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Biomedical subjects

S Woolhandler

Publications and source records attributed to S Woolhandler.

At least 19 recordsLinked to original sources
PubMed1997

Bound to gag.

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Commerce↗
PubMed1997

Costs of care and administration at for-profit and other hospitals in the United States.

BACKGROUND: In fiscal year 1990, administration accounted for 24.8 percent of total hospital costs in the United States - nearly twice the share in Canada. Studies from the 1970s and early 1980s found high costs, especially for administration, at for-profit hospitals. METHODS: We calculated administrative costs for 6227 nonfederal hospitals and the total costs of inpatient care for 5201 acute care hospitals in the United States for fiscal year 1994 on the basis of data the hospitals submitted to Medicare. We analyzed similar data for fiscal year 1990. Using multivariate analysis, we assessed the effect of hospital ownership (private not-for-profit, for-profit, and public) on administrative costs, controlling for hospital type, census region, hospital size, and the proportion of revenues derived from outpatient services. We adjusted inpatient costs for local wage levels, hospitals' reporting periods, and case mix. RESULTS: Administrative costs accounted for an average of 26.0 percent of total hospital costs in fiscal year 1994, up 1.2 percentage points from 1990. They increased by 2.2 percentage points, to 34.0 percent, for for-profit hospitals; by 1.2 percentage points, to 24.5 percent, for private not-for-profit hospitals; and by 0.6 percentage point, to 22.9 percent, for public hospitals. In 1994, administration accounted for 37.5 percent of total costs at psychiatric hospitals (44.4 percent at for-profit hospitals) and 33.0 percent of total costs at rehabilitation hospitals (37.7 percent at for-profit hospitals). In a multivariate analysis, for-profit ownership was associated with a 7.9 percent absolute (34 percent relative) increase in the proportion of hospital spending devoted to administration as compared with public hospitals and a 5.7 percent absolute (23 percent relative) increase as compared with private not-for-profit hospitals. Among acute care hospitals, for-profit institutions had higher adjusted costs per discharge ($8,115) than did private not-for-profit ($7,490) or public ($6,507) hospitals. Much of the difference was due to higher administrative costs ($2,289, $1,809, and $1,432 per discharge, respectively). CONCLUSIONS: Administrative costs as a percentage of total hospital costs increased in the United States between 1990 and 1994 and were particularly high at for-profit hospitals. Overall costs of care were also higher at for-profit hospitals.

Health Services Research↗
PubMed1996

TennCare.

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Health Care Reform↗
PubMed1996

US emergency department costs: no emergency.

BACKGROUND: Many perceive emergency department (ED) overuse as an important cause of high medical care costs in the United States. Managed care plans and politicians have seen constraints on ED use as an important element of cost control. METHODS: We measured ED-associated and other medical care costs, using the recently released 1987 National Medical Expenditure Survey of approximately 35,000 persons in 14,000 households representative of the US civilian, noninstitutionalized population. RESULTS: In 1987, total ED expenditures were $8.9 billion, or 1.9% of national health expenditures. People with health insurance represented 86% of the population and accounted for 88% of ED spending. The uninsured paid 47% of ED costs themselves; free care covered only 10%. For the uninsured, the cost of hospitalization initiated by ED visits totaled $3.3 billion, including $1.1 billion in free care. Whites accounted for 75% of total ED costs. The ED costs of poor and near-poor individuals accounted for only 0.47% of national health costs. CONCLUSIONS: ED use accounts for a small share of US medical care costs, and cost shifting to the insured to cover free ED care for the uninsured is modest. Constraining ED use cannot generate substantial cost savings but may penalize minorities and the poor, who receive much of their outpatient care in EDs.

Adolescent↗
PubMed1996

Who administers? Who cares? Medical administrative and clinical employment in the United States and Canada.

OBJECTIVES: We compared US and Canadian health administration costs using national medical care employment data for both countries. METHODS: Data from census surveys on hospital, nursing home, and outpatient employment in the United States (1968 to 1993) and Canada (1971 and 1986) were analyzed. RESULTS: Between 1968 and 1993, US medical care employment grew from 3.976 to 10.308 million full-time equivalents. Administration grew from 0.719 to 2.792 million full-time equivalents, or from 18.1% to 27.1% of the total employment. In 1986, the United States deployed 33,666 health care full-time equivalent personnel per million population, and Canada deployed 31,529. The US excess was all administrative; Canada employed more clinical personnel, especially registered nurses. Between 1971 and 1986, hospital employment per capita grew 29% in the United States (mostly because of administrative growth) and fell 14% in Canada. In 1986, Canadian hospitals still employed more clinical staff per million. Outpatient employment was larger and grew faster in the United States. Per capita nursing home employment was substantially higher in Canada. CONCLUSIONS: If US hospitals and outpatient facilities adopted Canada's staffing patterns, 1,407,000 fewer managers and clerks would be necessary. Despite lower medical spending, Canadians receive slightly more nursing and other clinical care than Americans, as measured by labor inputs.

Administrative Personnel↗
PubMed1996

Medical care employment in the United States, 1968 to 1993: The importance of health sector jobs for African Americans and women.

OBJECTIVES: The purpose of this study was to elucidate the social and economic impact of health sector employment. METHODS: US medical care employment was analyzed for each year between 1968 and 1993, with data from the March Current Population Survey. RESULTS: Between 1968 and 1993, medical care employment grew from 4.32 million to 11.40 million persons, accounting for 5.7% of all jobs in 1968 and 8.4% in 1993. Today, one seventh of employed women work in medical care; they hold 78% of medical care jobs. One fifth of all employed African-American women work in medical care. African-Americans hold 15.5% of jobs in the health sector: they hold 24.1% of the jobs in nursing homes, 15.9% of the jobs in hospitals, but only 5.6% of the jobs in practitioners' offices. Hispanics constitute 6.4% of medical care employees. Real wages rose 25% to 50% between 1968 and 1993 for most health occupations. Wages of registered nurses rose 86%; physicians' incomes rose 22%. Wages of nursing home workers were far lower than those of comparable hospital workers, and the gap has widened. In 1993, 11.7% of all medical care workers lacked health insurance and 597 000 lived in poverty. CONCLUSIONS: Hospital cuts and the continuing neglect of long-term care exacerbate unemployment and poverty among women and African Americans.

Adolescent↗
PubMed1995

Care denied: US residents who are unable to obtain needed medical services.

OBJECTIVES: This study analyzed data on US residents reporting that they were unable to obtain needed care. Inadequately immunized children and women inadequately screened for breast or cervical cancer were also examined. METHODS: Data from the 1987 National Medical Expenditure Survey was analyzed. RESULTS: A total of 6,375,000 (90% confidence interval [CI] = 6,039,000, 6,711,000) people could not get hospitalization, prescription medications, medical equipment/supplies, or emergency, pediatric, mental health, or home care. Although the uninsured were more likely to forego care unavailable, three quarters of those unable to obtain services were insured, and 46% (90% CI = 42.4%, 49.6%) had private coverage. Of those reporting the reason why they failed to obtain care, 65.1% (90% CI = 61.7%, 68.6%) listed high costs or lack of insurance, including 60.7% (90% CI = 57.1%, 64.3%) of the privately insured. More than a third of women had not had a breast examination in the previous 2 years, a fifth had not had a Pap smear within the previous 4 years, and half had never had a mammogram (ages 50-69 only). Of children 2 to 5 years old, 35.1% (90% CI = 31.5%, 35.7%) were inadequately immunized. Medicaid recipients had measures of access to care similar to those of the uninsured. CONCLUSIONS: Many US residents--most of whom have insurance--are unable to obtain needed care, usually because of high costs.

Adolescent↗
PubMed1995

The growing epidemic of uninsurance: new data on the health insurance coverage of Americans.

Despite a massive expansion of Medicaid and an upswing in the economy, the total number of Americans uninsured in 1993 was 39.7 million, more than at any time since the passage of Medicaid and Medicare in the 1960s. Since 1989, the ranks of the uninsured have swelled by 6.3 million. Millions more would be uninsured if Medicaid enrollment had not risen dramatically, by 10.5 million people since 1989. Loss of health coverage is a growing problem for middle-income families, women, and children, as it has long been for low-income families. Even in Hawaii, whose employer mandate program is often cited as a model of universal coverage, there was a large increase in uninsurance. Nationwide, the sharp upswing in the number of Americans who are uninsured has coincided with government and corporate policies to encourage medical competition and push people into managed care plans. Republican proposals to limit AFDC benefits threaten to further increase uninsurance, particularly among women and children. Only a Canadian-style single-payer reform can assure universal coverage and simultaneously contain costs.

Adolescent↗
PubMed1994

Inappropriate drug prescribing for the community-dwelling elderly.

OBJECTIVE: To examine the amount of inappropriate drug prescribing for Americans aged 65 years or older living in the community. DESIGN: Cross-sectional survey of a national probability sample of older adults. SETTING: The 1987 National Medical Expenditure Survey, a national probability sample of the US civilian noninstitutionalized population, with oversampling of some population groups, including the elderly. SUBJECTS: The 6171 people aged 65 years or older in the National Medical Expenditure Survey sample, using appropriate weighting procedures to produce national estimates. MAIN OUTCOME MEASURES: Incidence of prescribing 20 potentially inappropriate drugs, using explicit criteria previously developed by 13 United States and Canadian geriatrics experts through a modified Delphi consensus technique. Three cardiovascular drugs identified as potentially inappropriate were analyzed separately since they may be considered appropriate for some noninstitutionalized elderly patients. RESULTS: A total of 23.5% (95% confidence interval [CI], 22.4% to 24.6%) of people aged 65 years or older living in the community, or 6.64 million Americans (95% CI, 6.28 million to 7.00 million), received at least one of the 20 contraindicated drugs. While 79.6% (95% CI, 77.2% to 82.0%) of people receiving potentially inappropriate medications received only one such drug, 20.4% received two or more. The most commonly prescribed of these drugs were dipyridamole, propoxyphene, amitriptyline, chlorpropamide, diazepam, indomethacin, and chlordiazepoxide, each used by at least half a million people aged 65 years or older. Including the three controversial cardiovascular agents (propranolol, methyldopa, and reserpine) in the list of contraindicated drugs increased the incidence of probably inappropriate medication use to 32% (95% CI, 30.7% to 33.3%), or 9.04 million people (95% CI, 8.64 million to 9.44 million). CONCLUSION: Physicians prescribe potentially inappropriate medications for nearly a quarter of all older people living in the community, placing them at risk of drug adverse effects such as cognitive impairment and sedation. Although most previous strategies for improving drug prescribing for the elderly have focused on nursing homes, broader educational and regulatory initiatives are needed.

Aged↗
PubMed1994

Clinton's health plan: Prudential's choice.

President Clinton has proposed a managed competition model for health care reform. This strategy would accelerate the corporatization of U.S. health care resulting in more bureaucracy, less patient choice, and a health system owned by a few insurance giants. There is no evidence that competition or other central features of Clinton's plan can lower costs or improve quality. Because cost containment is doubtful, the promised expansion of coverage is unlikely to be implemented.

Competitive Medical Plans↗
PubMed1994

Health care paper chase, 1993: the cost to the nation, the states, and the District of Columbia.

The U.S. health care payment system is an elaborate and increasingly wasteful paper chase. This article presents new state-by-state estimates of health care administrative costs in the United States, and savings that could be realized with single-payer reform. In 1993, health care bureaucracy will consume 24.7 cents of every health care dollar, a total of $232.3 billion. Administration's share of health spending is up from 23.9 percent in 1987, and from 21.9 percent in 1983. Reducing the cost of administration to Canadian levels by adopting a single-payer health care system would cut U.S. health care bureaucracy by more than half (50.7 percent), saving at least $117.7 billion in 1993. The savings achievable with a single-payer system could fund universal access for the uninsured and improve benefits for the tens of millions of Americans who currently have only partial coverage, without any increase in overall health spending. Reform measures such as electronic billing, insurance industry consolidation, and increased competition (including "managed competition") would save little or nothing on administration. Only a single-payer reform that incorporates the "macro-management" approach to cost control, as in Canada, can achieve significant administrative savings.

Cost Savings↗