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.     

The Meaning of Home: A Chimerical Concept or a Legal Challenge?

'Home' is not an easy concept to pin down. Although the term is instantly familiar, and the physical reality of home is an important and omnipresent feature of our everyday lives, the legal conception of home has received surprisingly little attention. The relative neglect of home is particularly striking, however, in light of the substantial body of research which has been carried out on the subject of home in other disciplines. This article discusses the meanings of home which have evolved from interdisciplinary research. It is argued that this research could provide a starting point for the development of a more clearly articulated socio–legal understanding of the meaning and value of home to occupiers. It is suggested that a legal concept of the meaning of home would be useful, for instance, when considering the conflict of interests between the occupiers of a property 'as a home', and other parties with 'non–home' interests in the property, for example, creditors. This article seeks to identify some of the values of home which might inform a legal concept of home, and so be 'weighed in the balance' on the occupier's side when decisions involving conflicts between home interests and commercial interests are considered.     

Tax administration as health policy: hospitals, the Internal Revenue Service, and the courts

Since 1969 federal tax policy has permitted nonprofit hospitals to turn away indigent patients or to transfer them to public hospitals. The Internal Revenue Service made health policy, but its officials remain convinced that they were not making policy at all. Convinced that it was reasoning from legal principles, the Revenue Service accepted the hospital industry's view of the history and purpose of hospitals. The federal courts further obscured the problem. Moreover, the Revenue Service took no interest in the effects of its ruling on the services provided by tax-exempt hospitals until 1989. We describe these events and seek to explain them by linking the recent history of health policy to the assumptions that govern the making of tax policy. We conclude that the making of health policy by tax officials who are not accountable for it and who believe that they are not making policy at all is not in the public interest.