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Biomedical subjects

Thomas Rice

Publications and source records attributed to Thomas Rice.

At least 19 recordsLinked to original sources
PubMed2006

Can limiting choice increase social welfare? The elderly and health insurance.

Herbert Simon's work on bounded rationality has had little impact on health policy discourse, despite numerous supportive findings. This is particularly surprising in regard to the elderly, a group marked by a decline in higher cognitive functions. Elders' cognitive capacity to make decisions will be challenged even further with the introduction of the new Medicare prescription drug benefit program, mainly because of the many options available. At the same time, a growing body of evidence points to the perils of having too many choices. By combining research from decision science, economics, and psychology, we highlight the potential problems with the expanding health insurance choices facing the elderly and conclude with some policy suggestions to alleviate the problem.

Aged↗
PubMed2006

Who will be denied Medicare prescription drug subsidies because of the asset test?

OBJECTIVE: To determine the number and characteristics of Medicare beneficiaries who will be excluded from low-income prescription drug subsidies because they do not qualify under an asset test. STUDY DESIGN: Cross-sectional, using the US Census Bureau's Survey of Income and Program Participation (SIPP); results were based on interviews occurring between October 2002 and January 2003. The sample included 9278 Medicare beneficiaries, 2929 with incomes below 150% of the federal poverty level (FPL). METHODS: Using SIPP, each sample member's income was compared to the FPL. Income was adjusted to include only liquid assets and primary residences. The number of individuals excluded by the asset test and their characteristics and types of assets responsible were calculated. RESULTS: Of 13.97 million noninstitutionalized Medicare beneficiaries, 2.37 million (17%) with low incomes would be excluded from subsidized drug coverage due to the asset test. Compared to higher-income beneficiaries, the excluded individuals tended to be older, female, widowed, and living alone. Almost half of their assets were checking and savings accounts. Half of the individuals failing the test had assets less than 35,000 dollars above the allowing thresholds. CONCLUSIONS: Widows are disproportionately affected by the asset test. When a husband dies, income plummets but accumulated assets often exceed those allowed under Medicare legislation. During their working years Americans are encouraged to save for retirement, but by accumulating modest amounts of assets, these same people often will then not qualify for low-income drug subsidies. Modifying or eliminating the asset test would help protect individuals disadvantaged by low incomes who have modest amounts of asset holdings.

Aged↗
PubMed2005

Children welcome, adults need not apply: changes in public program enrollment across states and over time.

This article describes changes in the extent of public health insurance coverage for low-income children and adults from 1979 through 2001. Although previous research has demonstrated that public coverage among children has increased substantially during the past 20 years, our work shows that almost all of the increase has occurred among children in families with incomes between 100% and 200% of the federal poverty level (FPL), with little change among children in families with incomes below 100% of FPL. In contrast to the increase in public coverage among children, there has been virtually no change in the generosity of public programs for low-income adults. The overall stability of public coverage for adults masks substantial changes at the state level: public coverage for adults increased substantially in Tennessee, Vermont, Arizona, and other states that implemented Section 1115 Medicaid waivers, while declining in New York, California, and many Rust Belt states.

Adult↗
PubMed2005

The impact of private and public health insurance on medication use for adults with chronic diseases.

This article examines the impact of public and private health insurance on the use of medications for California adults with any of four chronic diseases: heart disease, high blood pressure, diabetes, and asthma. The data set used is the 2001 California Health Interview Survey. Multivariate analyses were conducted on individuals who had been diagnosed with each of these diseases. Controlling for various demographic, health status, and employment characteristics, the authors find that the uninsured are far less likely to be taking medications for each of the conditions than those with private insurance. Interestingly, those with Medicaid coverage are even more likely than those with private insurance to be taking such medications. The results of this study underscore the importance of health insurance for all persons with chronic conditions and the benefits of Medicaid in particular for low-income adults with chronic conditions.

Adolescent↗
PubMed2005

Association between physician compensation methods and delivery of guideline-concordant STD care: is there a link?

OBJECTIVE: To examine the association between primary care physician (PCP) reimbursement and delivery of sexually transmitted disease (STD) services. STUDY DESIGN: Cross-sectional sample of PCPs contracted with Medicaid managed care organizations in 2002 in 8 California counties with the highest rates of Medicaid enrollment and chlamydia cases. METHODS: The association between physician reimbursement methods and physician practices in delivery of STD services was examined in multiple logistic regression models, controlling for a number of potential confounders. RESULTS: Evidence of an association between reimbursement based on management of utilization and the PCP practice of providing chlamydia drugs for the partner's treatment was most apparent. In adjusted analyses, physicians reimbursed with capitation and a financial incentive for management of utilization (odds ratio [OR] = 1.63) or salary and a financial incentive for management of utilization (OR = 2.63) were more likely than those reimbursed under other methods to prescribe chlamydia drugs for the partner. However, PCPs least often reported they annually screened females aged 15-19 years for chlamydia (OR = 0.63) if reimbursed under salary and a financial incentive for productivity, or screened females aged 20-25 years (OR = 0.43) if reimbursed under salary and a financial incentive for financial performance. CONCLUSION: Some physician reimbursement methods may influence care delivery, but reimbursement is not consistently associated with how physicians deliver STD care. Interventions to encourage physicians to consistently provide guideline-concordant care despite conflicting financial incentives can maintain quality of care. In addition, incentives that may improve guideline-concordant care should be strengthened.

Adult↗
PubMed2004

Effect of an imaging-based streamlined electronic healthcare process on quality and costs.

RATIONALE AND OBJECTIVES: A streamlined process of care supported by technology and imaging may be effective in managing the overall healthcare process and costs. This study examined the effect of an imaging-based electronic process of care on costs and rates of hospitalization, emergency room (ER) visits, specialist diagnostic referrals, and patient satisfaction. MATERIALS AND METHODS: A healthcare process was implemented for an employer group, highlighting improved patient access to primary care plus routine use of imaging and teleconsultation with diagnostic specialists. An electronic infrastructure supported patient access to physicians and communication among healthcare providers. The employer group, a self-insured company, manages a healthcare plan for its employees and their dependents: 4,072 employees were enrolled in the test group, and 7,639 in the control group. Outcome measures for expenses and frequency of hospitalizations, ER visits, traditional specialist referrals, primary care visits, and imaging utilization rates were measured using claims data over 1 year. Homogeneity tests of proportions were performed with a chi-square statistic, mean differences were tested by two-sample t-tests. Patient satisfaction with access to healthcare was gauged using results from an independent firm. RESULTS: Overall per member/per month costs post-implementation were lower in the enrolled population (126 dollars vs 160 dollars), even though occurrence of chronic/expensive diseases was higher in the enrolled group (18.8% vs 12.2%). Lower per member/per month costs were seen for inpatient (33.29 dollars vs 35.59 dollars); specialist referrals (21.36 dollars vs 26.84 dollars); and ER visits (3.68 dollars vs 5.22 dollars). Moreover, the utilization rate for hospital admissions, ER visits, and traditional specialist referrals were significantly lower in the enrolled group, although primary care and imaging utilization were higher. Comparison to similar employer groups showed that the company's costs were lower than national averages (119.24 dollars vs 146.32 dollars), indicating that the observed result was not attributable to normalization effects. Patient satisfaction with access to healthcare ranked in the top 21st percentile. CONCLUSION: A streamlined healthcare process supported by technology resulted in higher patient satisfaction and cost savings despite improved access to primary care and higher utilization of imaging.

Electronics, Medical↗
PubMed2004

Tales from the new frontier: pioneers' experiences with consumer-driven health care.

OBJECTIVE: To conduct site visits to study the early experiences of firms offering consumer-driven health care (CDHC) plans to their employees and firms that provide CDHC products. DATA SOURCES/STUDY SETTING: A convenience sample of three firms offering CDHC products to their employees, one of which is also a large insurer, and one firm offering an early CDHC product to employers. STUDY DESIGN: We conducted onsite interviews of four companies during the spring and summer of 2003. These four cases were not selected randomly. We contacted organizations that already had a consumer-driven plan in place by January 2002 so as to provide a complete year's worth of experience with CDHC. PRINCIPAL FINDINGS: The experience of the companies we visited indicated that favorable selection tends to result when a CDHC plan is introduced alongside traditional preferred provider organization (PPO) and health maintenance organization (HMO) plan offerings. Two sites demonstrated substantial cost-savings. Our case studies also indicate that the more mundane aspects of health care benefits are still crucial under CDHC. The size of the provider network accessible through the CDHC plan was critical, as was the role of premium contributions in the benefit design. Also, companies highlighted the importance of educating employees about new CDHC products: employees who understood the product were more likely to enroll. CONCLUSIONS: Our site visits suggest the peril (risk selection) and the promise (cost savings) of CDHC. At this point there is still far more that we do not know about CDHC than we do know. Little is known about the extent to which CDHC changes people's behavior, the extent to which quality of care is affected by CDHC, and whether web-based information and tools actually make patients become better consumers.

Consumer Behavior↗
PubMed2004

The impact of cost-sharing on appropriate utilization and health status: a review of the literature on seniors.

This article provides a review of research that has addressed the impact of patient cost sharing on the use of services and resulting health status impacts, among the population age 65 and older. Nearly all of the 22 relevant studies examined that have been published since 1990-16 focusing on cost-sharing for prescription drugs and 6 on cost-sharing for medical services--conclude that increased cost-sharing reduces either or both the utilization and health status of seniors. Most of the studies, however, rely on cross-sectional and self-reported data. Further research, employing stronger study designs as well as clinical and administrative data, is necessary before drawing more definitive conclusions.

Aged↗
PubMed2004

The distributional consequences of a Medicare premium support proposal.

This article analyzes the distributional consequences of enacting a particular premium support proposal known as Breaux-Frist I. Under the proposal, the federal government would contribute a certain amount toward the purchase of Medicare coverage, based on the premiums charged by different health plans. Beneficiaries could choose something akin to the traditional fee-for-service option or a privately sponsored ealth plan such as a health maintenance organization. The article simulates the expected distributional impacts in three areas: among beneficiaries who choose to retain fee-for-service coverage, between different geographic areas, and according to various beneficiary characteristics. We find that the legislation would result in increased premiums for beneficiaries remaining in the Medicare fee-for-service program as a result of unfavorable selection; lead to a geographic redistribution in premium payments, with those living in areas with high levels of Medicare expenditures paying more; and a much lower financial burden than is the case now for near-poor beneficiaries who do not have full Medicaid coverage. Finally, the article discusses how these results compare to those that may occur under the premium support demonstration project, beginning in 2010, established under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Aged↗
PubMed2004

Does open enrollment control premiums? A case study from the "Medigap" market.

This article analyzes a change in "Medigap" regulations that occurred in Missouri in 1999. It allows Medicare beneficiaries in the state to switch to a different carrier each year so long as they retain the same standardized policy type, without losing their open enrollment privileges. The analysis is based on a comparison of various outcomes in Missouri and those in two comparison states, Kansas and Florida. We found little evidence that the policy change affected premiums charged by insurance carriers in Missouri, but conclude that other desirable aspects of the change make it potentially attractive for other states to follow.

Aged↗
PubMed2003

Medigap reform legislation of 1990: a 10-year review.

The 1990 Medigap reform legislation sought to make it easier for consumers to compare policies, provide market stability, promote competition, and avoid adverse selection. Evidence is that the standardization of benefits has simplified consumer choice and is strongly supported by consumers and State regulators. The 1990 reforms also decreased carrier and agent abuses. However, loss ratios (the proportion of premiums paid in benefits versus being retained for administration and profit) have changed little since 1990, bringing into question whether price competition has been enhanced. The prescription drug benefit, which is included in 3 of the 10 standardized plans, provides only limited financial protection yet is expensive, one reason being adverse selection. Access to coverage for Medicare disabled beneficiaries is problematic in most States.

Aged↗
PubMed2002

Difference in the incidence of Clostridium difficile among patients infected with human immunodeficiency virus admitted to a public hospital and a private hospital.

OBJECTIVE: To compare the occurrence of Clostridium difficile among inpatients infected with human immunodeficiency virus (HIV) in two different hospitals. DESIGN: Prospective, observational study. SETTING: Specialized HIV inpatient units. PATIENTS: HIV-infected inpatients at Cook County Hospital (CCH) and Rush Presbyterian St. Luke's Medical Center (RPSLMC). INTERVENTIONS: A clinical and epidemiologic assessment of patient risk factors for C. difficile was performed. C. difficile isolates found on stool, rectal, and environmental cultures were typed by pulsed-field gel electrophoresis. RESULTS: Twenty-seven percent of patients admitted to CCH versus 4% of patients admitted to RPSLMC had positive cultures for C. difficile (P = .001). At CCH, 14.7% of environmental cultures were positive versus 2.9% at RPSLMC (P = .002). Risk factors for C. difficile acquisition included hospitalization at CCH, more severe HIV, use of acyclovir and H2-blockers, and longer hospital stay. Patients admitted to CCH were taking more antibiotics, had longer hospital stays, and more frequently had a history of C. difficile infection. During the study, two strains (CD1A and CD4) extensively contaminated the CCH environment. However, only CD1A caused an outbreak. CONCLUSIONS: The C. difficile acquisition rate at CCH was sevenfold higher than that at RPSLMC, and CCH had a more contaminated environment. Differences in patient acquisition rates likely reflect a greater prevalence of traditional C. difficile risk factors and a concurrent outbreak at CCH. Although two strains heavily contaminated the environment at CCH, only one caused an outbreak, suggesting that factors other than the environment are important in initiating C. difficile outbreaks.

Chicago↗
PubMed2002

Who switches from Medigap to Medicare HMOs?

OBJECTIVE: To determine the factors affecting whether Medigap owners switch to Medicare managed care plans. DATA SOURCES: The primary data were the 1993-1996 Medicare Current Beneficiary Survey (MCBS) Cost and Use Files. These were supplemented by data available from the Centers for Medicare & Medicaid Services (CMS) website. STUDY DESIGN: Individuals on the MCBS files with Medigap coverage in the period 1993-1996 were included in the study. The person-year was the unit of analysis. We used multivariate logistic regression analysis to determine whether or not a Medigap owner switched to a Medicare-managed care plan during a particular year. Independent variables included measures of affordability, need for services, health insurance benefits, sociodemographics, and supply of managed care plans. PRINCIPAL FINDINGS: We did not detect strong evidence that beneficiaries in poorer health were more likely than others to switch from Medigap coverage to Medicare-managed care. In addition, higher Medigap premiums did not appear to induce beneficiaries to switch into managed care. CONCLUSIONS: We examined selection bias in joining managed care plans among the subset of Medicare beneficiaries who have Medigap policies. No strong evidence of selection bias was found in this population. We conclude that there was no evidence that the Medigap market is becoming prohibitively expensive as a result of unfavorable selection.

Aged↗
PubMedDate not supplied

A field trial of back belts to reduce the incidence of acute low back injuries in New York City home attendants.

To determine the effect of black belt use on the incidence of low back injury in home attendants, a cluster-randomized trial involving employees of nine home attendant agencies in New York City was conducted. Nine agencies employing 12,772 home attendants between June 1997 and September 1999 were randomized into three groups-one group received back belts with use instruction, one group received lifting advice only, and one group served as a control. Low back injury rates per 100 full-time equivalents and rate ratios adjusted for potential confounders were estimated with random-effects Poisson regression. The back-belt group had a lower rate of low back injury than did those in both the advice-only and control groups, though the differences were marginally significant. Age, body mass index, history of back injury, years worked as a home attendant, and level of exercise were associated with risk of low back injury. The findings suggest that use of back belts is associated with some reduction in risk of low back injury.

Adolescent↗
PubMedDate not supplied

Suicides at work: misclassification and prevention implications.

To determine the extent of misclassification of suicides with regard to work-relatedness and the implication for intervention, a matched case-control design was used. Cases were identified from California's master mortality file using ICD 9-CM external cause codes E950-959 and a positive response to the "injury-at-work" designation on the death certificate. Two controls matched on the same external cause of death codes, age, date of death, and county of occurrence were randomly selected. Outcome measures were odds ratios and accuracy assessments. Over 11% of cases and 23% of controls were misclassified. Extrapolation to the United States suggests thousands of suicides are misclassified as to a work-related connection. The findings point to misappropriation of the work-relatedness of suicide and hence, an inaccurate understanding of underlying risk factors and their intervention potential.

California↗
PubMedDate not supplied

Is the doctor in? The evolving role of organized medicine in health policy.

Until recently, physicians were viewed as the dominant player in health policy. Now, however, they compete with many other effective interest groups. This article analyzes this changing role, and specifically how organized medicine has changed its approach to influencing health policy. The essay begins with a review of the reasons for the growth and subsequent decline of physicians' influence. This is followed by a case study of physician payment reform under Medicare, which illustrates the ways in which organized medicine chooses when and when not to cooperate with government. The article concludes with a discussion of where physicians are likely to continue to be influential in future health policy reform. Three such areas are noted: payment policy, quality and clinical innovation, and medical education and training.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Consumer-driven health plans: are they more than talk now?

This paper reports marketplace developments for consumer-driven health plans in spring 2002. Findings are from interviews with executives from start-up and health insurance firms, benefit consultants, employee benefit managers, Wall Street analysts, consumer organizations, thought leaders, and policymakers. We detail available evidence about the performance of consumer-driven health plans concerning access to care, risk selection, cost containment, use of information, and legal issues. We find that these health plans are now a central pillar of health insurers' business strategy and that an estimated 1.5 million persons are enrolled in them.

Community Participation↗