Hospital care for the "self-pay" patient

The number of hospitalized patients lacking an identifiable source of third-party payment has risen substantially in recent years. This study examines trends in the hospitalization of "self-pay" patients and investigates causal influences on the propensity of hospitals to accept such patients for treatment. Our analysis pays particular attention to the relationship between Medicare's prospective payment system (PPS) and hospitals' self-pay patient share. Our results show an overall increase in both the number and proportion of self-pay patients treated by hospitals between 1980 and 1985. Substantial differences existed among the types of hospitals that accepted such patients, with major teaching hospitals treating an increasingly disproportionate share. The mix of self-pay patients in terms of age, sex, and reason for hospitalization remained stable during the period under study. Our conclusion is that the regression analysis shows no evidence that PPS reduced hospitals' willingness to treat uninsured patients.     

How do uncompensated care pools affect the level and type of care? Results from New York State

Uncompensated care pools have been used by several states in their attempt to aid hospitals and increase the volume of care provided to patients without health insurance. We examined the uncompensated care pool used in New York State between 1983 and 1987. Our primary interest was to estimate the impact of the pools on the level and type of care provided to uninsured patients. Our results indicate that hospitals responded to the pools by increasing the volume of care provided to uninsured patients. Without the pools, over 30,000 fewer adjusted hospital admissions would have been provided to the uninsured in a typical year. Many of these newly purchased admissions were for "nondiscretionary" medical care, suggesting that beneficial care to the indigent was rationed prior to the introduction of the uncompensated care pools.     

No room at the inn: a snapshot of an American emergency room

The emergency rooms of American hospitals have frequently become the principal suppliers of nonurgent primary care to the under- and uninsured. Canvassing published reports and using original data obtained from a representative urban hospital, Erik Olson examines the demographics of the American emergency room and analyzes its finances. The costs of providing primary care are shifted, to the extent possible, to those who can pay. The result is escalating health care costs and a deterioration of quality of care due to overcrowding, leading some hospitals to close their emergency rooms and others to turn away ambulances or "dump" patients who still require critical care. Mr. Olson explains that state antidumping laws and the federal COBRA statute have been ineffective at stemming these practices in the face of severe economic pressure to continue them. Pointing out that emergency rooms are an excessively expensive method of treating uninsured nonemergency patients, he proposes a system of primary care clinics created through a public/private partnership between municipalities and existing private health care providers. The partnership is designed to maintain a high standard of care at the clinics. As an incentive to stimulate the appearance of such clinics, a tax would be imposed on private health care providers; the tax on a given provider would be reduced to the extent that provider subsidizes a local primary care clinic that offers universal coverage, regardless of insurance status. Because the existence of such clinics would reduce inefficient use of hospital emergency rooms, in the long run hospitals should find it less expensive to finance local primary care clinics than to continue to sustain unreimbursed expenses due to improper use of their emergency departments.     

The impact of prospective payment: a multi-dimensional analysis of New Jersey's SHARE program

The SHARE program, which set per diem prospective rates for New Jersey hospitals during the period 1975-1982, is evaluated. Analysis suggests that this program did contain hospital cost increase. However, the program threatened the viability of most inner-city hospitals. Indirect evidence suggests that there was cost-shifting in response to this program, which regulated payment for only Blue Cross and Medicaid patients. Structural features of this program and its successor, the New Jersey DRG program, are analyzed; and implications for the Medicare prospective payment system are examined.     

Improved access to care for the uninsured poor in large cities: do public hospitals make a difference?

This study compares the volume of uncompensated care provided to the uninsured poor in cities with public hospitals to that provided in cities without a public hospital in order to determine whether public hospitals increase access to care. Multiple regression analysis is used to control for selected variables that also influence utilization of hospital care. Cities with public hospitals were found to provide between 31 and 34 uncompensated adjusted admissions per 100 uninsured poor; in cities without a public hospital, 24 such admissions were provided. In the regression analysis the coefficients for dummy variables representing three types of public hospital governance structures were all positive and statistically significant. The coefficient measuring teaching commitment among a city's hospitals was also positive and statistically significant. This analysis suggests that local tax support for public hospitals does not merely offset philanthropic or other revenue sources for voluntary hospital uncompensated care but is also likely to increase the amount of uncompensated care offered. We also find that public hospital closures may reduce access to care for the uninsured poor in large cities.     

The use of expensive health technologies in the era of managed care: the remarkable case of neonatal intensive care

The use of neonatal intensive care (NIC) continued to rise rapidly in the 1990s despite the concerns of observers about its cost effectiveness and its successes being mostly in facilities with high volume and capabilities. The objective of this study is to test the effects of insurance type, competition among hospitals, and market pressure from managed care plans on the supply and cost of NIC. The analysis uses logistic and linear models with techniques to avoid bias from (a) market area definitions based on actual patient flows and (b) self-selection of hospitals by patients with unmeasured risk of needing NIC. The data source contains all births in short-term hospitals in New Jersey during 1990 and 1994. Both the number of days and charges for NIC are reported. Key findings are that the decision of a hospital to offer NIC was associated with teaching status, the proportion of infants in the market area with documented high risk, and the market concentration of major competitors. The market share of managed care plans and the concentration of enrollment were not associated with either NIC being offered or with the standardized charges. Whether a particular patient was given to a NIC depended on patient risk factors and whether a NIC unit was present, but not on payer group. The results are consistent with the hypothesis that young insured parents (with the advice of their obstetricians) prefer hospitals with NIC and also are relatively profitable enrollees for health plans. In conclusion: using the results here and in other research, public and private policy makers may consider several ways to strengthen the incentives for health plans to contract for cost-effective birth-related services. The results also raise questions for a number of regulatory and payment policies and call for better public data on costs and outcomes for NIC.     

CHILD SUPPORT GUIDELINES:

Since 1984, all U.S. jurisdictions have established child support guidelines. Using computerized worksheets, we compared the guidelines of New York, New Jersey, and Connecticut (which use the “Income Shares” model also employed by 30 other jurisdictions). We calculated how child care, alimony to a prior spouse, and subsequent children change the support obligation. We found that, generally, Connecticut requires the most child support, New York is second, and New Jersey third. However, if children require child care, New York requires the most support. In Connecticut, child care costs have virtually no impact. When a noncustodial parent is paying alimony to a prior spouse, support is dramatically greater in Connecticut than in New Jersey, with New York in between. Only New Jersey reduces the support paid by the noncustodial parent who has subsequent children. New York's and Connecticut's mathematical guidelines do not consider subsequent children.     

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.     

Casino-related deaths in Atlantic City, New Jersey 1982-1986

The first legalized casino-hotel opened in Atlantic City, New Jersey in 1978. Annually, more than 30 million people visit the "Gambling Capitol of the East Coast." As a result of this growing influx of people, the Atlantic County Medical Examiner's Office began compiling statistics in 1982 of casino-related deaths. Data on 398 casino-related deaths occurring in 1982-1986 were collected and analyzed: 83% of the total number of fatalities were sudden cardiac deaths. Most of the victims were elderly white retired men who had previously diagnosed medical conditions. Many of the victims' underlying medical problems are of a type known to be associated with compulsive gambling. The majority of deaths occurred during the afternoon hours on weekends in October, January, and May. Of the victims, 86% were from New Jersey, New York, and Pennsylvania. For Atlantic City, a gambling community known to have a relatively high rate of crime and drug-trafficking, only 1% of all deaths were homicides. We speculate that the stress of gambling activities may induce sudden cardiac death. We therefore recommend that communities planning to legalize casino gambling mandate that gambling establishments provide emergency health care services for their patrons.     

Does all-payer rate setting work? The case of the New York Prospective Hospital Reimbursement Methodology

By 1983, four states had received waivers from the Health Care Financing Administration and adopted experimental reimbursement programs covering all third-party payers. In general, these programs were designed to moderate cost growth as well as to promote a number of broader distributive objectives. Among the concerns for equity were financing uncompensated care and spreading the costs across all payers, reducing the differential between hospital charges and costs, and rejuvenating fiscally distressed hospitals. These diverse goals represent a fundamental shift in the role of state rate setting; as a result, broader outcome measures are required to determine their overall impact. The New York Prospective Hospital Reimbursement Methodology (NYPHRM) is evaluated in this broader context. The NYPHRM successfully channeled revenues to fiscally blighted hospitals, increasing the volume of care to the uninsured while maintaining cost growth at national levels. According to this broader set of outcome measures, the NYPHRM would be viewed as a policy success.     

Individual-level and socio-structural characteristics of violence: an Emergency Department study

In this article, the authors present a data collection system to provide information about assault-related injuries within Newark, New Jersey. In 2001, Emergency Department (ED) staff at the six hospitals providing emergency medical care within the city collected data on all assault-related ED visits. Individual-level (n = 1,204) and neighborhood-level (n = 262) analyses were conducted; the latter used data from the 2000 U.S. Census. A hotspots map was also generated. At the individual level, one in three ED patients was assaulted by an intimate partner or other family member. In addition, African American males were disproportionately likely to be treated for assault-related injuries. At the socio-structural level, as hypothesized based on Social Disorganization Theory, hierarchical regression analyses reveal that poorer neighborhoods with more vacant housing units have significantly higher rates of assault-related injuries.     

The role of tax exemption in a competitive health care market

The Federal Trade Commission and Department of Justice 2004 report on competition in health care raises the issue of nonprofit versus for-profit form in several contexts, including their relative financial performance, pricing behavior, and role in caring for the uninsured poor. The report, however, does not discuss in detail the connection between tax exemption and the nonprofit/for-profit debate. Is tax exemption, for example, "buying" charity care for the poor, and would withdrawal of exemption negatively impact health care for the uninsured poor? Or is tax exemption justified on the grounds of other nonprofit behavior outside the financial realm and thus not considered by the report? If nonprofit status does not result in differential financial behavior (as the report concludes) and if competition will end the ability of hospitals to cross subsidize free care for the poor (as the report speculates), is there any reason to retain tax exemption for nonprofit hospitals? This article summarizes the debate on these issues and offers some alternatives to the current structure of tax exemption for nonprofit health care providers.     

Eyewitnesses in the courtroom: a jury-level experimental examination of the impact of the Henderson instructions

Journal of Experimental Criminology - The New Jersey Supreme Court in New Jersey v. Henderson (2011) proposed judicial instructions designed to assist juries in evaluating eyewitness evidence. The...     

Hill-Burton: the unfulfilled promise

The poor and uninsured encounter numerous barriers to health care access. The Hill-Burton Act of 1946 required many hospitals to make their services available to all persons, yet ineffective enforcement has limited the utility of the act's requirements. Hill-Burton hospital audits have revealed widespread facility noncompliance. In light of these findings, alternative enforcement procedures should be considered.     

Per case prospective payment for psychiatric inpatients: an assessment and alternatives

Psychiatric hospitals and clinics are exempted from the Medicare prospective payment system. In this paper we examine the appropriateness of the DRG classification system for psychiatric patients and argue that, using this system as the basis of payment, two types of problems are likely to arise. We categorize these problems as "risks to hospitals" and "risks to patients" and examine the existing literature to determine whether these risks are likely to be significant. We propose a different approach to paying prospectively for psychiatric care, and suggest modifications that could be made to the structure of PPS to mitigate negative incentives embedded in the current system. Although the main focus of the paper is on the unit of payment, we also make some observations about issues arising in connection with the level of payment.     

THE FOSTER CARE OMBUDSMAN: APPLYING AN INTERNATIONAL CONCEPT TO HELP PREVENT INSTITUTIONAL ABUSE OF AMERICA'S FOSTER YOUTH

Children today are often abused while in foster care, undermining the theoretical goal of the modern foster care system: to create a temporary, safe, homelike setting to protect and nurture children who are unable to live with their biological parents due to various reasons such as abuse, neglect, or abandonment. Often this abuse is worse than the type for which they were removed from their parents’ care in the first place. First examining the reasons why this complex problem exists, this Note recommends an internationally based, innovative concept as a partial solution: the foster care ombudsman. This Note explains the concept of an ombudsman and demonstrates how it can be particularly helpful to foster children, highlighting existing child welfare ombudsman offices in California, Rhode Island, and New Jersey, as well as international approaches. It also illustrates how a foster care ombudsman can complement class action litigation of foster care abuse claims.     

Constitutional law--New Jersey abortion statute unconstitutionally vague on its face

The old New Jersey abortion statute held that abortion before the quickening of the child was not indictable. The Young Women's Christian Association (YWCA) of Princeton, New Jersey, is a consolidation of 2 suits in the District Court questioning the constitutionality of the New Jersey statute. The court ruled that the women plaintiffs were without standing to raise the question of constitutionality. The court also ruled that because of the prosecutions for committing illegal abortions, the abortions, the physicians had a sufficient legal interest to argue that the statute deprives the physician of the right to practice medicine according to the highest standards of medical practice and violates the right to privacy of the patients.     

Expanding health insurance coverage: who will pay?

Recent discussions on extending health insurance to the more than thirty million uninsured Americans have focused on two strategies: expanding the Medicaid program and mandating that employers sponsor coverage for their employees. This analysis, using a microsimulation model of the U.S. health care financing system, suggests that these two options would result in very different distributions of financial burden. Employer-sponsored coverage is financed in a highly regressive fashion, in contrast to the Medicaid program, which is proportional to income. Furthermore, the burden of paying for health care under Medicaid varies little among generations, whereas the cost of employer-sponsored care is lowest in households headed by persons over sixty-five years old. Low health status populations do not pay disproportionately higher taxes or premiums to finance either the Medicaid program or employer-sponsored coverage. Their incomes, however, are more effectively protected by Medicaid, because it offers more comprehensive benefits.     

A dose of reality: assessing the Federal Trade Commission/Department of Justice report in an uninsured, underserved, and vulnerable population context

Despite the size of their report, the Federal Trade Commission and Department of Justice pay virtually no attention to tens of millions of uninsured and underinsured persons. By focusing on an increasingly rarified group of health care customers--healthy, affluent, and highly insured--the report takes on an untethered quality, with only the slightest tip of the hat to its own limitations. Furthermore, the report overstates the extent of legal constraints on the market, in particular, the degree to which the market is free to select its customers and tailor its goods and services to the best risks. By miscasting the legal context of the American health care system, the report ultimately undermines much of its potential value.