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Biomedical subjects

J Holahan

Publications and source records attributed to J Holahan.

At least 19 recordsLinked to original sources
PubMed1995

Insuring the poor through Section 1115 Medicaid waivers.

With the demise of health care reform at the national level, much of the attention has shifted to state-level efforts. Recently, several states have begun looking to the Medicaid program as a way to solve their health care problems. A principal way in which states are implementing health care reform is through the Section 1115 research and demonstration Medicaid waiver program. The 1115 waiver authority provides states considerable flexibility to restructure their Medicaid programs to offer health care to new populations and thus has great potential for covering large segments of the uninsured population. While it shows great promise, however, there are many obstacles states must overcome both in implementing and in maintaining an 1115 program.

Eligibility Determination↗
PubMed1995

A shifting picture of health insurance coverage.

Data from the Current Population Survey are used in this DataWatch to explore the changing composition of health insurance coverage of the U.S. nonelderly population. The authors analyze coverage trends across various subpopulations for 1988-1993. During this time significant declines in employer-sponsored coverage coincided with equally significant increases in Medicaid coverage. Thus, the increase in the proportion of nonelderly persons without health insurance appears relatively small. However, this analysis reveals that the relative stability of the uninsurance rate for the entire nonelderly population belies more significant changes in insurance coverage--and lack of coverage--among various groups. The authors also discuss the extent to which a growing level of public insurance "crowds out" (or substitutes for) private health insurance.

Adolescent↗
PubMed1994

State responses to the Medicaid spending crisis: 1988 to 1992.

In recent years the growth of Medicaid spending has been a serious state budgetary problem. Between 1988 and 1992, state Medicaid expenditures increased at an average annual rate of 21 percent. Even when accounting for funds from special revenue programs, such as provider tax and donation programs, state Medicaid spending increased by 16 percent each year between 1988 and 1992, which is far higher than in previous years. This rapid expenditure growth occurred when states were having economic slowdowns and facing fiscal pressures in many other areas. Using a case study approach, we investigated the strategies used by nine states to address the recent surge in Medicaid spending. Despite fiscal pressures, the states generally avoided large-scale cutbacks in Medicaid. Instead they implemented a wide range of budgetary actions to reduce the effect of Medicaid growth, including increment program cutbacks, constraining other budgetary sectors, shifting program costs to the federal government, and raising state taxes.

Budgets↗
PubMed1994

Strategies for implementing global budgets.

Implementing global budgets requires setting a desired level of spending as well as establishing a set of policies to assure the budget will be met. Four alternative approaches are analyzed: one relies on all-payer rate setting coupled with volume controls; the second is a system of premium regulation that controls both the levels and rates of insurance premium increase; in another system, price competition among insuring organizations limits growth in spending while incorporating a global budget that limits the aggregate costs of all premiums; finally, either managed competition or premium regulation is combined with all-payer rate setting. The fourth model is singled out for its ability to control costs. An independent policy toward capital expenditures could increase the likelihood of success under any of the strategies.

Budgets↗
PubMed1993

Measuring prices of Medicare physician services.

This study develops two sets of price indices for Medicare physician services. The first measures price changes, and the second measures geographic price differentials. The indices can be used to adjust Medicare physician spending data to examine growth or variations in the volume and intensity of services. In both instances, it is necessary to apply an index form that reflects both the rapid changes and variability in the mix of physician services received by Medicare beneficiaries and their relative importance. This suggests that an index based on a fixed basket of services (e.g., a Laspeyres index) can produce a biased measure of price. An alternative methodology based on the Fisher's Ideal Index form was used. This index allows service weights to vary over time and across areas. In the case of price change, the index is "chained" to acknowledge the introduction of new services over several years. It is concluded that the Fisher's Ideal approach is essential for cross-sectional price comparisons, in light of the high variability in service mix across areas. In measuring price changes, it was found that "chaining" was more important empirically than allowing the relative importance of services to change between years. During the 1985-1989 study period, Medicare payment rates grew, on average, by 3.5% annually. This rate varied across both time and types of services as a result of differential fee updates and explicit pricing policies implemented by Medicare (e.g., reductions in payments for "overvalued" procedures). Cross-sectionally, our results show that 1988 fees in the highest-priced areas were more than 1.5 times those in the lowest-priced areas.

Abstracting and Indexing↗
PubMed1993

Explaining the recent growth in Medicaid spending.

Medicaid spending more than doubled from 1988 to 1992, reversing a long trend of cost containment in the program. Reasons for the cost explosion are severalfold. (1) Congress expanded eligibility to more children, pregnant women, and low-income elderly persons. (2) The recession has added more people to the Medicaid rolls. (3) Growing numbers of disabled cash assistance recipients have increased Medicaid enrollment. (4) States have increased their use of federal Medicaid funds to supplement previously state-funded programs and have become more skillful in leveraging federal funds to defray the cost of their Medicaid programs. This DataWatch explores the relative impact of enrollment changes, inflation, and increased reimbursement on the increase in Medicaid spending.

Cost Control↗
PubMed1993

The future of Medicare Volume Performance Standards.

A policy of Medicare Volume Performance Standards (MVPS) was established to control the rate of growth in Medicare physician spending. The standards control spending growth by lowering fee updates when spending exceeds a preset standard, or increasing updates when spending is below the standard. Separate standards are established for surgical and nonsurgical services. This paper examines the policy's weaknesses and proposes refinements that would enhance the equity of MVPS rewards and penalties, and therefore, the policy's long-term viability. Specifically, we suggest that MVPS policy permit differentials in standards across areas when utilization rates vary geographically and for some types of services when volume growth differs significantly.

Economics, Medical↗
PubMed1992

Measuring growth in the volume and intensity of Medicare physician services.

Congress adopted a policy of Volume Performance Standards that will adjust Medicare fees downward (or upward) in direct relation to the amount that spending exceeds (or falls below) a preset target. Using data from the 1985 through 1989 Medicare Part B Annual Data (BMAD), we show there are wide differences in the rate of growth in volume and intensity across types of services, specialties, and geographic areas. This suggests the current policy that bases adjustments on two national standards for surgical and nonsurgical services could lead to inequitable fee rewards and penalties. A greater number of targets based on more homogeneous service categories could reduce these inequities.

Cost Control↗
PubMed1992

Who pays for health care in the United States? Implications for health system reform.

This paper examines the distribution of health care spending and financing in the United States. We analyze the distribution of employer and employee contributions to health insurance, private nongroup health insurance purchases, out-of-pocket expenses, Medicaid benefits, uncompensated care, tax benefits due to the exemption of employer-paid health benefits, and taxes paid to finance Medicare, Medicaid, and the health benefit tax exclusion. All spending and financing burdens are distributed across the U.S. population using the Urban Institute's TRIM2 microsimulation model. We then examine the distributional effects of the U.S. health care system across income levels, family types, and regions of the country. The results show that health care spending increases with income. Spending for persons in the highest income deciles is about 60% above that of persons in the lowest decile. Nonetheless, the distribution of health care financing is regressive. When direct spending, employer contributions, tax benefits, and tax spending are all considered, the persons in the lowest income deciles devote nearly 20% of cash income to finance health care, compared with about 8% for persons in the highest income decile. We discuss how alternative health system reform approaches are likely to change the distribution of health spending and financing burdens.

Adult↗
PubMed1991

An American approach to health system reform.

In terms of the major objectives one would have for health system reform, this plan makes the following choices: 1. It would cover everyone, through Medicare (the elderly), employer-based coverage (some workers and dependents) or a state-level public program that would replace Medicaid (the poor, unemployed, and other workers and dependents). 2. There would be a standard minimum package of required benefits for employer-based and public programs, with legislative requirements on maximum cost-sharing. Choice of provider might be restricted in some states. 3. Administration of the private programs would be the responsibility, as now, of the employers and/or insurance companies. Administration of the public program would be the responsibility of the states, with the objective of maximizing responsiveness to local needs and conditions. 4. It would control costs through giving the states a substantial financial stake in ensuring that the public program costs did not grow faster than nominal GNP. State control would also allow the testing of different mechanisms for cost control, with the ultimate objective of identifying the most effective cost-containment strategies. 5. The cost would be borne by employers, employees, and taxpayers. Employers would be protected from exorbitant costs by being allowed the option of paying into a public plan rather than providing health insurance themselves. The poor and unemployed would be protected by having their coverage under the public program subsidized on a sliding scale. 6. The political feasibility test would be met by retaining a major role for insurance companies and by retaining the role of employer-based coverage--thus reducing the tax increase needed to ensure universal coverage. By allowing flexibility in design of cost-containment strategy, some of the controversy over this issue would also be deflected. Our proposal is also not without problems. First, our approach would still have adverse effects on the profitability of small businesses and on the employment prospects for low-wage workers--although these effects would be less than under conventional mandates and less than under proposals with higher tax rates. Second, some states may not want the responsibility we envision or have the capacity to carry it out. But several Canadian provinces are relatively small and are able to perform the same administrative functions within the Canadian national health system. In addition, since the federal government would continue to administer the Medicare program, states would have the option of tying their policies for hospital and physician payment and utilization control to those of Medicare.(ABSTRACT TRUNCATED AT 400 WORDS)

Canada↗
PubMed1991

Nursing home transfers and mean length of stay in the prospective payment era.

Under Medicare's Prospective Payment System (PPS), hospitals have incentives to discharge Medicare patients as quickly as medically feasible, but because of shortages of nursing home beds and differential long-term care arrangements, some hospitals may encounter difficulty placing patients in nursing homes, leading to hospital backup days. This study relied on Tobit and weighted least-squares analysis to examine the determinants of hospital mean length of stay and transfer rates to skilled and intermediate care homes for selected diagnosis-related groups (DRGs) with high levels of postacute service use. Hospitals in low bed supply areas were found to have proportionately fewer nursing home transfers and longer mean lengths of stay. Having swing beds or a long-term care unit led to speedier discharges and higher skilled nursing facility (SNF) transfers, especially for patients with hip or femur procedures or major joint and limb reattachment procedures (DRGs 209 and 210). The results suggest that Medicare should consider compensating hospitals for back-up days and that bundled payment experiments could reduce current inequities resulting from differential access to nursing home care.

Aged↗
PubMed1991

Has PPS increased Medicare expenditures on physicians?

We use data from 1983 and 1985 on the volume of Medicare physician services to analyze whether Medicare's Prospective Payment System (PPS), which resulted in a significant decline in hospital spending, led to a partially offsetting increase in real expenditures for physician services. We also analyze the effect of increases in assignment rates, increasing incomes of the elderly, and other factors on real expenditures during this period. Our main conclusion is that PPS has at most a small positive effect on real physician expenditures. Because people spent less time in the hospital, Medicare physician spending declined; but because of incentives to shift radiology and other services out of the hospital, some of this decline was offset. We also conclude that the sharp increase in Medicare assignment rates over this period, along with the rising incomes of the elderly during this period, contributed to the observed growth.

Aged↗
PubMed1990

The nursing home market and hospital discharge delays.

One way for hospitals to respond to the incentives in Medicare's PPS is to reduce the patients' length of stay by discharging to nursing home care those patients who no longer require hospital care but are not well enough to go home to informal care. In this study, we find that patients experience more discharge delays at hospitals located in areas with few nursing home beds and in states with prospective Medicaid nursing home reimbursement policies. Hospitals with their own nursing home units or swing beds experience earlier discharges, other things being equal. Our findings suggest that some hospitals are at a disadvantage compared with others and that a policy response may be warranted.

Costs and Cost Analysis↗
PubMed1990

Urban-rural differences in Medicare physician expenditures.

Policymakers have long been concerned with urban-rural disparities in access to health care. These disparities may be particularly severe in the case of the elderly and others covered by Medicare. Descriptive tables show that the total volume of physician services provided to rural beneficiaries is more than 40% lower than the volume of physician services provided to urban beneficiaries. This result is fairly consistent across all types of care and sites of care. In our econometric analysis, we investigate the factors that may explain these differences in utilization. The results indicate that, with prices held constant, variations in demographic and economic characteristics are not the major reasons for the urban-rural gap. Differences in hospital and physician (particularly specialist) availability appear to be the main factors.

Aged↗