An empirical examination of cost-adjusting in outpatient clinics

This paper presents an empirical methodology for examining cost-adjusting in relation to multiple-output health care providers. The methodology is subsequently implemented using a sample of California outpatient clinics. The empirical evidence is that these clinics do cost-adjust; that is, the clinics respond to low Medicare reimbursement by using lower quality to control the marginal costs of those patient groups not insured under a government-sponsored plan. In addition, clinics do not cost-adjust with respect to Medi-Cal patients, implying that various government reimbursement systems have different effects on a provider’s cost-adjusting behavior.     

Barriers to Managing Coronary Artery Disease Among Older Women

Numerous barriers to managing coronary artery disease (CAD) among older women are reported in the literature; however, few studies adjust for demographic and health status differences. A survey assessing barriers and other factors was distributed to a stratified random sampling of older women with CAD. Factor analysis and multiple logistic regression procedures were used to estimate the impact of these issues on receiving a CAD-related office visit. The most problematic barriers included denial and low health literacy. Efforts to promote patient awareness of heart health and better communication between patients and clinicians may alleviate these barriers.     

Medicare and Amyloid PET Imaging: The Battle Over Evidence

We examine a recent dispute regarding the Centers for Medicare and Medicaid Services’ (CMS) refusal to unconditionally pay for amyloid positron emission tomography (PET) imaging for Medicare beneficiaries being assessed for Alzheimer’s disease. CMS will only pay for amyloid PET imaging when patients are enrolled in clinical trials that meet certain criteria. The dispute reflects CMS’s willingness in certain circumstances to require effectiveness evidence that differs from the Food and Drug Administration’s standard for pre-market approval of a medical intervention and reveals how stakeholders with differing perspectives about evidentiary standards have played a role in attempting to shape the Medicare program’s coverage policies.     

Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change

Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and “culture change” NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH’s payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices.     

Conservative Ideas and Social Policy in the United States

This article explores social policy development in the United States since the beginning of the George W. Bush presidency. Starting from an analysis of the discourse about compassionate conservatism at the centre of the 2000 presidential campaign and proceeding to a discussion of the meaning of the more recent ownership society blueprint, it underlines the fragmented nature of the conservative policy agenda in the United States. Yet, the article suggests that, despite this fragmentation, the ideological dominance of the right and the related absence of needed reform in key policy areas are of great significance for the future of federal social policy. Overall, the article shows how paying close attention to the nature of conservative ideas improves our understanding of social policy development in the United States. As argued, the old liberal and the traditionalist sides of American conservatism have inspired distinct yet related blueprints and reform proposals that both promote a scaling-down of existing federal social programmes and a return to traditional forms of economic security (i.e. charity and personal savings). The article underlines the relationship between these blueprints and policy drift.     

Home birth and the National Australian Maternity Services Review: too hot to handle?

Background

In February 2009 the Improving Maternity Services in Australia – The Report of the Maternity Services Review (MSR) was released, with the personal stories of women making up 407 of the more than 900 submissions received. A significant proportion (53%) of the women were said to have had personal experience with homebirth. Little information is provided on what was said about homebirth in these submissions and the decision by the MSR not to include homebirth in the funding and insurance reforms being proposed is at odds with the apparent demand for this option of care.

Method

Data for this study comprised 832 submissions to the MSR that are publicly available on the Commonwealth of Australia Department of Health and Aging website. All 832 submissions were downloaded, coded and then entered into NVivo. Content analysis was used to analyse the data that related to homebirth.

Findings

450 of the submissions were from consumers of maternity services (54%). Four hundred and seventy (60%) of the submissions mentioned homebirth. Overall there were 715 references to home birth in the submissions. The submissions mentioning homebirth most commonly discussed the ‘Benefits’ and ‘Barriers’ in accessing this option of care. Benefits to the baby, mother and family were described, along with the benefits obtained from having a midwife at the birth, receiving continuity of care and having a good birth experience. Barriers were described as not having access to a midwife, no funding, no insurance and lack of clinical privileging for midwives.

Conclusion

Many positive recommendations have come from the MSR, however the decision to exclude homebirth from these reforms is perplexing considering the large number of submissions describing the benefits of and barriers to homebirth in Australia. A concerning number of submissions discuss having had or having considered an unattended birth at home due to these barriers. Overall there is the belief that not enabling access to funded, insured homebirth in Australia is a violation of human rights. It appears that homebirth was considered by the MSR as ‘too hot to handle’ and by dismissing it as a minority issue the government sought to avoided dealing with homebirth as a ‘sensitive and controversial issue.’     

Gender and geographic differences in Medicare service utilization during the last six months of life

ABSTRACT

End-of-life issues are important for senior women, particularly rural women, who are more likely than their urban counterparts to live alone. The role of residence as a factor for health-care utilization among Medicare beneficiaries during the last six months of life has yet to be investigated. The purpose of this study is to examine whether service utilization in the last six months of life differs across gender and rurality. The sample was restricted to fee-for-service Medicare beneficiaries who died between July 1, 2013, and December 31, 2013 (n = 39,508). The odds of rural beneficiaries using home health (aOR 0.87; 95% CI 0.81–0.93) and/or hospice (aOR 0.82; 95% CI 0.77–0.87) in the last six months of life were lower than urban beneficiaries. Female beneficiaries were more likely to use support services such as hospice (aOR 1.24; 95% CI 1.18–1.29) and/or home health services (aOR 1.07; 95% CI 1.02–1.13) than male beneficiaries. The odds of female beneficiaries using inpatient (aOR 1.14; 95% CI 1.08–1.20) and/or outpatient (aOR 1.06; 95% CI 1.01–1.12) were higher than male beneficiaries. This research is important as we examine the range of health services used during the last six months of life, by gender and rurality. Future research is needed to understand how access to health services, residential isolation, and age- and disease-related factors relate to women’s observed greater use of inpatient, outpatient, hospice, and home health services in the last six months of life.     

Racial/Ethnic Disparities in Access to Medicare Home Health Care: The Disparate Impact of Policy

The Balanced Budget Act of 1997 dramatically decreased reimbursements for traditional Medicare home health patients. A multivariate analysis of Medicare Current Beneficiary Survey data showed that African American and “other” users experienced greater decreases in home care between 1996 and 1998 than did White users. These results suggest (a) race/ethnicity is an independent factor in determining service use post-BBA and (b) health policy has a disparate impact on minority older adults. Capitated payment systems must be pursued cautiously to avoid negative effects on vulnerable populations. The potential for current and future Medicare policy changes to negatively affect vulnerable populations is also discussed.     

Integrating Mental Health Parity for Homebound Older Adults Under the Medicare Home Health Care Benefit

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.     

Service Credit Banking:

Informal care provided by family and friends is widely recognized as one of the key factors in keeping long-term care financially manageable for individuals as well as for public programs. Sociodemographic trends predict that the demand for formal and informal home care services among the elderly will increase faster than the supply. Programs that allow volunteers to earn credits later redeemable for comparable services when they may be required are beginning to be examined as a way to help fill the need for respite services and other basic home care services. This paper examines key considerations of the service credit concept in the context of existing programs and initiatives designed to encourage its development.