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PubMed2005

Testing for statistical discrimination in health care.

OBJECTIVE: To examine the extent to which doctors' rational reactions to clinical uncertainty ("statistical discrimination") can explain racial differences in the diagnosis of depression, hypertension, and diabetes. DATA SOURCES: Main data are from the Medical Outcomes Study (MOS), a 1986 study conducted by RAND Corporation in three U.S. cities. The study compares the processes and outcomes of care for patients in different health care systems. Complementary data from National Health And Examination Survey III (NHANES III) and National Comorbidity Survey (NCS) are also used. STUDY DESIGN: Across three systems of care (staff health maintenance organizations, multispecialty groups, and solo practices), the MOS selected 523 health care clinicians. A representative cross-section (21,480) of patients was then chosen from a pool of adults who visited any of these providers during a 9-day period. DATA COLLECTION: We analyzed a subsample of the MOS data consisting of patients of white family physicians or internists (11,664 patients). We obtain variables reflecting patients' health conditions and severity, demographics, socioeconomic status, and insurance from the patients' screener interview (administered by MOS staff prior to the patient's encounter with the clinician). We used the reports made by the clinician after the visit to construct indicators of doctors' diagnoses. We obtained prevalence rates from NHANES III and NCS. FINDINGS: We find evidence consistent with statistical discrimination for diagnoses of hypertension, diabetes, and depression. In particular, we find that if clinicians act like Bayesians, plausible priors held by the physician about the prevalence of the disease across racial groups could account for racial differences in the diagnosis of hypertension and diabetes. In the case of depression, we find evidence that race affects decisions through differences in communication patterns between doctors and white and minority patients. CONCLUSIONS: To contend effectively with inequities in health care, it is necessary to understand the mechanisms behind the problem. Discrimination stemming from prejudice is of a very different character than discrimination stemming from the application of rules of conditional probability as a response to clinical uncertainty. While in the former case, doctors are not acting in the best interests of their patients, in the latter, they are doing the best they can, given the information available. If miscommunication is the culprit, then efforts should be aimed at reducing disparities in the ways in which doctors communicate with patients.

Adult↗

PubMed2006

Health care access among individuals involved in same-sex relationships.

OBJECTIVES: We used data from the National Health Interview Survey to compare health care access among individuals involved in same-sex versus opposite-sex relationships. METHODS: We conducted descriptive and logistic regression analyses from pooled data on 614 individuals in same-sex relationships and 93418 individuals in opposite-sex relationships. RESULTS: Women in same-sex relationships (adjusted odds ratio [OR]=0.60; 95% confidence interval [CI]=0.39, 0.92) were significantly less likely than women in opposite-sex relationships to have health insurance coverage, to have seen a medical provider in the previous 12 months (OR=0.66; 95% CI=0.46, 0.95), and to have a usual source of health care (OR=0.50; 95% CI=0.35, 0.71); they were more likely to have unmet medical needs as a result of cost issues (OR=1.85; 95% CI=1.16, 2.96). In contrast, health care access among men in same-sex relationships was equivalent to or greater than that among men in opposite-sex relationships. CONCLUSIONS: In this study involving a nationwide probability sample, we found some important differences in access to health care between individuals in same-sex and opposite-sex relationships, particularly women.

Adolescent↗

PubMed2000

Hostility and violent ideation: physical rehabilitation patient and community samples.

OBJECTIVES: To assess the relative frequency of violent ideation [VI] in physical rehabilitation and community samples, and to identify associated factors. DESIGN: Analysis of variables from the Battery for Heath Improvement using MANOVA, ANOVA and chi(2) analyses. SETTING: Medical sites in 30 US states, and community sites in 16 US states, overall representing 36 US states. PARTICIPANTS: 527 physical rehabilitation patients suffering from both acute and chronic pain conditions, and 725 community members. Subjects from both groups were drawn from a larger pool of 2,262 subjects. INTERVENTIONS: None. OUTCOME MEASURES: The Hostility scale and a VI critical item from the Battery for Heath Improvement (BHI). RESULTS: The patient group reported significantly more violent ideation than did the community group. VI was also significantly associated with involvement in workers' compensation or personal injury insurance systems, work conditioning programs, the BHI Hostility scale, and a number of other psychosocial factors. CONCLUSIONS: Recent research supports the contention that there is a relationship between ideation, angry affect, aggressive behavior and delayed recovery. Thus the presence of VI in the patient should be a cause for concern, and has clear ramifications for those working in the clinical setting. Primary prevention should involve not only the identification of hostile patients at risk for VI and aggression, it should also involve identifying programs or systems where a higher incidence of VI is likely to be observed. As VI was found to be associated with a range of variables, including characterological disorders, mood and social conflict, a further evaluation of factors contributing to VI would be recommended prior to intervention.

Journal Article↗

PubMed1989

A national health program for the United States. A physicians' proposal.

Our health care system is failing. Tens of millions of people are uninsured, costs are skyrocketing, and the bureaucracy is expanding. Patchwork reforms succeed only in exchanging old problems for new ones. It is time for basic change in American medicine. We propose a national health program that would (1) fully cover everyone under a single, comprehensive public insurance program; (2) pay hospitals and nursing homes a total (global) annual amount to cover all operating expenses; (3) fund capital costs through separate appropriations; (4) pay for physicians' services and ambulatory services in any of three ways: through fee-for-service payments with a simplified fee schedule and mandatory acceptance of the national health program payment as the total payment for a service or procedure (assignment), through global budgets for hospitals and clinics employing salaried physicians, or on a per capita basis (capitation); (5) be funded, at least initially, from the same sources as at present, but with all payments disbursed from a single pool; and (6) contain costs through savings on billing and bureaucracy, improved health planning, and the ability of the national health program, as the single payer for services, to establish overall spending limits. Through this proposal, we hope to provide a pragmatic framework for public debate of fundamental health-policy reform.

Budgets↗

PubMed1996

Uncompensated hospital care. Will it be there if we need it?

The debates over health care system reform continue, but they rarely mention the enduring need for free or reduced-cost hospital care as a safety net for uninsured and underinsured individuals. Policy changes on numerous fronts threaten the ability or willingness of hospitals to provide uncompensated care. These changes include the decline of Hill-Burton funds, the closings or mergers of not-for-profit and public hospitals, the dominance of competitive forces, and the redirection of funds intended for disproportionate share hospitals or uncompensated pools. Federal and state governments lack coordinated approaches toward uncompensated care, and health system reforms may not have the expected effects on reducing hospitals' burden of paying for services to indigents. Furthermore, measurement of uncompensated care is inconsistent. In light of the persistent growth in the number of persons with inadequate health insurance coverage and the central role that uncompensated care will continue to play in ensuring access to care for the poor and uninsured, these policies need to be reexamined. Guidelines for policy based on past experience are presented herein.

Cost Allocation↗

PubMed2026

Survival by Race and Ethnicity in Children and Adolescents/Young Adults With Relapsed/Refractory Hodgkin Lymphoma: A Pooled Analysis of Children's Oncology Group Trials.

PURPOSE: Despite 5-year survival rates of over 90% among children and adolescents/young adults (CAYAs) with classic Hodgkin lymphoma (cHL), 15%-20% relapse after frontline therapy. Prior analysis of frontline Children's Oncology Group (COG) clinical trials demonstrated that, despite similar rates of relapse, non-Hispanic Black (NHB) and Hispanic (vs. non-Hispanic White [NHW]) patients experienced higher post-relapse mortality. It is unknown whether post-relapse disparities persist when second-line treatment is delivered in a cooperative group trial setting. We examined overall survival (OS) by race and ethnicity in CAYAs enrolled in COG trials for relapsed/refractory (r/r) cHL. METHODS: A pooled analysis of individual-level data from CAYAs (≤ 29 years) receiving therapy for r/r cHL on COG clinical trials (2001-2016) was conducted. The Kaplan-Meier method estimated 3-year OS by racial and ethnic groups. Cox regression models examined associations of race and ethnicity and OS, adjusted for age, insurance, first versus ≥2 relapse, and time from initial diagnosis to relapse trial enrollment. RESULTS: Among 175 CAYAs treated on COG trials for r/r cHL (5.7% Asian or Pacific Islander, 14.9% Hispanic, 14.3% NHB, 61.7% NHW, 3.4% other), at median follow-up of 4.9 years, 3-year OS was 82.1% (95% confidence interval [CI], 75.3%-87.1%) and did not differ by race and ethnicity (p = 0.36). In multivariable analyses, shorter time from diagnosis to relapse trial enrollment (p = 0.01) and ≥2 relapses (vs. first, p = 0.004) conferred worse OS, with no significant effect of race and ethnicity (p = 0.43). CONCLUSION: Post-relapse survival did not differ by race and ethnicity among CAYAs enrolled in COG trials for r/r cHL, suggesting access to clinical trials may mitigate OS disparities.

Humans↗

PubMed2002

A "health commons" approach to oral health for low-income populations in a rural state.

Oral health needs are urgent in rural states. Creative, broad-based, and collaborative solutions can alleviate these needs. "Health commons" sites are enhanced, community-based, primary care safety net practices that include medical, behavioral, social, public, and oral health services. Successful intervention requires a comprehensive approach, including attention to enhancing dental service capacity, broadening the scope of the dental skills of locally available providers, expanding the pool of dental providers, creating new interdisciplinary teams in enhanced community-based sites, and developing more comprehensive oral health policy. By incorporating oral health services into the health commons primary care model, access for uninsured and underserved populations is increased. A coalition of motivated stakeholders includes community leaders, safety net providers, legislators, insurers, and medical, dental, and public health providers.

Adult↗

PubMed1999

Cross-national comparison of capitation funding: the American, British and Dutch experience.

In this paper we review the performance of the capitation payment systems of three countries--the Adjusted Average Per Capita Cost (AAPCC) system used in the United States to reimburse Health Maintenance Organizations (HMOs) for insuring Medicare recipients, a somewhat similar system in the Netherlands which reimburses third-party payers for insuring the entire population and a weighted system utilized in Britain for regional funding. Our review revealed significant problems with the current version of the AAPCC formula as there is evidence of the biased selection of beneficiaries and actual losses to Medicare through its use. Furthermore, several studies show that the demographic adjusters utilized in the AAPCC formula are extremely poor predictors of future healthcare utilization relative to the potential of direct and indirect health status measures. The Dutch experience with capitated funding has been similar to that of the United States. While Dutch researchers have built on the work of their American counterparts they acknowledge that further work is needed before a fully functional system is implemented. Britain's weighted system has fulfilled its original mandate to redistribute healthcare resources based on population need but recent changes giving increased influence to age weighting could reverse some of these gains. A number of proposed improvements to these risk adjustment problems were reviewed including the development of diagnostic cost groups, the coexisting hierarchical conditions model and the use of community-rated high-risk pooling. The findings from this study can help others narrow the alternatives they need to consider when thinking of introducing capitation funding or refining already existing systems.

Capitation Fee↗

PubMed1998

Epidemiology of hospitalization for near-drowning.

BACKGROUND: Although drowning is the third leading cause of accidental death among children less than 4 years of age, few studies have described the hospitalization of near-drowning victims. Our study emphasizes the local epidemiology and charges associated with pediatric hospitalization in cases of near-drowning. METHODS: Data regarding time, place, injury severity, circumstances, outcome, and hospital charges were collected by retrospective medical record review. Cross tabulation of datasets with descriptive statistical analysis was done using R:Base System V. RESULTS: Between 1987 and 1991, 53 victims of near-drowning were admitted or transferred to Children's Hospital of Alabama in Birmingham. Thirty-three of the incidents occurred during the months of June, July, and August; 32 occurred in pools, 11 in lakes and rivers, 6 in bathtubs, 3 in mop buckets, and 1 in a cesspool. The mean hospital stay was 8 days (combined total, 439 days), accounting for total charges of $749,507 (mean $14,141). Outcomes included 15 deaths, 5 discharges with neurologic sequelae, and 33 discharges without sequelae. Private insurance covered 31 patients, 7 were Medicaid patients, and 15 had no coverage. CONCLUSION: Near-drowning injuries have high case fatality rates, a high case sequelae rate, and high hospitalization charges.

Alabama↗

PubMedDate not supplied

Charity care: a proposal for reform.

Changing political attitudes and new financing trends jeopardize our commitment to providing equitable access to medical services for all citizens regardless of ability to pay. The commitment is further threatened by the lack of coordination and the fragmentation that make charity care expensive and ineffective. This article proposes that we bring continuity and consistency to our charity care efforts by considering four options for reform: reallocate health spending to emphasize primary, preventive care in the community setting: create special HMOs for the medically disadvantaged through a revitalized community health center program; develop a voucher program to ensure access to the HMOs as well as risk-sharing pools to ensure access to secondary and tertiary care; and radically restructure the public hospital systems and eliminate most hospitals in the veterans administration system.

Charities↗

PubMed2000

Predictors of intentions to stop smoking early in prenatal care.

OBJECTIVE: To determine baseline variables associated with low intentions of stopping smoking early in pregnancy. DESIGN: Cross sectional survey. PARTICIPANTS: Pregnant smokers pooled across seven Smoke-Free Families trials (n = 1314). RESULTS: 36% of pregnant smokers had low intentions of stopping smoking within the next 30 days. In contrast to pregnant smokers with higher intentions of quitting, pregnant smokers with low intentions were less confident in their ability to quit, less likely to have private health insurance, and less likely to agree that smoking harms the unborn child. They were more likely to smoke heavily, more likely to have fewer years of education, and more likely to have friends and family members who smoke. CONCLUSIONS: Three options to smoking cessation assistance are proposed for pregnant smokers with low intentions of quitting: targeting, triage, and tailoring. Further research is needed to determine which approach is most appropriate.

Adult↗

PubMedDate not supplied

[Usefulness of specific bronchial provocation tests in the diagnosis of compensable occupational allergic pneumopathies].

The A.A studied the bronchial reactivity of 309 subjects accusing a working respiratory disease. It had been valued the utility of specific provocation bronchial test for diagnosis of allergic bronchopneumopathies. The test, performed with working antigens pool, not only confirms the low percentage of allergic respiratory disease among considered workers (joiners, painters and millers) it also shows its sensibility only in subjects with a sure story of bronchial asthma. The A.A. say, that it's not really necessary to perform the test in all subjects that submit to diagnostic screening for industrial insurance reasons.

Asthma↗

PubMed1988

Protecting the uninsured. Use of state risk-pools. Council on Medical Service.

Society already bears a large part of the costs attributable to the lack of adequate health expense protection for the uninsured, whether through lost manhours and productivity resulting from the postponement of needed medical attention or through defraying the economic burden of uncompensated care. The question, therefore, is not whether such costs should be met, but how they can be met in a way that best maintains and preserves the health of the needy while apportioning this cost equitably over all sectors of the American economy. The Council on Medical Service believes that the establishment of state risk-pools with the modifications suggested in this report, coupled with the other AMA policy initiatives identified at the beginning of this report, will go a long way toward meeting the needs of the uninsured population.

American Medical Association↗

PubMed2003

Grants to states for operation of qualified high risk pools. Final rule with comment period.

This final rule with comment period implements a provision of the Trade Assistance Reform Act of 2002 by providing $40 million in Federal fiscal year 2003 and $40 million in Federal fiscal year 2004 to States that have incurred losses in connection with the operation of qualified high risk pools that meet certain criteria. This grant program implements section 2745 of the Public Health Service Act, as added by the Trade Adjustment Assistance Reform Act of 2002.

Financing, Government↗

PubMed2004

Radiofrequency ablation of primary and metastatic hepatic malignancies.

Radiofrequency interstitial tissue ablation is a local ablative therapy in which tumors are destroyed in situ by thermal coagulation and protein denaturation through frictional heating produced by tissue ionic agitation from high-frequency alternating current. This technology can be used to destroy primary and metastatic hepatic lesions generally considered nonresectable or nonoperable, thus providing patients with these tumors, who have few treatment options, a relatively safe and effective alternative with the potential for improved chance of survival. Knowledge of the broad spectrum of potential complications associated with radiofrequency ablation (RFA) is essential for prevention, early detection, and proper management. Combining RFA with other modalities such as surgical resection or hepatic artery infusional chemotherapy is feasible, has increased the pool of operable patients, and may improve treatment efficacy and clinical outcome in properly selected patients. The approach to perform RFA percutaneously, laparoscopically, or during laparatomy should take into consideration tumor characteristics, imaging and technical limitations, and the role of other treatment modalities. Therefore, patients considered for RFA should be evaluated within the context of a multidisciplinary approach to insure proper patient selection and coordination of adjunct therapy.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2000

[Intracellular iron metabolism].

Iron is essential to life but it is poorly soluble in biological fluids and toxic in excess. Organisms have developed multiple proteins to insure iron transport and storage, and some of these have only been discovered recently. Among them, members of the Nramp family are transmembrane proteins which transport several divalent cations, including Fe2+. These proteins participate in intestinal iron absorption, erythopoiesis and microbial defence. Frataxin, which is deficient in Friedreich's ataxia, regulates iron flux through mitochondria. The intracellular labile iron pool, an intermediate form of iron between different subcellular compartments, regulates ferritin synthesis and stability of mRNA coding for proteins of iron transport. Subunit composition of ferritin plays an important role in the control of the size of this labile iron pool.

Carrier Proteins↗

PubMed2006

Rewards for organ donation: the time has come.

Strategies to expand the pool of solid organs for transplantation have had only limited success. Waiting times exceeding 5 years and/or waiting mortality are not uncommon. A system of financial rewards for living and deceased organ donation is proposed. The reward program would be administered by the federal government. Donors or beneficiaries would receive a fixed financial reward, similar to the payout of an insurance policy, from a federal agency. Such a system would be consistent with similar financial rewards given in our society to recognize instances of personal self-sacrifice and risk taking performed for the benefit of others.

Altruism↗

PubMed1999

Retirement patterns and bridge jobs in the 1990s.

During most of the post-World War II period, American men have been leaving the labor force at earlier and earlier ages. Evidence suggests that this trend has been under way for more than a century. However, in the mid-1980s, this trend came to an abrupt halt. Male labor force participation rates have been flat since 1985, and have actually increased over the past several years. Understanding these issues is especially important given the looming increase in the Social Security normal retirement age to 67 and the possibility of even more increases in the ages of eligibility under Social Security and Medicare reform. Because of the influx of married women into the labor market in the post-World War II period, older women's participation rates did not decline as men's did. In contrast, their rates were relatively steady, rising or falling very slowly. Since the mid-1980s, however, older women's participation rates have increased significantly. Many more older men and women are working today than the pre-1986 trends would have suggested. Many older Americans leave the labor force gradually, utilizing "bridge jobs" between employment on a full-time career job and complete labor force withdrawal. These bridge jobs are often part-time, often in a new line of work, and sometimes involve a switch from wage and salary work to self-employment. Estimates suggest that between one-third and one-half of older Americans will work on a bridge job before retiring completely, and for these workers retirement is best viewed as a process, not as a single event. These changes in retirement behavior are consistent with societal changes that have altered the relative attractiveness of work and leisure late in life. Mandatory retirement has been outlawed for most American workers. Social Security has become more age-neutral, no longer penalizing the average worker who wants to continue working after age 65. An increasing proportion of employer pension coverage has been in defined contribution plans, which do not contain the age-specific retirement incentives that many defined benefit plans do. The composition of jobs has shifted from manufacturing to service occupations. Americans are living longer and healthier lives, and many look forward to years to productive activity after age 65. These structural changes have been accompanied by an important cyclical factor: the strength of the American economy over the past decade. This has increased the demand for all types of labor, including older workers. Evidence suggests that there is more than this cyclical factor at work, however, and that new attitudes about work late in life are developing. Labor supply decisions late in life are correlated in expected ways with the individual's health (measured in several ways), age, and pension and health insurance status. Retirement patterns in America are much richer and more varied than the stereotypical one-step view of retirement suggests. Public policy is changing in ways that make continued work late in life more likely. If employers are willing to provide flexible job opportunities to meet the needs of these potential employees, then society can tap a growing pool of older, experienced, and willing workers for years to come.

Aged↗