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Biomedical subjects

J Holahan

Publications and source records attributed to J Holahan.

At least 37 records · Page 2Linked to original sources
PubMed1991

An American approach to health system reform.

In terms of the major objectives one would have for health system reform, this plan makes the following choices: 1. It would cover everyone, through Medicare (the elderly), employer-based coverage (some workers and dependents) or a state-level public program that would replace Medicaid (the poor, unemployed, and other workers and dependents). 2. There would be a standard minimum package of required benefits for employer-based and public programs, with legislative requirements on maximum cost-sharing. Choice of provider might be restricted in some states. 3. Administration of the private programs would be the responsibility, as now, of the employers and/or insurance companies. Administration of the public program would be the responsibility of the states, with the objective of maximizing responsiveness to local needs and conditions. 4. It would control costs through giving the states a substantial financial stake in ensuring that the public program costs did not grow faster than nominal GNP. State control would also allow the testing of different mechanisms for cost control, with the ultimate objective of identifying the most effective cost-containment strategies. 5. The cost would be borne by employers, employees, and taxpayers. Employers would be protected from exorbitant costs by being allowed the option of paying into a public plan rather than providing health insurance themselves. The poor and unemployed would be protected by having their coverage under the public program subsidized on a sliding scale. 6. The political feasibility test would be met by retaining a major role for insurance companies and by retaining the role of employer-based coverage--thus reducing the tax increase needed to ensure universal coverage. By allowing flexibility in design of cost-containment strategy, some of the controversy over this issue would also be deflected. Our proposal is also not without problems. First, our approach would still have adverse effects on the profitability of small businesses and on the employment prospects for low-wage workers--although these effects would be less than under conventional mandates and less than under proposals with higher tax rates. Second, some states may not want the responsibility we envision or have the capacity to carry it out. But several Canadian provinces are relatively small and are able to perform the same administrative functions within the Canadian national health system. In addition, since the federal government would continue to administer the Medicare program, states would have the option of tying their policies for hospital and physician payment and utilization control to those of Medicare.(ABSTRACT TRUNCATED AT 400 WORDS)

Canada↗
PubMed1991

Nursing home transfers and mean length of stay in the prospective payment era.

Under Medicare's Prospective Payment System (PPS), hospitals have incentives to discharge Medicare patients as quickly as medically feasible, but because of shortages of nursing home beds and differential long-term care arrangements, some hospitals may encounter difficulty placing patients in nursing homes, leading to hospital backup days. This study relied on Tobit and weighted least-squares analysis to examine the determinants of hospital mean length of stay and transfer rates to skilled and intermediate care homes for selected diagnosis-related groups (DRGs) with high levels of postacute service use. Hospitals in low bed supply areas were found to have proportionately fewer nursing home transfers and longer mean lengths of stay. Having swing beds or a long-term care unit led to speedier discharges and higher skilled nursing facility (SNF) transfers, especially for patients with hip or femur procedures or major joint and limb reattachment procedures (DRGs 209 and 210). The results suggest that Medicare should consider compensating hospitals for back-up days and that bundled payment experiments could reduce current inequities resulting from differential access to nursing home care.

Aged↗
PubMed1991

Has PPS increased Medicare expenditures on physicians?

We use data from 1983 and 1985 on the volume of Medicare physician services to analyze whether Medicare's Prospective Payment System (PPS), which resulted in a significant decline in hospital spending, led to a partially offsetting increase in real expenditures for physician services. We also analyze the effect of increases in assignment rates, increasing incomes of the elderly, and other factors on real expenditures during this period. Our main conclusion is that PPS has at most a small positive effect on real physician expenditures. Because people spent less time in the hospital, Medicare physician spending declined; but because of incentives to shift radiology and other services out of the hospital, some of this decline was offset. We also conclude that the sharp increase in Medicare assignment rates over this period, along with the rising incomes of the elderly during this period, contributed to the observed growth.

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PubMed1990

Hospital back-up days: impact on joint Medicare and Medicaid beneficiaries.

In this article the question of whether nursing home market characteristics affect the ability of hospitals to discharge patients to nursing homes is examined. Also examined is the question of whether joint Medicare and Medicaid beneficiaries have a more difficult time being placed than do other patients. The principal conclusions are first, that the nursing home bed supply and the type of Medicaid payment system affect the ability of hospitals to discharge patients to nursing homes. Joint Medicare and Medicaid beneficiaries have a more difficult time being placed in nursing homes in States with fewer beds and more restrictive Medicaid payment policies, and joint beneficiaries do not appear to have longer stays in hospitals. Rather, they have a greater likelihood of being discharged to home.

Health Services Accessibility↗
PubMed1990

The nursing home market and hospital discharge delays.

One way for hospitals to respond to the incentives in Medicare's PPS is to reduce the patients' length of stay by discharging to nursing home care those patients who no longer require hospital care but are not well enough to go home to informal care. In this study, we find that patients experience more discharge delays at hospitals located in areas with few nursing home beds and in states with prospective Medicaid nursing home reimbursement policies. Hospitals with their own nursing home units or swing beds experience earlier discharges, other things being equal. Our findings suggest that some hospitals are at a disadvantage compared with others and that a policy response may be warranted.

Costs and Cost Analysis↗
PubMed1990

Urban-rural differences in Medicare physician expenditures.

Policymakers have long been concerned with urban-rural disparities in access to health care. These disparities may be particularly severe in the case of the elderly and others covered by Medicare. Descriptive tables show that the total volume of physician services provided to rural beneficiaries is more than 40% lower than the volume of physician services provided to urban beneficiaries. This result is fairly consistent across all types of care and sites of care. In our econometric analysis, we investigate the factors that may explain these differences in utilization. The results indicate that, with prices held constant, variations in demographic and economic characteristics are not the major reasons for the urban-rural gap. Differences in hospital and physician (particularly specialist) availability appear to be the main factors.

Aged↗
PubMed1989

Assessing Medicare reimbursement options for skilled nursing facility care.

In this article, a broad array of Medicare payment options for skilled nursing home care are examined, ranging from cost-based retrospective systems to various prospective arrangements. Each system contains different incentives to meet four policy goals: provide access for Medicare patients; increase access for patients requiring resource-intensive care; contain growth in program costs; and assure the delivery of high-quality care. The financial impacts of alternative policy options on nursing homes are presented through the use of a simulation model. Facility-specific payment systems are shown to most effectively incorporate incentives to contain costs and promote beneficiary access to care.

Computer Simulation↗
PubMed1989

Physician payment reform: implications for physicians and hospitals.

This article examines a number of problems with the Medicare system of paying for physician services. It examines and critiques three types of policy initiatives that are likely to be given serious consideration in the near future. These initiatives include the development of a physician fee schedule, modification of current policies toward balance billing, and the introduction of policies to control the growth in volume. The article concludes that the adoption of a fee schedule could have dramatic effects on fees for physician services. Moreover, there is likely to be significant redistribution of income between physician specialties and among physicians within specialties. There is likely to be increased pressure to limit balance billing and perhaps to adopt mandatory assignment for Medicare services. Policies to reduce the growth in volume such as expenditure target policies will also be seriously considered, though the implementation problems appear quite formidable.

Economics, Medical↗
PubMed1989

Should Medicare compensate hospitals for administratively necessary days?

Days that a patient remains in a hospital due to inability to secure nursing home placement are termed administratively necessary days (ANDs). Some hospitals under Medicare's prospective payment system have incurred discharge delays of this kind. Nursing home bed supply is one major problematic factor; others include adequacy of Medicare nursing home reimbursement rates relative to nursing home costs in an area, the willingness of facilities in an area to serve those needing skilled care, and stringency of relevant Medicaid reimbursement policy. Two promising approaches for dealing with ANDs are increasing nursing home reimbursement rates, and adjusting Medicare payments for exceptionally long-staying patients or those requiring exceptionally intensive care in hospitals.

Aged↗
PubMed1988

Medicare's fiscal problems: an imperative for reform.

Many observers have noted that Medicare expenditures will significantly outstrip projected revenues over the course of the next 25 years. This paper examines the economic and demographic assumptions behind forecasts of Medicare hospital insurance and supplementary medical insurance expenditures and revenues and analyzes various strategies for closing the impending gap. It is argued that the present forecasts already assume considerable success in controlling hospital costs and physician payments, making substantial further savings unlikely. Shifting more of the burden onto the elderly through increased cost sharing or higher premiums also will not solve the program's fiscal problems over the long term. The remaining alternative--imposing higher income or payroll taxes on the under-65 population--is also unlikely to be a welcome solution. The authors argue that, eventually, the nation must choose between some form of a two-tier system of benefits or a Canadian-style national health insurance system.

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PubMed1988

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.

Economics, Hospital↗
PubMed1988

The impact of alternative hospital payment systems on Medicaid costs.

From 1982 onward, 25 states adopted three broad strategies to control their Medicaid hospital costs: multiple-payer rate setting, Medicaid-only prospective payment, and selective contracting. In this analysis of the three approaches, I found that the multiple-payer systems were particularly effective at controlling Medicaid payments because of their ability to control statewide hospital costs. The Medicaid-only prospective payment systems were also successful, but appear to be effective only in the short term. California's Medicaid-only selective contracting program was also successful, largely because of the simultaneous implementation of cost-control incentives for all hospitals in the state. I also found sharp reductions in Medicaid admissions where rates were set low relative to costs, as well as a shift in Medicaid admissions to public hospitals in Medicaid-only prospective payment states.

California↗
PubMed1987

Formation of multinucleated cells that respond to osteotropic hormones in long term human bone marrow cultures.

Studies of osteoclasts and their precursors in normal and pathological states have been severely hampered by the lack of an in vitro system for forming osteoclasts. We developed a human marrow culture system in which multinucleated cells with several characteristics of osteoclasts form. Multinucleated cells began to form during the first week of culture, with maximum numbers formed after 3 weeks. PTH (25-50 ng/ml) and 1,25-dihydroxyvitamin D3 (10(-10)-10(-8) M) increased formation of these cells, and these effects were inhibited by calcitonin. These multinucleated cells contained nonspecific esterase and tartrate-resistant acid phosphatase, a marker enzyme of osteoclasts, and had several ultrastructural features of osteoclasts. We used this marrow cell culture technique to study a patient with hyperparathyroidism and markedly increased osteoclasts on bone marrow biopsy. The marrow from this patient formed increased numbers of multinucleated cells in vitro. After parathyroidectomy both multinucleated cell formation in vitro and osteoclast numbers on bone biopsy decreased significantly. This long term marrow culture system represents the first demonstration of human osteoclast-like cell formation in vitro. This system should permit studies to evaluate factors controlling formation of cells with certain osteoclast characteristics in vitro and their precursors as well as to evaluate abnormalities in osteoclast formation in patients with metabolic bone disease.

Bone Marrow Cells↗
PubMed1987

Nursing home reimbursement: implications for cost containment, access, and quality.

The individual states have many options in designing Medicaid reimbursement systems for nursing homes. Each option has a differential effect on incentives--and outcomes--for containing costs, providing quality care, and maintaining access to care. The mix and consequences of specific choices are analyzed in a framework that disaggregates costs into three components. Tradeoffs among competing elements will be inevitable, but reimbursement policy can maximize both efficiency and equity.

Cost Control↗