RESUMEN
BACKGROUND: Certificate of Need (CON) laws, currently in place in 35 US states, require certain health care providers to obtain a certification of their economic necessity from a state board before opening or undertaking a major expansion. We conduct the first systematic review and cost-effectiveness analysis of these laws. METHODS: We review 90 articles to summarize the evidence on how certificate of need laws affect regulatory costs, health expenditures, health outcomes, and access to care. We use the findings from the systematic review to conduct a cost-effectiveness analysis of CON. RESULTS: The literature provides mixed results, on average finding that CON increases health expenditures and overall elderly mortality while reducing heart surgery mortality. Our cost-effectiveness analysis estimates that the costs of CON laws somewhat exceed their benefits, although our estimates are quite uncertain. CONCLUSIONS: The literature has not yet reached a definitive conclusion on how CON laws affect health expenditures, outcomes, or access to care. While more and higher quality research is needed to reach confident conclusions, our cost-effectiveness analysis based on the existing literature shows that the expected costs of CON exceed its benefits.
Asunto(s)
Certificado de Necesidades/economía , Certificado de Necesidades/legislación & jurisprudencia , Análisis Costo-Beneficio , Humanos , Estados UnidosRESUMEN
This commentary argues against Medicaid expansion in North Carolina for 5 reasons: Expansion will reduce access to care for highly vulnerable individuals who are already enrolled in Medicaid; it is unlikely to save lives; it is unaffordable in the long run; its current financing structure encourages fiscal irresponsibility; and it will eliminate more jobs than it creates.
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Medicaid/economía , Empleo , Accesibilidad a los Servicios de Salud , Humanos , Pacientes no Asegurados , North Carolina , Médicos/provisión & distribución , Estados UnidosRESUMEN
OBJECTIVES: To examine the relationship among use of an on-site employer-provided primary care medical home, and health services use and health plan costs for inpatient and outpatient services and pharmaceuticals. STUDY DESIGN: The study was a retrospective observational analysis of health plan claims, human resources data, and Health Care Center (HCC) encounters. METHODS: Three years of data for employees and dependents designating the HCC as their primary care provider (HCC major users) were compared with data from 2 comparison groups: "casual" HCC users and HCC nonusers. The outcomes of interest were: 1) health services utilization, and 2) monetized use of the health plan. Secondary data from an employer-provided Health Care Center (HCC). RESULTS: After adjusting for several potential confounders, HCC major users had less use of external healthcare services than the comparison groups (employees had 2.7 fewer external encounters than HCC casual users [P < .001] and 1.2 fewer external encounters than nonusers [P < .001]; dependents had 3.5 fewer external encounters than HCC casual users [P < .001] and 1.9 fewer external encounters than non-users [P < .001]). Annual monetized use of the health plan for employees and dependents was highest for HCC casual users relative to HCC major users (employees: $482 greater, P < .01; dependents: $598 greater, P < .001). CONCLUSIONS: Employees and their dependents who were "casual users" of the HCC had the highest claims costs and use of outside healthcare services. Additional research is needed to assess the extent to which employees' utilization of services at on-site primary care medical homes affects employee health outcomes, resulting in potential effects on company healthcare plan expenditures, worker productivity, and return on investment.
Asunto(s)
Servicios de Salud/economía , Servicios de Salud/estadística & datos numéricos , Atención Dirigida al Paciente/estadística & datos numéricos , Lugar de Trabajo , Adolescente , Adulto , Femenino , Planes de Asistencia Médica para Empleados/economía , Planes de Asistencia Médica para Empleados/estadística & datos numéricos , Estado de Salud , Humanos , Revisión de Utilización de Seguros , Masculino , Persona de Mediana Edad , Salud Laboral , Ocupaciones , Atención Dirigida al Paciente/economía , Atención Primaria de Salud/economía , Atención Primaria de Salud/estadística & datos numéricos , Grupos Raciales , Estudios Retrospectivos , Adulto JovenRESUMEN
HIV triply-diagnosed adults (those with chronic mental illness and substance abuse disorders) must rely heavily on public insurance to cover high annual medical costs (approximately $50,000). This study examines the nature and determinants of insurance coverage (including managed care) for this population, along with annual transitions in coverage. Relative to people living with HIV/AIDS in general, fewer triply-diagnosed adults rely on private coverage (3% vs. 30%), but their rate of being uninsured is only slightly lower (16% vs. 20%). More than one third of such adults below poverty are uninsured-a matter of significant policy concern since the annual income of this group is less than 10% of the amount needed to cover their expected medical expenses. Those with the lowest mental health status were disproportionately represented in managed care. While coverage appears relatively stable over time, those with low incomes and moderate mental health status may face barriers in securing Medicaid.
Asunto(s)
Infecciones por VIH/complicaciones , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/economía , Trastornos Mentales/complicaciones , Trastornos Relacionados con Sustancias/complicaciones , Adolescente , Adulto , Enfermedad Crónica , Femenino , Estudios de Seguimiento , Infecciones por VIH/economía , Costos de la Atención en Salud , Humanos , Masculino , Asistencia Médica , Trastornos Mentales/economía , Persona de Mediana Edad , Factores Socioeconómicos , Trastornos Relacionados con Sustancias/economía , Estados Unidos , Adulto JovenRESUMEN
Genetic testing for inherited susceptibility to breast and ovarian cancer can be compared with similar testing for colorectal cancer as a "natural experiment." Inherited susceptibility accounts for a similar fraction of both cancers and genetic testing results guide decisions about options for prophylactic surgery in both sets of conditions. One major difference is that in the United States, Myriad Genetics is the sole provider of genetic testing, because it has sole control of relevant patents for BRCA1 and BRCA2 genes, whereas genetic testing for familial colorectal cancer is available from multiple laboratories. Colorectal cancer-associated genes are also patented, but they have been nonexclusively licensed. Prices for BRCA1 and 2 testing do not reflect an obvious price premium attributable to exclusive patent rights compared with colorectal cancer testing, and indeed, Myriad's per unit costs are somewhat lower for BRCA1/2 testing than testing for colorectal cancer susceptibility. Myriad has not enforced patents against basic research and negotiated a Memorandum of Understanding with the National Cancer Institute in 1999 for institutional BRCA testing in clinical research. The main impact of patenting and licensing in BRCA compared with colorectal cancer is the business model of genetic testing, with a sole provider for BRCA and multiple laboratories for colorectal cancer genetic testing. Myriad's sole-provider model has not worked in jurisdictions outside the United States, largely because of differences in breadth of patent protection, responses of government health services, and difficulty in patent enforcement.
Asunto(s)
Neoplasias de la Mama/genética , Neoplasias del Colon/genética , Predisposición Genética a la Enfermedad/genética , Pruebas Genéticas/ética , Licencia Médica/ética , Neoplasias Ováricas/genética , Patentes como Asunto/ética , Proteína BRCA1/genética , Proteína BRCA2/genética , Neoplasias de la Mama/diagnóstico , Neoplasias del Colon/diagnóstico , Análisis Costo-Beneficio , Femenino , Genes , Pruebas Genéticas/economía , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/ética , Humanos , Masculino , Neoplasias Ováricas/diagnósticoRESUMEN
To determine healthcare access and costs for triply diagnosed adults, we examined baseline data from the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site cohort study of HIV+ adults with co-occurring mental and substance abuse disorders conducted between 2000 and 2004. Baseline interviews were conducted with 1138 triply diagnosed adults in eight predominantly urban sites nationwide. A modified version of Structured Interview for DSM-IV Axis I Disorders (SCID) was used to assign Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses for the preceding year. Utilization of a broad range of inpatient and outpatient services and medications over the preceding three months was patient-reported in face-to-face interviews. We then applied nationally representative unit costs to impute average monthly expenditures. We measured (poor) access to care during the three-month period by whether the patient had: (a) no outpatient medical visits; (b) at least one emergency room visit without an associated hospitalization; and (c) at least one hospitalization. At baseline, mean expenditures were $3880 per patient per month. This is nearly twice as high as expenditures for HIV/AIDS patients in general. Inpatient care (36%), medications (33%), and outpatient services (31%) each accounted for roughly one-third of expenditures. Expenditures varied by a factor of 2:1 among subgroups of patients, with those on Medicare or Medicaid, not in stable residences, or with poor physical health or high viral loads exhibiting the highest costs. Access to care was worse for women and those with low incomes, unstable residences, same-sex exposure, poor physical or mental health, and high viral loads. We conclude that HIV triply diagnosed adults account for roughly one-fifth of medical spending on HIV patients and that there are large variations in utilization/costs across patient subgroups. Realized access is good for many triply diagnosed patients, but remains suboptimal overall. Deficiencies in HIV care are unevenly distributed, tending to concentrate on already disadvantaged populations.
Asunto(s)
Infecciones por VIH/economía , Trastornos Mentales/economía , Adulto , Anciano , Enfermedad Crónica , Femenino , Infecciones por VIH/psicología , Infecciones por VIH/terapia , Costos de la Atención en Salud , Gastos en Salud , Accesibilidad a los Servicios de Salud/economía , Humanos , Renta , Masculino , Trastornos Mentales/terapia , Persona de Mediana Edad , Aceptación de la Atención de Salud , Trastornos Relacionados con Sustancias/economía , Trastornos Relacionados con Sustancias/terapiaRESUMEN
BACKGROUND: Triply diagnosed patients, who live with HIV and diagnosed mental health and substance abuse disorders, account for at least 13% of all HIV patients. This vulnerable population has substantial gaps in their care, attributable in part to the need for treatment for three illnesses from three types of providers. AIMS OF THE STUDY: The HIV/AIDS Treatment Adherence, Health Outcomes and Cost study (HIV Cost Study) sought to evaluate the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services among triply diagnosed patients. The analysis was conducted from a health sector budget perspective. METHODS: Patients from four sites were randomly assigned to intervention group (n=232) or control group (n=199) that received care-as-usual. Health service costs were measured at baseline and three, six, nine and 12 months and included hospital stays, emergency room visits, outpatient visits, residential treatment, formal long-term care, case management, and both prescribed and over-the-counter medications. Costs for each service were the product of self-reported data on utilization and unit costs based on national data (2002 dollars). Quality of life was measured at baseline and six and 12 months using the SF-6D, as well as the SF-36 physical composite score (PCS) and mental composite score (MCS). RESULTS: During the 12 months of the trial, total average monthly cost of health services for the intervention group decreased from USD 3235 to USD 3052 and for the control group decreased from USD 3556 to USD 3271, but the decreases were not significant. For both groups, the percentage attributable to hospital care decreased significantly. There were no significant differences in annual cost of health services, SF-6D, PCS or MCS between the intervention and control group. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The results of this randomized controlled trial did not demonstrate that the integrated interventions significantly affected the health service costs or quality of life of triply diagnosed patients. Professionals could pursue coordination or integration of care guided by the evidence that it does not increase the cost of care. The results do not however, provide an imperative to introduce multi-disciplinary care teams, adherence counseling, or personalized nursing services as implemented in this study. IMPLICATIONS FOR HEALTH POLICIES: There is not enough evidence to either limit continued exploration of integration of care for triply diagnosed patients or adopt policies to encourage it, such as financial reimbursement, grants regulation or licensing. IMPLICATIONS FOR FURTHER RESEARCH: Future trials with interventions with lower baseline levels of integration, longer duration and larger sample sizes may show improvement or slow the decline in quality of life. Future researchers should collect comprehensive cost data, because significant decreases in the cost of hospital care did not necessarily lead to significant decreases in the total cost of health services.
Asunto(s)
Prestación Integrada de Atención de Salud/economía , Infecciones por VIH/economía , Costos de la Atención en Salud , Trastornos Mentales/economía , Trastornos Relacionados con Sustancias/economía , Adolescente , Adulto , Enfermedad Crónica/economía , Análisis Costo-Beneficio , Diagnóstico Dual (Psiquiatría) , Femenino , Infecciones por VIH/terapia , Humanos , Masculino , Trastornos Mentales/terapia , Persona de Mediana Edad , Mortalidad , Cooperación del Paciente , Honorarios por Prescripción de Medicamentos , Calidad de Vida , Perfil de Impacto de Enfermedad , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/terapia , Estados Unidos/epidemiología , Carga Viral , Adulto JovenRESUMEN
Although AIDS is a chronic illness, little is known about the patterns and correlates of long-term care use among triply diagnosed HIV patients. We examined nursing and home care use among 1,045 participants in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site study of HIV-positive patients with at least one mental health and one substance disorder. Patient interviews and medical record review data were used to examine the average monthly cost of nursing home, formal home and informal home care. Multinomial logit and two-part regression models were used to identify correlates of the use of formal and informal home care and the number of informal home care hours used. During the three months prior to baseline, 2, 7 and 23% of participants used nursing home, formal home and informal home care, respectively. Patients who were better-educated, had higher incomes, had Medicaid insurance (with or without Medicare coverage) and whose transmission mode was homosexual sex had higher regression-adjusted probabilities of receiving any formal home care; Latinos and physically healthier patients had lower probabilities. Women and patients who abused drugs or alcohol (but not both) were more likely to receive informal care only. Overall, patients who were female, better-educated, physically or mentally sicker or single-substance abusers were more likely to receive any home care (either formal or informal), while those contracting HIV through heterosexual sex were less likely. Women received 28 more monthly hours of informal care than men and married patients received 31 more hours than unmarried patients. We conclude that at least one mutable policy factor (Medicaid insurance) is strongly associated with formal home care use among triply diagnosed patients. Further research is needed to explore possible implications for access among this vulnerable subpopulation.
Asunto(s)
Infecciones por VIH/enfermería , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Atención Domiciliaria de Salud/estadística & datos numéricos , Trastornos Mentales/enfermería , Trastornos Relacionados con Sustancias/enfermería , Adolescente , Adulto , Costos y Análisis de Costo , Diagnóstico Dual (Psiquiatría) , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/economía , Gastos en Salud , Servicios de Atención de Salud a Domicilio/economía , Atención Domiciliaria de Salud/economía , Humanos , Seguro/estadística & datos numéricos , Modelos Logísticos , Masculino , Trastornos Mentales/complicaciones , Trastornos Mentales/economía , Persona de Mediana Edad , Factores Socioeconómicos , Trastornos Relacionados con Sustancias/complicaciones , Trastornos Relacionados con Sustancias/economía , Encuestas y Cuestionarios , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVE: To examine the effects of race/ethnicity, insurance, and type of substance abuse (SA) diagnosis on utilization of mental health (MH) and SA services among triply diagnosed adults with HIV/AIDS and co-occurring mental illness (MI) and SA disorders. DATA SOURCE: Baseline (2000 to 2002) data from the HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study. STUDY DESIGN: A multiyear cooperative agreement with 8 study sites in the United States. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was administered by trained interviewers to determine whether or not adults with HIV/AIDS had co-occurring MI and SA disorders. DATA COLLECTION/EXTRACTION METHODS: Subjects were interviewed in person about their personal characteristics and utilization of MH and SA services in the prior 3 months. Data on HIV viral load were abstracted from their medical records. PRINCIPAL FINDINGS: Only 33% of study participants received concurrent treatment for MI and SA, despite meeting diagnostic criteria for both: 26% received only MH services, 15% received only SA services, and 26% received no services. In multinomial logistic analysis, concurrent utilization of MH and SA services was significantly lower among nonwhite and Hispanic participants as a group and among those who were not dependent on drugs and alcohol. Concurrent utilization was significantly higher for people with Veterans Affairs Civilian Health and Medical Program of the Uniformed Services (VA CHAMPUS) insurance coverage. Two-part models were estimated for MH outpatient visits and 3 SA services: (1) outpatient, (2) residential, and (3) self-help groups. Binary logistic regression was estimated for any use of psychiatric drugs. Nonwhites and Hispanics as a group were less likely to use 3 of the 5 services; they were more likely to attend SA self-help groups. Participants with insurance were significantly more likely to receive psychiatric medications and residential SA treatment. Those with Medicaid were more likely to receive MH outpatient services. Participants who were alcohol dependent but not drug dependent were significantly less likely to receive SA services than those with dual alcohol and drug dependence. CONCLUSION: Among adults with HIV/AIDS and co-occurring MH and SA disorders, utilization of MH and SA services needs to be improved.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/terapia , Infecciones por VIH/terapia , Trastornos Mentales/terapia , Servicios de Salud Mental/estadística & datos numéricos , Centros de Tratamiento de Abuso de Sustancias/estadística & datos numéricos , Trastornos Relacionados con Sustancias/terapia , Síndrome de Inmunodeficiencia Adquirida/complicaciones , Síndrome de Inmunodeficiencia Adquirida/etnología , Adolescente , Adulto , Negro o Afroamericano/estadística & datos numéricos , Anciano , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/etnología , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Seguro/estadística & datos numéricos , Entrevistas como Asunto , Modelos Logísticos , Masculino , Trastornos Mentales/complicaciones , Trastornos Mentales/etnología , Servicios de Salud Mental/economía , Persona de Mediana Edad , Modelos Teóricos , Factores Socioeconómicos , Centros de Tratamiento de Abuso de Sustancias/economía , Trastornos Relacionados con Sustancias/complicaciones , Trastornos Relacionados con Sustancias/etnología , Encuestas y Cuestionarios , Estados Unidos , Población Blanca/estadística & datos numéricosRESUMEN
BACKGROUND: This paper examines the labor market outcomes of HIV triply-diagnosed adults having a combination of HIV, mental illness and substance abuse problems. AIMS OF THE STUDY: We sought to determine the sources of money income for HIV triply diagnosed adults (public or private), receipt of transfer income (e.g., welfare) and financial support from others. We further sought to ascertain their employment status and analyze the characteristics associated with full- and part-time employment. METHODS: We use self-reported money income during the past 30 days and self-reported employment status. We calculate earnings losses due to illness by subtracting self-reported earnings from average earnings for all U.S. workers based on 5-year age and gender categories. We provide descriptive statistics to show how income and employment vary by patient characteristics and logistic regression analysis to examine correlates of income and employment. RESULTS: Average income is below the poverty level for single individuals, with more than two-thirds coming from public income sources. The likelihood of receiving disability/retirement income was lower among those with the worst mental health (RR=0.80; 95% CI=0.64, 0.97). Blacks were more likely than others to rely on public assistance (RR=1.24; 95% CI=1.02, 1.55) and married individuals were less likely (RR=0.60; 95% CI=0.41, 0.79). While most private income comes from employment, less than 15 percent of this population is employed full- or part-time. On a monthly basis, the average individual in our sample lost $2,726 in income when compared to the earnings of individuals of the same age and sex in the general population. The relative probability of current full-time/part-time employment was lower among females (RR=0.56; 95% CI=0.34, 0.83); such employment also was lower among those in the worst physical health (RR=0.39; 95% CI=0.26, 0.65) and those in moderate physical health (RR=0.55; 95% CI=0.34, 0.81) relative to those in the best physical health. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This population represents an important opportunity for better health and labor market outcomes through prevention and improved treatment adherence. IMPLICATIONS FOR HEALTH POLICIES: Despite its relatively small size (at least 100,000), this population merits closer attention due to a combination of their high medical and companion social costs (e.g., income transfers) and the large potential for improving their ability to earn income. IMPLICATIONS FOR FURTHER RESEARCH: Future research should determine the marginal contribution of mental health conditions or substance abuse on income or labor market outcomes relative to individuals having only HIV/AIDS. This would allow policymakers to better understand how much of income and employment can be attributed to HIV/AIDS, mental health or substance abuse. Future work also should examine the impact of integrated treatment services on income and employment for this population.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/economía , Empleo/estadística & datos numéricos , Infecciones por VIH/economía , Infecciones por VIH/epidemiología , Renta , Trastornos Mentales/economía , Trastornos Mentales/epidemiología , Síndrome de Inmunodeficiencia Adquirida/epidemiología , Síndrome de Inmunodeficiencia Adquirida/etnología , Adulto , Enfermedad Crónica , Comorbilidad , Demografía , Diagnóstico Dual (Psiquiatría) , Empleo/economía , Femenino , Infecciones por VIH/etnología , Humanos , Masculino , Trastornos Mentales/etnología , Persona de Mediana Edad , Trastornos Relacionados con Sustancias/economía , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/etnología , Encuestas y Cuestionarios , Estados Unidos/epidemiologíaRESUMEN
Conversions of Blue Cross plans to for-profit status have the potential to remake the corporate landscape of health care finance. Absent regulatory intervention, current trends could easily result in more than half of Blue Cross subscribers being in for-profit plans, a phenomenon far more significant than the conversion of nonprofit hospitals. Therefore, regulators' deliberations over conversion proposals are beginning to focus on the health policy impacts. This chapter surveys the full range of health policy implications by analyzing all existing studies of Blue Cross conversions and reporting on the authors' own case studies of conversion impacts. These studies conclude that conversions have not caused major negative impacts on the availability or accessibility of health care in the states in which conversions have occurred so far. However, a great deal of uncertainty exists about the actual effects of previous conversions, and each state is unique; therefore, even if the historical record were clear, it is difficult to predict with great certainty what the actual effects will be in another state undergoing a Blue conversion.
Asunto(s)
Planes de Seguros y Protección Cruz Azul/organización & administración , Política de Salud , Accesibilidad a los Servicios de Salud/tendencias , Inversiones en Salud , Organizaciones sin Fines de Lucro/organización & administración , Propiedad/tendencias , Planes de Seguros y Protección Cruz Azul/tendencias , Estudios de Evaluación como Asunto , Investigación sobre Servicios de Salud , Humanos , Organizaciones sin Fines de Lucro/tendencias , Propiedad/economía , Salud Pública , Estados UnidosRESUMEN
Using statewide data on health spending and uninsurance rates, we investigate the impact of Blue Cross conversions on health care costs and coverage. We find mixed results, with some conversion states improving their performance on either or both measures relative to the national average and others experiencing a decline. A multivariate analysis suggests that overall, the impact of Blue Cross conversion may be to reduce hospital and total spending, but whether this effect endures depends in part on how "conversion" is defined. State policymakers and regulators might find these results useful in considering future Blue Cross conversions.
Asunto(s)
Planes de Seguros y Protección Cruz Azul/organización & administración , Gastos en Salud , Pacientes no Asegurados , Planes de Seguros y Protección Cruz Azul/economía , Honorarios y Precios , Accesibilidad a los Servicios de Salud , Cobertura del Seguro , Estados UnidosAsunto(s)
Planes de Seguros y Protección Cruz Azul/organización & administración , Honorarios y Precios , Accesibilidad a los Servicios de Salud , Inversiones en Salud/economía , Organizaciones sin Fines de Lucro/organización & administración , Propiedad/economía , Bienestar Social , Planes de Seguros y Protección Cruz Azul/economía , Planes de Seguros y Protección Cruz Azul/legislación & jurisprudencia , Investigación sobre Servicios de Salud , Humanos , Selección Tendenciosa de Seguro , Inversiones en Salud/legislación & jurisprudencia , Estudios de Casos Organizacionales , Innovación Organizacional , Organizaciones sin Fines de Lucro/economía , Organizaciones sin Fines de Lucro/legislación & jurisprudencia , Propiedad/legislación & jurisprudencia , Política Pública , Responsabilidad Social , Estados UnidosRESUMEN
This study assesses the determinants of conversions in hospital ownership from 1986 through 1996. To place such changes in context, we also analyze causes of hospital mergers and closures, which are often alternatives to hospital ownership conversion. A consistent result from our analysis is that an important antecedent of ownership conversions is a low profit margin. Conversions from private nonprofit or government ownership to for-profit status are preceded by chronically low margins and high debt-to-asset ratios. By contrast, conversions from for-profit ownership occur quickly following declines in margins. Many mergers seem motivated by a desire to increase market power--a consideration not evident for conversions.
Asunto(s)
Toma de Decisiones en la Organización , Clausura de las Instituciones de Salud/economía , Instituciones Asociadas de Salud/economía , Planificación de Instituciones de Salud/economía , Propiedad/economía , Clausura de las Instituciones de Salud/estadística & datos numéricos , Instituciones Asociadas de Salud/estadística & datos numéricos , Planificación de Instituciones de Salud/estadística & datos numéricos , Investigación sobre Servicios de Salud , Hospitales con Fines de Lucro/organización & administración , Hospitales Públicos/organización & administración , Hospitales Filantrópicos/organización & administración , Renta , Modelos Econométricos , Innovación Organizacional , Privatización/economía , Probabilidad , Estados UnidosRESUMEN
This article presents information on the rates of return obtained by purchasers of U.S. hospitals since the mid 1980s. The key hypothesis tested in this study was whether for-profit acquirers are able to purchase hospitals at below-market prices. We test the hypothesis by comparing internal rates of return to an estimate of the weighted cost of capital for all for-profit hospitals in the year the transaction occurred.
Asunto(s)
Administración Financiera de Hospitales/tendencias , Instituciones Asociadas de Salud/economía , Hospitales con Fines de Lucro/economía , Gastos de Capital , Asignación de Costos , Eficiencia Organizacional , Hospitales Filantrópicos/economía , Inversiones en Salud/economía , Propiedad/economía , Estados UnidosRESUMEN
BACKGROUND: TennCare expanded Medicaid coverage, substituting managed care for fee-for-service reimbursement in Tennessee. METHODS: To study effects of TennCare on utilization of obstetric care (office visits, prenatal tests, care at labor/delivery), we used a before (1993) and after (1995) design with North Carolina as a control state. Data came from interviews with women with various forms of insurance, delivering in 1993 or 1995 in both states. Multivariate logistic analysis was used to control for other utilization determinants (eg, demographic factors). RESULTS: TennCare women were only 38% as likely to have initiated prenatal care during the first trimester as those with traditional Medicaid. Ultrasonography and alpha-fetoprotein testing rates were higher for TennCare women, and the cesarean section rate was equivalent. However, access to care remained lower for TennCare than for the privately insured women. CONCLUSIONS: Overall, relative to traditional Medicaid, TennCare did not adversely affect access to obstetric care during the program's early years.