Health care cost-containment regulation: prospects and an alternative.

Regulation of the health care system to achieve appropriate containment of overall costs is characterized by Professor Havighurst as requiring public officials to engage, directly or indirectly, in the rationing of medical services. This rationing function is seen by the author as peculiarly difficult for political institutions to perform, given the public's expectations and the symbolic importance of health care. An effort on the part of regulators to shift the rationing burden to providers is detected, as is a trend toward increasingly arbitrary regulation, designed to minimize regulators' confrontations with sensitive issues. Irrationality and ignorance are found to plague regulatory decision making on health-related issues, even though it is the consumer who is usually thought to suffer most from these disabilities. The author argues that consumer choice under some cost constraints is a preferable mechanism for allocating resources because it better reflects individuals' subjective preferences, has a greater capacity for facing trade-offs realistically, and can better contend with professional dominance of the resource allocation process. In view of the unlikelihood of regulation that is both sensitive and effective in containing costs, the author proposes that we rely primarily on consumer incentives to reform the system. A simple change in the tax treatment of health insurance or other health plan premiums, to strengthen consumers' interest in cost containment while also subsidizing needy consumers, is advocated. Steps to improve opportunities for innovation in cost containment by health insurers, HMOs, and other actors are outlined briefly.     

Perceptions of help resources for victims of intimate partner violence

Intimate partner violence (IPV) constitutes a major public health problem in the United States. This cross-sectional survey of 108 emergency department (ED) care providers and 146 ED visitors at three metropolitan EDs compared the beliefs of ED health care providers with those of community members about the relative benefits of the helpfulness of resources for IPV victims using hypothetical case scenarios. Although providers generally indicated that help resources were helpful in all scenarios, visitors were more discriminating, showing less support for resources in the lower-risk scenario. Regarding differences between groups, visitors selected police and attorneys more frequently than providers as a helpful resource, whereas providers selected shelters and counselors more frequently than visitors. Adjustment for previous experience with IPV did not change these results. Understanding the differences between health care providers' and community members' perceptions of resources for victims of IPV may improve the effectiveness of referral to IPV resources.     

A conversation with Donald Berwick on implementing national health reform

Michael Birnbaum interviews Donald Berwick shortly after his departure from the Centers for Medicare and Medicaid Services about the national health care landscape. Berwick discusses the strategic vision, policy levers, operational challenges, and political significance of federal health care reform. He rejects the notion that the Affordable Care Act represents a government takeover of health care financing or service delivery but says the law's Medicaid expansion and its creation of health benefit exchanges present a "watershed moment for American federalism." Berwick argues that the solution to Medicare's cost-containment challenge lies in quality improvement. He is optimistic that accountable care organizations can deliver savings and suggests that shifting risk downstream to providers throws the health insurance model into question. Finally, looking to the future, Berwick sees a race against time to make American health care more affordable.     

Access to health care: what a difference shades of color make

Professor Majette's timely article examines an age-old problem: the effect of race and ethnicity on a patient's receipt of health care. Her article analyzes some of the major health care access issues, with a focus on barriers confronting African Americans, Asians, Hispanics, and Native Americans. Some of the barriers include inability to pay, cultural insensitivity, a shortage of health care providers, and discrimination. She also examines some of the unsuccessful legal solutions and remedies designed to eliminate these barriers. Given the complexity of the access barriers encountered by people of color, Professor Majette concludes that only an interdisciplinary approach can eliminate them. Her proposed approach requires business, legal, and medical professionals to collaborate in developing a health care system that meets the needs of aracially and ethnically diverse population.     

Race and Ethnicity Effects in Federal Sentencing: A Propensity Score Analysis

Research has examined the role of race and ethnicity in the punishment of offenders. Narrative and meta-analytic reviews have indicated that race/ethnicity influences key sentencing outcomes, at least under certain conditions. This research relies almost exclusively on regression-based analyses for determining race and ethnicity effects. While this technique is useful, recent statistical advances may provide more accurate race/ethnicity estimates. The current study employs propensity score analysis to compare punishment outcomes across White, Black, and Hispanic offenders sentenced in US federal courts during the years 2006 through 2008. Results suggest that (a) during the in/out decision the effect of minority status is frequently smaller than that estimated by regression modeling and (b) during the sentence length decision the effect of minority status is frequently larger than that estimated by regression modeling. Consequently, the modeling strategy may produce different conclusions regarding the presence of race- and ethnic-based disparity in sentencing outcomes.     

Competition in the market for nursing home care

The competitive model may fit the nursing home sector better than it fits other health care markets, but Medicaid subsidies and regulation have not allowed the market to work freely, and nursing home insurance may cause further divergence from a competitive ideal. Incentives for both providers and consumers that capitalize on competitive aspects of the market might be used to improve outcomes of the nursing home market, especially under a system of comprehensive long-term care insurance.     

Decisions without consequences: cost control and access in state Medicaid programs.

States have implemented a number of strategies to provide services, pay providers, and control Medicaid spending. We test the effects of some differences in state Medicaid policies on program enrollees' access to and use of health care services. Logistic and OLS regression analyses of cross-sectional data indicate that these policies exert significant influences on enrollees' access to health services but have a weaker direct effect on their use of them. However, we find evidence that utilization is affected indirectly (through increased access) by state policy decisions. Somewhat surprisingly, Medicaid policies designed to contain costs by limiting utilization appear to affect neither access nor utilization. Medicaid enrollees have greater access to a private physician in states with higher physician reimbursement and additional Medicare insurance for their enrollees. Other nonpolicy variables with pronounced impacts on access to private office physicians include race and the availability of private insurance.     

Attending to the role of race/ethnicity in family violence research

Since the 1970s, researchers and public health and/or social policy communities have devoted increasing attention to family violence. Although officially reported crime figures for family violence appear to be declining, rates continue to be high in broadly defined racial and/or ethnic minority groups. More careful assessments of the potential role of race/ethnicity in family violence, and similarities and differences occurring across and within groups categorized based on race/ethnicity, are essential if adequate interventions are to be developed and utilized. This article provides suggestions on conducting better studies on family violence in the United States, particularly with respect to issues of race/ethnicity. The authors begin by considering conceptions and definitions of race/ethnicity and providing a broad definition of family violence. They then suggest issues for consideration at each stage of the research process, from reviewing previous research, to making methodological decisions, selecting samples, choosing measures, and analyzing and interpreting findings.     

Evaluation of a Health Care Provider Training Program to Identify and Help Partner Violence Victims

This study tested four hypotheses about the impact of a 3-h domestic violence training program with 752 health care providers on attitudes and values related to screening and helping partner violence victims. Hypotheses 1, 2, and 3 were that training would be related to: 1) increased self-efficacy to identify and help partner violence victims, 2) increased endorsement of the role of health care providers and settings for helping partner violence victims, and 3) increased comfort making appropriate community referrals to help partner violence victims. Hypothesis 4 was that training effects would be moderated by prior training and by prior experience with helping a victim. Following training, health care providers reported increased self-efficacy, increased comfort making appropriate community referrals, and increased valuation of health care providers and the health care system as having an important role in stopping domestic violence. Hypothesis 4 was also supported. Prior training and/or experience with an abuse victim predicted smaller changes in the dependent variables. These gains held at a 6-month follow-up. Implications for training curriculum design are discussed, in addition to institutional policy implications for determining the benefits versus costs of universal training, including staff who demonstrate prior training or experience with battered victims. Study limitations and future research directions, including the need to measure performance and policy compliance will also be outlined.     

Waiting for Godot: wishes and worries in managed care

Managed care has done a better job at reducing expenditure growth than it has in improving quality. Although reduced expenditure growth is not appreciated by many, it has real benefits. For the majority of Americans who are privately insured, it results in greater disposable income for goods and services other than health care (although the illusion of employer-paid health insurance obscures this reality for many). For Medicaid programs, slower growth of expenditures facilitates efforts at expanding coverage. For low-income workers, slower expenditure growth results in larger numbers of people retaining insurance coverage than would have been the case if premiums rose more quickly. While there are some victories to which managed care organizations can point, we cannot credibly argue that overall levels of quality and health outcomes are improving as the health care system is massively disrupted by changes in health care finance and delivery. The disruptions create real hardships for some physicians and other health care workers, and worries for many consumers. These worries fuel the managed care backlash. The danger is that politicians will respond to these worries with policies that inhibit the development of high-quality delivery systems. The opportunity is for relatively modest public policy changes--external review organizations, better public-sector purchasing capabilities, public investment in producing and publicizing information on health plan and medical group performance, and establishment of a public ombudsperson--to respond to consumer worries and lead to improvements in health care quality and outcomes. Finally, I would be remiss without a reminder that the single most effective action politicians could take to improve health care quality and outcomes would be to change the rules of health care financing to assure that all Americans are covered by managed care. Even with all of its inadequacies, managed care is much superior to the patchwork care available to the 43 million Americans who are uninsured. The managed care backlash is concerned with protecting patients who are insured (and their providers). Far more valuable would be to protect those without insurance. Sadly, no politician has yet figured out how to do this. Still waiting.     

Community response and needs of African American female survivors of domestic violence

Relatively few studies have looked specifically at the experiences and needs of African American women who are survivors of domestic violence. This study sought to find out from African American survivors (a) what their experience was with various community entities and (b) how they feel race may have affected these experiences. Results indicate a great deal of dissatisfaction with the services received as they attempt to escape and/or stay away from their abusive partners. This dissatisfaction was in large measure due to lack of cultural competence. Implications for service and suggestions for community entities are presented.     

Attorneys’ career dissatisfaction in the new normal

The 2008 economic recession had a seismic impact on the legal market. In this article, we empirically assess whether the recession has made law an unsatisfying career. Relying on survey data from over 11,000 active members of the State Bar of Texas, we find that only 13.5 percent of all attorneys and 11.5 percent of full-time attorneys are dissatisfied with their careers. Newer attorneys report greater career dissatisfaction than more experienced attorneys, yet they too are largely satisfied. We also determine using logistic regression that three factors are highly predictive of lawyers’ career dissatisfaction: (1) comparatively low incomes; (2) working in private practice as opposed to in government or non-profit/public interest; and (3) law firm employment in a non-partnership role. Equally important, debt and lower class rank only slightly increase the odds of career dissatisfaction; and race, gender, years of practice experience, and firm size have no effect.     

Police Support for Community Problem-Solving and Broken Windows Policing

This paper explores overall police officer acceptance of tactics and tenets of broken windows and community problem-solving policing. It assesses differential support for each by police officer characteristics (i.e., race/ethnicity, gender, rank, education level, years of service, and assignment). This study presents the findings of a survey of 227 sworn police personnel from two urban police departments. Univariate analyses reveal the levels of support that police have for certain police tactics and tenets of broken windows and community problem-solving policing. Regression analyses examine the relationship between key officer characteristics and support for these tactics and tenets as measured by respondents’ agreement with various items and indices. Findings include support for community problem-solving (and also a reliance on traditional policing methods); a lag in investigators’ acceptance of community problem-solving; and differences by officer race/ethnicity, education, rank, and assignment in indices related to broken windows and rapid response policing. The differential acceptance of broken windows and rapid response tactics by race/ethnicity suggests interesting implications for future studies of race/ethnicity and broken windows policing. The greater acceptance of certain tactics by patrol officers supports current moves toward innovating in police investigations’ bureaus.     

Medicare program; changes concerning interest rates charged on overpayments and underpayments--HCFA. Final rule

We are revising the Medicare regulations to provide for the assessment of the higher of the private consumer rate or the current value of funds rate of interest on overpayments and underpayments to health care providers and suppliers. This change is being made to protect the Government's interest, as provided by the rules of the Secretary of the Treasury applicable to charges for late payments. We are also making clarifying changes in the regulations.     

Consumer beliefs and health plan performance: it's not whether you are in an HMO but whether you think you are

Surveys that rate how persons enrolled in HMOs and other types of health coverage feel about their health care are used to bolster claims that HMOs provide inferior quality care, providing justification for patient protection legislation. This research illustrates that the conventional wisdom regarding inferior care in HMOs may color how people assess their health care in surveys, resulting in survey findings biased toward showing HMOs provide inferior care and reinforcing existing stereotypes. Using merged data from the Community Tracking Study Household and Insurance Followback surveys, we identify privately insured persons who correctly and incorrectly know what kind of health plan they are covered by. Nearly a quarter misidentified their type of health coverage. Differences between responses by HMO and non-HMO enrollees to questions covering satisfaction with health care and physician choice, the quality of the last physician's visit, and patient trust in their physician shrink or disappear when we control for beliefs about what type of plan they are covered by. Results suggest that researchers and policy makers should be cautious about using consumer surveys to assess the relative quality of care provided under different types of health insurance.     

The impact of the adoption of gag laws on trust in the patient-physician relationship

Physician organizations, policy makers, and patient advocates have expressed concern that health plans have contractually limited the freedom of physicians to communicate with their patients. In response, many states have adopted gag laws that limit the ability of managed care contracts to restrict patient-physician communication. We examine the impact of these laws on patient trust in the physician. We analyzed patients' ratings of trust in their physicians in states before and after adoption of gag laws. Individuals in states that had such laws throughout the study period were used as the comparison group. The analysis is based on a nationally representative sample of adults obtained from the 1996-1997 and 1998-1999 Community Tracking Study Household Surveys. After adjustment for patient characteristics, it was estimated that the adoption of gag laws had no statistically significant impact on trust in the physician for the average patient. However, the adoption of gag laws is estimated to have increased trust in the physician by a modest amount (25 percent of a standard deviation) for health maintenance organization (HMO) enrollees who did not have a usual source of care. Gag laws may assure HMO enrollees without a usual source of care that their physicians are free to speak candidly about treatment options. This does not necessarily imply that physicians are prohibited from speaking freely in the absence of such laws, but gag laws indicate concerns (justified or not) that patients have about unrestricted communication with their health care providers.     

Playing fair: fairness beliefs and health policy preferences in the United States

Conventional wisdom suggests that the best way to persuade Americans to support changes in health care policy is to appeal to their self-interest - particularly to concerns about their economic and health security. An alternative strategy, framing problems in the health care system to emphasize inequalities, could also, however, mobilize public support for policy change by activating underlying attitudes about the unfairness or injustice of these inequalities. In this article, we draw on original data from a nationally representative survey to describe Americans' beliefs about fairness in the health domain, including their perceptions of the fairness of particular inequalities in health and health care. We then assess the influence of these fairness considerations on opinions about the appropriate role of private actors versus government in providing health insurance. Respondents believe inequalities in access to and quality of health care are more unfair than unequal health outcomes. Even after taking into account self-interest considerations and the other usual suspects driving policy opinions, perceptions of the unfairness of inequalities in health care strongly influence respondents' preferences for government provision of health insurance.     

Race,Ethnicity and the Risk of Homicide Victimization in the United States

Abstract

Linked data from the National Health Interview Surveys and Multiple Causes of Death Use Files are used to estimate the individual level effects of race and ethnicity, and relevant controls on homicide mortality. African American and Hispanic race/ethnicity are found to be leading factors in homicide victimization. Following some previous work this research also finds that the gap between white and minority homicide victimization is attenuated but not explained by SES, contextual and marital status variables. It is hypothesized that the experience and perception of racism, and the frustration, anger and resentment that result produce an ideological climate that sustains high levels of violence among minority members beyond what concentration of disadvantage variables predict.