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.     

PPS waivers: implications for Medicare, Medicaid, and commercial insurers

This paper compares the Medicare prospective payment system (PPS) to four all-payer rate-setting systems that operated under HCFA waiver authority. The study examines the experience of Medicare, Medicaid, and commercial insurers under the two approaches. Data from several American Hospital Association surveys and from Medicaid 2082 report forms are analyzed. The paper concludes that the all-payer waiver programs have been as successful as PPS in controlling the rate of growth in Medicare costs. In addition, Medicaid programs are more successful in controlling their outlays in all-payer rate-setting environments than when they "go alone." Finally, there is no evidence to suggest that hospitals can increase charges in response to greater financial need under either PPS or the state waivers. Nevertheless, it appears that commercial insurers are better able to compete with Blue Cross plans in all-payer rate-setting states than elsewhere.     

Industrial rationalization of a cottage industry: multi-institutional hospital systems

The environment facing hospitals, generally supportive until the 1970s, may now be characterized as complex, turbulent, and constrained. In response to such environmental conditions, hospitals have adopted new strategies and structures. The strategies, described as corporate rationalization, have led away from the traditional structure of freestanding, autonomous hospitals and toward the formation of multi-institutional systems. These systems are designed to provide sufficient strength to cope with the environment, to acquire scarce and valued resources, to allow organizational stability, to achieve organizational purpose, to enable growth and/or survival, and to enhance market position. The impact of multi-hospital systems is viewed in two major areas: acquisition, retention, and utilization of economic and human resources, and organizational, political, and social factors.     

Anchoring political preferences: The structural bases of stable electoral decisions and political attitudes in Britain

Abstract. The paper applies a structural perspective to the analysis of political preferences. Examining two British surveys, the 1987 cross–section of the electorate and a panel survey that covers the 1983 and 1987 elections, the research explores the bases of persistent voting for the same party, location on left–right scales, and the probability of holding the same policy views on a host of different issues over time. A set of structural variables rests at the heart of the paper's theory: discussion networks, patterns of interactions with members of political parties, social class networks, and location in the social structure. Several hypotheses guide the analysis: The effects of the structural variables on the probability of casting a ballot for the same political party in any one election and in adjacent elections will remain, even after controlling for party identification; political party socialization; location on left–right scales; positions taken on any and all political issues; age, and past levels of electoral stability. The effects of structural variables on left–right position will remain, even after controlling for locations on alternative left–right scales. Finally, reinforcing attitudinal context provides the only consistent determinant of stable policy positions, after controlling for a host of alternative explanations including level of education; age; interest in politics, and a general propensity to offer stable answers to political questions.     

The social logic of political choice: Picking a political party in the context of immediate social circles

The Social Logic of Politics places social learning at the center of political choice. People develop their political preferences, knowledge, values, perceptions of ability, and decisions about political behavior in interactions with others, usually members of their social circles. Political attitudes and goals are not derivatives of exogenous economic preferences. They are not the results of careful calculations, in which optimization of personal needs guides the mode of reasoning. This theoretical stance draws sustenance from recent work across the social science, even as it harkens back to established, if neglected principles of political analysis. My thanks to Rüdiger Schmitt-Beck for his encouragement and for the critical comments of several anonymous referees and to Josip Dasović and Jennifer Fitzgerald, my co-authors of Partisan Families: the Social Logic of Bounded Partisanship in Germany and Britain (Zuckerman et al. 2007). Material from that book appears in this essay.