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PubMed2001

What happened to long-term care in the health reform debate of 1993-1994? Lessons for the future.

During 1993 and 1994, the United States debated but did not enact major health care reform. Although the reform efforts focused on providing health coverage for the uninsured and controlling acute care costs, many proposals included substantial long-term care initiatives. President Clinton proposed creating a large home-care program for severely disabled people of all ages and all income groups, among several other initiatives. By stressing non-means-tested public programs, the president's plan was a major departure from the Medicaid-dominated financing system for long-term care. In designing the long-term care component, the Clinton administration addressed many of the basic policy choices that must be decided in all reform efforts, including whether initiatives should be limited to older people or cover people of any age, how to balance institutional and noninstitutional care, whether to rely on government programs or on the private sector, and how to control costs. Analyzing the political and intellectual history of long-term care during the health reform debate provides lessons for future reform.

Aged↗

PubMed1997

The impact of public assistance factors on the immunization levels of children younger than 2 years.

OBJECTIVES: This study examined how children's immunization status varied with enrollment in the Women, Infants, and Children (WIC); Aid to Families with Dependent Children (AFDC); food stamp; and Medicaid programs. METHODS: A statewide survey was used to determine the percentage of children less than 2 years of age who were up to date for diphtheria, tetanus, and pertussis; polio; and measles, mumps, and rubella vaccines. RESULTS: WIC and uninsured children were more likely and AFDC and Medicaid children less likely to be up to date than others. CONCLUSIONS: The higher immunization status of WIC and uninsured children suggests that integrating immunization practices with government programs may be effective.

Aid to Families with Dependent Children↗

PubMed1985

The impact of the Nurse Training Act on the supply of nurses, 1974-1983.

The number of nurses per capita in the United States increased 100% over the period 1972-1983, owing largely to funds made available through the Nurse Training Act (NTA). I studied the subsidy effect of the NTA by type of program (baccalaureate, associate, and diploma) and by type of school (public and private) using a fixed-effects analysis-of-covariance model that pooled time-series cross-sectional data from 639 schools over the 10-year period 1974-1983. I found that the estimated impact of the NTA ranged from +35,800 to +43,550 per nurse educated. I discuss whether this marginal price per additional nurse trained is a "good buy" as a government program in the context of other current nurse labor market issues.

Education, Nursing↗

PubMed2002

Addressing medical coding and billing part II: a strategy for achieving compliance. A risk management approach for reducing coding and billing errors.

Medical practice today, more than ever before, places greater demands on physicians to see more patients, provide more complex medical services and adhere to stricter regulatory rules, leaving little time for coding and billing. Yet, the need to adequately document medical records, appropriately apply billing codes and accurately charge insurers for medical services is essential to the medical practice's financial condition. Many physicians rely on office staff and billing companies to process their medical bills without ever reviewing the bills before they are submitted for payment. Some physicians may not be receiving the payment they deserve when they do not sufficiently oversee the medical practice's coding and billing patterns. This article emphasizes the importance of monitoring and auditing medical record documentation and coding application as a strategy for achieving compliance and reducing billing errors. When medical bills are submitted with missing and incorrect information, they may result in unpaid claims and loss of revenue to physicians. Addressing Medical Audits, Part I--A Strategy for Achieving Compliance--CMS, JCAHO, NCQA, published January 2002 in the Journal of the National Medical Association, stressed the importance of preparing the medical practice for audits. The article highlighted steps the medical practice can take to prepare for audits and presented examples of guidelines used by regulatory agencies to conduct both medical and financial audits. The Medicare Integrity Program was cited as an example of guidelines used by regulators to identify coding errors during an audit and deny payment to providers when improper billing occurs. For each denied claim, payments owed to the medical practice are are also denied. Health care is, no doubt, a costly endeavor for health care providers, consumers and insurers. The potential risk to physicians for improper billing may include loss of revenue, fraud investigations, financial sanction, disciplinary action and exclusion from participation in government programs. Part II of this article recommends an approach for assessing potential risk, preventing improper billing, and improving financial management of the medical practice.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1996

The brucellosis affected dairy herd and the program veterinarian.

A brucellosis task force was established in Ontario, California, in March 1989 for the purpose of attempting to eliminate brucellosis from a nearby, densely concentrated, community of dairy farms. The task force was a uniquely composed organization of both state and federal animal health agency personnel, diary owners and diary association representatives, private veterinary practitioners and the University of California veterinary extension dairy specialist. The task force focused on the entire dairy farm community rather than on individual brucellosis affected herds. The effort was successful. The task force developed a set of minimum standards that were required to be implemented at any dairy where transmission of brucellosis was still occurring 3 months after the disease was diagnosed in the herd. The observations and experiences of government program veterinarians, who worked with diligent and concerted effort in these herds, provide an insight into aspects of herd management and veterinarian/herd-owner relationship requirements for success.

Animals↗

PubMed1988

The impacts of health, education, family planning and electrification programs on fertility, mortality and child schooling in East Java, Indonesia.

This paper examines the effects of public health, family planning, education, electrification, and water supply programs on fertility, child mortality, and school enrollment decisions of rural households in East Java, Indonesia. The theoretical model assumes that parents maximize a utility function, subject to 1) a budget constraint that equates income with expenditures on children (including schooling and health inputs), and 2) a production function that relates health inputs to child survival possibilities. Public programs affect prices of contraceptives, schooling and health inputs, and environmental conditions that in turn affect child survival. Data are taken from the 1980 East Java Population Survey, the Socio-economic Survey, and the Detailed Village Census. The final sample consists of 3170 rural households with married women of childbearing age. Ordinary least squares and logit regressions of recent fertility, child mortality, and school enrollment on program and household variables yielded the following findings. 1) The presence of maternal and child health clinics reduced fertility but not mortality. 2) The presence of public health centers strongly reduced mortality but not fertility. 3) The presence of contraceptive distribution centers had no effect on fertility. 4) School attendance rates were influenced positively by the availability of primary and secondary schools. 5) Health and family planning programs had no effects on schooling. 6) The availability of public latrines reduced fertility and mortality. 7) The water supply variable did not affect the dependent variables when ordinary least squares techniques were applied but had statistically significant impact when logit methods were used. 8) Electricity supply had little effect on the dependent variables. 9) The mother's schooling had a strong positive correlation with children's schooling but no effect on fertility or mortality. 10) Household expenditures were related positively to school attendance and negatively to mortality. 11) There was little or no interaction between household variables and presence of government programs. 12) Subprovincial area measures of service availability appeared more appropriate for public health and family planning services, while village-level measures appeared more appropriate for schooling.

Asia↗

PubMed1995

Estimated societal costs of assertive community mental health care.

OBJECTIVE: The study used a societal costs model to estimate costs of assertive community treatment for persons with severe mental illness. METHODS: Resource use and cost data were collected for mental health, health, social, and law enforcement, and other maintenance services and family services for 94 clients enrolled in a mobile community treatment program in Madison, Wisconsin. Data sources included self-reports of clients and family members, private and public agency records, and insurance claims files. To make more precise estimates, outcome definitions were broadened, data sources were cross-validated, and prices of services were calculated independently of agencies' charges for such services. RESULTS: Average societal costs for participants in the study were estimated at $23,061 in 1988 ($29,965 in 1994 dollars). Use of a less sophisticated model with less careful costing methods would have resulted in an estimated average cost at least 30 percent lower. Maintenance costs (cash payments from government programs, subsidies, and in-kind services) were the largest cost component, followed by mental health treatment, family burden, indirect treatment, and law enforcement. Most of the financing for these services came from the public sector (85 percent). CONCLUSIONS: Accurate, reliable, and consistent measurement of societal costs will aid in the complex task of rationing fixed health and mental health care budgets.

Adult↗

PubMed1980

Income and illness.

Little research has been directed toward an examination of the health needs of low-income Americans in relation to major governmental medical care programs designed originally to narrow the health gap between "poor" and "nonpoor." Analysis of unpublished data from the 1977 Health Interview Survey of the National Center for Health Statistics shows that about 75 per cent of the gap in restricted activity days and bed disability days--two common measures of the impact of ill-health--between "poor" and "nonpoor" populations is attributable to greater prevalence and severity of activity-limiting chronic conditions among low-income people. Although both income groups report similar types of chronic conditions resulting in activity limitation, the prevalence of all major chronic conditions is greater in the low-income population. Approximately 25 per cent of the low-income population bears the burden of these conditions; the majority of the "poor" report disability day levels similar to the "nonpoor." The substantial impact of chronic conditions should be an important consideration in meeting the health needs of the low-income population. Current government programs, such as Medicare and medicaid, however, are designed primarily to pay for acute care received in hospitals and in physicians' offices.

Activities of Daily Living↗

PubMed1991

Long-term follow-up and benefit-cost analysis of the Jobs Program: a preventive intervention for the unemployed.

Results are reported from a 2 1/2 year follow-up of respondents who participated in a randomized field experiment that included the Jobs Program, a preventive intervention for unemployed persons. The intervention was intended to prevent poor mental health and loss of motivation to seek reemployment and to promote high-quality reemployment. The results of the long-term follow-up were consistent with those found 1 and 4 months after intervention (Caplan, Vinokur, Price, & van Ryn, 1989). The results demonstrate the continued beneficial effects of the intervention on monthly earnings, level of employment, and episodes of employer and job changes. These findings are supported by a benefit-cost analysis, which demonstrates large net benefits of the intervention to the participants and to the federal and state government programs that supported the project.

Cost-Benefit Analysis↗

PubMed1996

[The mechanisms of aging and perspective for elimination of deleterious effects].

Genetic programs and age-dependent changes in DNA and protein are involved in aging. The genetic program governs body weight, longevity, aging rate, sex-maturating period and metabolic rate in mammals, and such a number of life history variables are highly correlated with body size. Monogenic age-1 and daf-2 C. elegans mutants extend life span twice. However, human monogenic progeroids shorten lifespan. The Werner syndrome gene was mapped in 8p12. Mutations in the Cockayne syndrome genes (the CSA and CSB genes acting for preferential repair of active genes by interacting with transcription factor TFIIH) and in the ataxia telangictasia gene ATM (homologous with PI-3 kinase for signal transduction) have been disclosed. All such findings suggest a strong basis for the genetic program of aging. In addition, recent evidence indicates that genetic instability, such as telomere loss, somatic and mitochondrial DNA mutations, increases with age. In addition, amounts of carbonylated protein also increase during human aging, and greatly increase in an SOD-deficient C. elegans mutant, but to a less extent in long-living age-1. Therefore, the aging process involves gene action, genetic instability and protein oxidation. Dietary restriction and elimination of deleterious excessive reactive oxygen species may improve many abnormalities due to aging.

Aging↗

PubMed1999

Managed care under siege.

Managed Care Organizations (MCOs) are frequently criticized for their marketing mistakes. Often that criticism is leveled against an implicit benchmark of an ideal competitive market or an ideal system of government provision. But any accurate assessment in the choice of health care organizations always requires a comparative measure of error rates. These are high in the provision of health care, given the inherent uncertainties in both the cost and effectiveness of treatment. But the continuous and rapid evolution of private health care mechanisms is, in the absence of regulation, more likely to secure access and contain costs than any system of government regulation. State regulation is subject to the risk of capture and to the sluggish and acquisitive behavior of state run monopolies. The proposed fixes for the MCOs (rights to specialists, access to physicians outside the network, guaranteed emergency room access) are likely, when imposed from without, to cost more than they are worth. The long-term risk is that markets will fail under regulation, paving the way for greater losses from massive government control of the health care delivery system.

Benchmarking↗

PubMed1999

Shifting the costs of indigent care back to county governments.

Despite a decade of steadily rising prosperity, Texans are losing health care benefits at an alarming rate. As many as 41 million people in this country, or 15% of the population, lack health care coverage of any kind. Most of these people are under age 65 and are gainfully employed, but their employers don't provide coverage and/or don't pay them enough to afford it themselves. Most have minimum wage jobs and are ineligible for Medicaid. These individuals plant the gardens, work in fine restaurants, clean expensive houses, and generally benefit the communities in which they reside. Texas law suggests that county governments and property owners should pick up the tab for the medically indigent. However, as the uninsured numbers grow, county governments are finding ways to extricate their taxpayers and the institutions they support from the obligatory role as payer of "last resort" for these people. While reimbursement from government programs, managed care, and commercial insurers is putting tremendous financial pressure on health care providers, the county systems simply are not assuming their financial, legal, or ethical responsibilities for those outside the protective cover of these programs. In my experience, health care for the medically indigent has become "charity care" at the profit and nonprofit hospitals in the state. The strain is palpable in the emergency rooms, where by law the medical crises of the poor must be treated. This de facto safety net is fraying, and our political leaders need to make the painful decision to raise sufficient tax revenues to remove the weight.

Eligibility Determination↗

PubMed1981

Blue Shield plan physician participation.

Many Blue Shield Plans offer participation agreements to physicians that are structurally similar to the participation provisions of Medicaid programs. This paper examines physicians' participation decisions in two such Blue Shield Plans where the participation agreements were on an all-or-nothing basis. The major results show that increases in the Plans' reasonable fees or fee schedules significantly raise the probability of participation, and that physicians with characteristics associated with "low quality" are significantly more likely to participate than are physicians with characteristics associated with "high quality." In this sense the results highlight the tradeoff that must be faced in administering governmental health insurance policy. On the one hand, restricting reasonable and scheduled fees is the principal current tool for containing expenditures on physicians' services. Yet these restrictions tend to depress physicians' willingness to participate in government programs, thereby reducing access to high quality care by the populations those programs were designed to serve.

Blue Cross Blue Shield Insurance Plans↗

PubMed2001

Informational privacy and the public's health: the Model State Public Health Privacy Act.

Protecting public health requires the acquisition, use, and storage of extensive health-related information about individuals. The electronic accumulation and exchange of personal data promises significant public health benefits but also threatens individual privacy; breaches of privacy can lead to individual discrimination in employment, insurance, and government programs. Individuals concerned about privacy invasions may avoid clinical or public health tests, treatments, or research. Although individual privacy protections are critical, comprehensive federal privacy protections do not adequately protect public health data, and existing state privacy laws are inconsistent and fragmented. The Model State Public Health Privacy Act provides strong privacy safeguards for public health data while preserving the ability of state and local public health departments to act for the common good.

Community Health Planning↗

PubMed2026

Environmental benzene exposure induces a conserved neutrophil degranulation program across species.

Immune systems have evolved under constant pressure from pathogens and environmental challenges, leading to the emergence of conserved defense mechanisms across diverse organisms. Evidence indicates that environmental exposures perturb immune regulatory networks, particularly during development, when transcriptional programs governing hematopoiesis, immune cell differentiation, and inflammatory signaling are highly dynamic and sensitive to external stressors. Volatile organic compounds represent an important but incompletely understood source of immunological perturbation. Among these, benzene is a ubiquitous environmental contaminant associated with hematotoxicity and immune dysregulation; however, transcriptional responses to environmentally relevant low-level exposures during development remain poorly characterized. To determine whether benzene exposure engages conserved cross-species immune regulatory pathways, we performed a comparative transcriptomic analysis integrating developmental tissues from 3 vertebrate systems: human placenta, murine placenta, and zebrafish larvae. Bulk RNA sequencing datasets were analyzed to identify transcriptional responses associated with benzene exposure in experimental models (≤5 ppm) and with benzene adduct levels in maternal plasma for human samples. Because placental gene expression exhibits strong sexual dimorphism, murine datasets were stratified by fetal sex. Pathway- and network-level analyses were used to identify conserved biological responses. We observed a striking convergence on activation of innate immune pathways associated with neutrophil degranulation, IL-8 signaling, and Rho GTPase-mediated inflammatory responses. Further, network analyses identified CXCL8 and ERK1/2 as shared regulatory hubs linking transcriptional responses across datasets. Together, these findings uncover an evolutionarily conserved innate immune signature associated with benzene exposure during vertebrate development, suggesting that environmental chemical perturbations may disrupt fundamental immune regulatory programs across species.

Animals↗

PubMedDate not supplied

Social factors associated with pediatric emergency department visits for caries-related dental pain.

PURPOSE: This study was performed to describe and relate sociodemographic factors and management of visits to a pediatric hospital emergency department for caries-related dental pain. METHODS: Retrospective chart review of cases with a verifiable chief complaint of caries-related dental pain in 1998, was conducted using established protocol and trained reviewers. RESULTS: Three hundred of 984 hospital ED dental emergencies met the study's selection criteria and 109 children were six years old or younger. Almost two-thirds (66%) came from single parent families. Fifty-eight percent were self-pay or covered by government programs and the rest had some insurance. African-American children were 45% of cases. Over 80% were from within Franklin County, OH. Only 4 children (1%) had been seen for the same tooth previously. Lower primary molars were most often affected. Race, insurance, parental marital status were not significantly related to follow-up attendance at the facility (P > 0.05). Those living outside Franklin County and under 5 years of age were more likely to attend follow-up appointments (P < 0.05). When compared to the catchment population of Franklin County, this ED sample had six times as many uninsured children, two and a half times more African-Americans, and came from single parent families four and a half times more often. CONCLUSIONS: Children seen in the ED were predominantly poor, from single-parent families, and disproportionately minority, and were different from the catchment area population. These social risk factors were not related to attendance at follow-up.

Adolescent↗

PubMed2003

Physician, public, and policymaker perspectives on chronic conditions.

BACKGROUND: Chronic conditions are the leading reason why people seek medical care, yet the current financing and delivery system has been criticized for not promoting ongoing care. The perceptions of physicians, policymakers, and the general public were compared on how well the current system addresses the needs of people with chronic conditions. METHODS: National surveys of 1238 physicians and 1663 Americans and a convenience sample of 155 policymakers were compared. All 3 groups were given the same definition of a chronic condition and asked similar questions. RESULTS: There was strong agreement that chronic medical conditions affect men and women of all ages, ethnicities, and income levels (>90% strongly or somewhat agree). However, compared with the public and physicians, policymakers were less likely to respond that people with chronic conditions usually receive adequate medical care, that health insurance pays for most needed services, or that government programs are adequate. The public was most positive about the current system and policymakers the least. A majority of all 3 groups agreed that it is somewhat or very difficult for people with chronic conditions to obtain adequate care from primary care physicians, medical specialists, and other health care professionals. CONCLUSIONS: A majority of physicians, policymakers, and the general public are concerned that the current health care system is not addressing the needs of people with chronic conditions. Changes in how medical care is financed and delivered are necessary to respond to these concerns.

Adult↗

PubMed1997

Measuring quality of care in neurology.

Neurologists are being asked to incorporate methods into daily practice that measure quality of care. Standards of care are increasingly being defined using evidence-based assessments of neurological literature. To evaluate quality of care, a widely accepted and useful model considers the structure, process, and outcomes of care. Outcomes, the impact of care on patients' health, should include measures of mortality, morbidity, disability, patient functioning and well-being (health-related quality of life), and patient satisfaction with care. A variety of private organizations and government programs exist to encourage documentation and promotion of high quality of care. This explosion in quality information is not yet standardized, so that much confusion exists about appropriate data elements to be measured. The challenge is to collect, summarize, and disseminate practical data useful to neurologists and the purchasers and consumers of our services.

Evidence-Based Medicine↗