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Biomedical subjects

L M Nichols

Publications and source records attributed to L M Nichols.

At least 19 recordsLinked to original sources
PubMed1998

Nonprofit conversion: theory, evidence, and state policy options.

OBJECTIVE: To describe the contributions of nonprofit hospitals and health plans to healthcare markets and to analyze state policy options with regard to the conversion of nonprofits to for-profit status. DATA SOURCES/STUDY SETTING: Secondary national and state data from a variety of sources, 1980-present. STUDY DESIGN: Policy analysis. DATA COLLECTION/EXTRACTION METHODS: Development of a conceptual economic framework; analysis of empirical, legal, and theoretical literature; and review of statutes, rules, and court decisions. PRINCIPAL FINDINGS: Three main rationales support special status for nonprofits, especially hospitals: charity care, other community benefits, and consumer protection. The main social rationale for for-profits is their incentives for better efficiency. There are reasons to expect that nonprofit and for-profit goals differ; however, measured differences in community hospital cost, prices, and quality between nonprofit and for-profit hospitals are undetectable or inconclusive. Nonprofit hospitals do provide more uncompensated care than for-profit hospitals. Similarities between nonprofit and for-profit hospitals may exist because nonprofits may set norms that for-profits follow to some degree. States have substantial power and discretion in overseeing nonprofit conversions. Some have regularized oversight through new legislation that constrains, but does not eliminate, state officials' discretion. These statutes may be deferential to converting entities and their buyers or may be very restrictive of them. CONCLUSIONS: Overseeing the appropriate disposition of nonprofit assets in individual conversions is extremely important. States should also monitor local market conditions through community benefits assessments and other data collection, however, to accurately assess (and possibly redress) what is lost or gained from conversion. Local market conditions are likely more important in determining hospital behavior than ownership form. Potentially, a mix of for-profit and nonprofit hospitals in a given market may improve market performance due to constraints the two ownership types may exercise over one another. If nonprofits disappear, the states may need to maintain quality and access norms through regulation.

Community-Institutional Relations↗
PubMed1997

The resurgence of selective contracting restrictions.

As managed care has spread, so has legislation to force plans to contract with any willing provider (AWP) and give patients freedom of choice (FOC). Managed care organizations' selective networks and provider integration reduce patient access to providers, along with provider access to paying patients, so many providers have lobbied for AWP-FOC laws. In opposition are managed care organizations (MCOs), which want full freedom to contract selectively to control prices and utilization. This article comprehensively describes laws in all fifty-one jurisdictions, classifies their relative strength, and assesses the implications of the laws. Most are relatively weak forms and all are limited in application by ERISA and the federal HMO Act. The article also uses an associative multivariate analysis to relate the selective contracting environments to HMO penetration rates, rural population, physician density, and other variables. States with weak laws also have higher HMO penetration and higher physician density, but smaller rural populations. We conclude that the strongest laws overly restrict the management of care, to the likely detriment of cost control. But where market power is rapidly concentrating, not restricting selective contracting could diminish long-term competition and patient access to care. In the face of uncertainty about the impact of these laws, an intermediate approach may be better than all or nothing. States should consider mandating that plans offer point-of-service options, for a separate premium. This option expands patient choice of plans at the time of enrollment and of providers at the time of care, yet maintains plans' ability to control core providers.

Community Participation↗
PubMed1997

Winners and losers under medical savings accounts.

As legislators wait to see how the MSA approach to health care reform plays out in the laboratory of the states, authors Marilyn Moon, Len M. Nichols and Susan Wall have put the numbers to work. The researchers simulated the effects of introducing MSAs into the health insurance market. What they found is what critics of MSAs suspected: As the young and healthy shift to MSAs, the premiums for those left in the remaining insurance pool will escalate. However, the authors conclude that if you are male, young and healthy, you stand to gain a lot from the MSA experiment.

Cost Sharing↗
PubMed1996

First, do no harm: developing health insurance market reform packages.

Health insurance reform is complex, and discussions about preferred reforms are often marked by confusion. This paper focuses on the fundamental issue: how best to address adverse selection. We develop four reform packages that could improve insurance market performance without aggravating risk selection problems. We then compare the principles applied in our packages with two specific proposals that formed the basis for the compromise federal legislation passed in August 1996. We also review the evidence to date on the effects of small-group reforms on health insurance markets in various states, and conclude with suggestions for further research.

Health Care Reform↗
PubMed1996

Patient choice of physician: do health insurance and physician characteristics matter?

Generous health insurance coverage is widely believed to have contributed to both high and rising health care costs. This paper tests the hypothesis that better insured patients will demand higher "quality" by choosing more often to visit specialists rather than generalist physicians. We model the conditional decision to seek care from a specialist physician as a function of health insurance status, physician characteristics, and other socioeconomic factors. Analysis of data from the 1987 National Medical Expenditure Survey and the American Medical Association suggests that the presence of insurance coverage does not affect choice of physician. The results do show that people enrolled in health maintenance organizations (HMOs) see specialists less often than other patients.

Adolescent↗
PubMed1994

A mutation in ribosomal protein L9 affects ribosomal hopping during translation of gene 60 from bacteriophage T4.

Ribosomes hop over a 50-nt coding gap during translation of gene 60 mRNA from bacteriophage T4. This event occurs with near-unitary efficiency when gene 60-lacZ fusions are expressed in Escherichia coli. One of the components necessary for this hop is an RNA hairpin structure containing the 5' junction of the 50-nt coding gap. A mutant E. coli was isolated and found to significantly increase hopping when carrying gene 60-lacZ constructs with altered hairpins. The mutation, hop-1, changed Ser93 to Phe in rplI, the gene coding for ribosomal large-subunit protein L9. Ribosomal hopping on a synthetic sequence in the absence of a hairpin was also increased by this mutation. These data suggest that hop-1 may substitute for the function of the hairpin during ribosomal hopping.

Amino Acid Sequence↗
PubMed1994

Financing, estimation, and economic effects.

Health reform is necessary to strengthen our economy and to ensure long-run federal deficit reduction. Comprehensive reform such as that proposed by President Bill Clinton is ambitious but may be the only way to guarantee universal coverage and deficit reduction in this decade. This paper describes the sources and uses of federal funds and the methodologies used to derive the administration's estimates. In addition, the paper briefly analyzes the economic effects of an employer mandate and other dimensions of the Health Security Act.

Cost-Benefit Analysis↗
PubMed1991

The signal for a leaky UAG stop codon in several plant viruses includes the two downstream codons.

Expression of the RNA replicase domain of tobacco mosaic virus (TMV) and certain protein-coding regions in other plant viruses, is mediated by translational readthrough of a leaky UAG stop codon. It has been proposed that normal tobacco tyrosine tRNAs are able to read the UAG codon of TMV by non-conventional base-pairing but recent findings that stop codons can also be bypassed as a result of extended translocational shifts (tRNA hopping) have encouraged a re-examination. In light of the alternatives, we investigated the sequences flanking the leaky UAG codon using an in vivo assay in which bypass of the stop codon is coupled to the transient expression of beta-glucuronidase (GUS) reporter genes in tobacco protoplasts. Analysis of GUS constructions in which codons flanking the stop were altered allowed definition of the minimal sequence required for read through as UAG-CAA-UUA. The effects of all possible single-base mutations in the codons flanking the stop indicated that 3' contexts of the form CAR-YYA confer leakiness and that the 3' context permits read through of UAA and UGA stop codons as well as UAG. Our studies demonstrate a major role for the 3' context in the read through process and do not support a model in which teh UAG is bypassed exclusively as a result of anticodon-codon interactions. No evidence for tRNA hopping was obtained. The 3' context apparently represents a unique sequence element that affects translation termination.

Base Composition↗
PubMed1990

Analysis of leaky viral translation termination codons in vivo by transient expression of improved beta-glucuronidase vectors.

Plant RNA viruses commonly exploit leaky translation termination signals in order to express internal protein coding regions. As a first step to elucidate the mechanism(s) by which ribosomes bypass leaky stop codons in vivo, we have devised a system in which readthrough is coupled to the transient expression of beta-glucuronidase (GUS) in tobacco protoplasts. GUS vectors that contain the stop codons and surrounding nucleotides from the readthrough regions of several different RNA viruses were constructed and the plasmids were tested for the ability to direct transient GUS expression. These studies indicated that ribosomes bypass the leaky termination sites at efficiencies ranging from essentially 0 to ca. 5% depending upon the viral sequence. The results suggest that the efficiency of readthrough is determined by the sequence surrounding the stop codon. We describe improved GUS expression vectors and optimized transfection conditions which made it possible to assay low-level translational events.

Base Sequence↗
PubMedDate not supplied

Worker decisions to purchase health insurance.

Studying worker health insurance choices is usually limited by the absence of price data for workers who decline their employer's offer. This paper uses a new Medical Expenditure Panel Survey file which links household and employer survey respondents, supplying data for both employer insurance takers and declines. We test for whether out-of-pocket or total premium better explains worker behavior, estimate price elasticities with observed prices and with imputed prices, and test for worker sorting among jobs with and without health insurance. We find that out-of-pocket price dominates, that there is some upward bias from estimating elasticities with imputed premiums rather than observed premiums, and that workers do sort among jobs but this does not affect elasticity estimates appreciably. Like earlier studies with less representative worker samples, we find worker price elasticity of demand to be quite low. This suggests that any premium subsidies must be large to elicit much change in worker take-up behavior.

Adult↗
PubMedDate not supplied

A different kind of 'new federalism'? The Health Insurance Portability and Accountability Act of 1996.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 has been praised and criticized for asserting federal authority to regulate health insurance. We review the history of federalism and insurance regulation and find that HIPAA is less of a departure from traditional federal authority than it is an application of existing tools to meet evolving health policy goals. This interpretation could clarify future health policy debates about appropriate federal and state responsibilities. We also report on the insurance environments and the HIPAA implementation choices of thirteen states. We conclude with criteria for judging the success of HIPAA and the evolving federal/state partnership in health insurance regulation.

Career Mobility↗
PubMedDate not supplied

Who really wants price competition in Medicare managed care?

There is much policy talk about making Medicare more competitive, like private markets. But when reform proposals near implementation, local opponents of competition are often able to stop reform experiments. This paper reports on one recent example, the Competitive Pricing Advisory Committee, created by the 1997 Balanced Budget Act (BBA) to bring competitive bidding to Medicare + Choice plans. After design and site-selection choices were announced, members representing local interests were able to delay and perhaps kill competitive bidding before it could start, once again. A public report of this story may save future market-based Medicare reforms from a similar fate.

Budgets↗
PubMedDate not supplied

The health status of workers who decline employer-sponsored insurance.

This paper uses data from the 1997 National Health Interview Survey to compare workers who decline employers' offers of health insurance (decliners) with comparison groups of workers who take up offers of employer coverage and those who do not have such offers. Uninsured decliners fare much worse than coverage takers on every mental health measure. While the evidence on physical health measures is somewhat mixed, decliners who are not healthy appear to have greater difficulty obtaining needed services than do workers who take up employer coverage, although decliners tend to have somewhat better access than do the uninsured who are not offered such coverage.

Adolescent↗