whereas aging is the main reason for higher long-term care expenditure. DISCUSSION: Both increases in the absolute number of elderly persons and in their longevity will increase future Medicare expenditures. Yet, the expected increase in per person health care expenditures caused by greater longevity of Medicare beneficiaries will be less than expected because of the concentration of expenditures at the end of life rather than during extra years of a relatively healthy life. The latter conclusion may be altered, however, because of other underlying considerations, such as technological change.

Age Factors↗

PubMed2003

Understanding biased selection in Medicare HMOs.

OBJECTIVE: To investigate the extent of favorable health maintenance organization (HMO) selection for a longitudinal cohort of Medicare beneficiaries, examine whether the extent of favorable selection varies with the degree of Medicare HMO market penetration in a county, and explain conflicting findings in the literature on favorable HMO selection. DATA SOURCES: A panel of 1992-1996 data from the Medicare Current Beneficiary Survey (MCBS), supplemented with linked data from the Area Resource File and Medicare administrative datasets. STUDY DESIGN: Using random effects probit estimation, we model a beneficiary's HMO enrollment status as a function of self-reported health status and Medicare HMO market penetration. DATA EXTRACTION METHODS: The MCBS data for beneficiaries residing in states served by Medicare HMOs in 1992-1996 were linked by county to the supplementary datasets. PRINCIPAL FINDINGS: We find that favorable selection persists in the cohort over time on some, but not all, measures. We find no substantial association between favorable HMO selection and HMO market penetration. We find that conflicting findings in the literature on favorable HMO selection may be explained by several methodological choices, including the choice of health status measure and the structure of the sample. CONCLUSIONS: Our results support further risk adjustment of the adjusted average per capita cost (AAPCC) payment formula.

Aged↗

PubMed2003

Medicare maximization by state Medicaid programs: effects on Medicare home care utilization.

Medicaid programs in some states have attempted to shift home health care costs to Medicare by using retrospective billing practices. The authors explored whether retrospective billing practices increase Medicare utilization for dual eligibles by analyzing primary data on the existence of retrospective billing practices collected from 47 state Medicaid offices complemented with individual-level secondary data from the 1992-1997 Medicare Current Beneficiary Survey. An individual-level random effects model was used to estimate the increase in the probability and amount of Medicare home care visits from state retrospective billing practices. Retrospective billing practices were found not to affect either the probability or the amount of Medicare home care visits in these data, but the significant inverse relationship found between Medicaid and Medicare visits shows that states with high Medicaid utilization have opportunity to shift some of these visits to Medicare.

Adolescent↗