Changing the way the elderly live: Evidence from the home health care market in the United States

I examine how decreases in government coverage of home health care visits to the elderly in the United States have affected their living arrangements. Specifically, I exploit geographic variation in the Medicare Home Health Care reimbursement rate that arose as a result of legislation passed in 1997 and I identify its impact on the living arrangements of older Medicare beneficiaries. I find that less generous reimbursement policies lead to a greater fraction of elderly giving up independent living. Baseline-model estimates suggest that a decline in reimbursement of one visit per user leads to a 0.98% increase in the fraction of elderly Medicare beneficiaries living in shared living arrangements, that is, living with somebody else, rather than alone or with only the spouse. This estimate implies that a decline in reimbursement of 5.1 visits per Medicare beneficiary increases the fraction of elderly that live in shared living arrangements by 1.12 percentage points. Such an increase is consistent with the time-series increase in the fraction of elderly that live in shared living arrangements between 1997 and 2000.     

Estimating an hedonic translog cost function for the home health care industry

Medicare home health care plays an important role in providing cost effective care for the chronically ill and elderly. Long seen as a cost effective substitute for nursing home care, home care has become even more important with expenditures increasing by 31.4% from 1990 to 1996. The purpose of this paper is to provide a short run cost analysis of a sample of home health care providers to gain insight into the efficient provision of home health care services. This paper is a significant improvement over previous studies in that it uses a nationwide database to more accurately represent the multiproduct nature of the industry and uses an hedonic translog cost estimation with desirable economic properties.     

An interview with Gail R. Wilensky. Interview by Carmella A. Bocchino

In this interview, conducted just 4 months after assuming her new position as Administrator of HCFA, Dr. Wilensky discusses her goals for the agency, the emergence of Medicaid as a separate bureau, Medicare reimbursement policies, and nurses' potential as recognized health care providers.     

Restructuring: specifics for home health

The current reimbursement climate, job characteristics, and health care personnel shortages challenge home health nurses in providing quality patient care. Through relatively simple restructuring efforts, home health nursing can become more satisfying and productive.     

Complex home care: Part 2- family annual income, insurance premium, and out-of-pocket expenses

Annual costs paid by families for intravenous infusion of home parenteral nutrition (HPN) health insurance premiums, deductibles, co-payments for health services, and the wide range of out-of-pocket home health care expenses are significant. The costs of managing complex chronic care at home cannot be completely understood until all out-of-pocket costs have been defined, described, and tabulated. Non-reimbursed and out-of-pocket costs paid by families over years for complex chronic care negatively impact the financial stability of families. National health care reform must take into account the long-term financial burdens of families caring for those with complex home care. Any changes that may increase the out-of-pocket costs or health insurance costs to these families can also have a negative long-term impact on society when greater numbers of patients declare bankruptcy or qualify for medical disability.     

Physician participation in health insurance plans: evidence on Blue Shield

Various health insurance programs, including Blue Shield, have developed arrangements whereby the physician agrees to accept the insurer's reimbursement as payment in full. Incentives facing the physician to accept an arrangement of this type are reviewed in this study. The empirical work uses data on individual physicians from a 1973 survey. The results indicate that physician willingness to accept insurer reimbursement as payment in full is sensitive to the amount the insurer pays for specific procedures and to other insurance program characteristics. Physicians located in high patient income areas and/or with relatively prestigious credentials are less likely to accept insurer payments as payment in full. The empirical findings are used to generate policy implications pertaining to the Medicare and Medicaid programs, to medical care quality-access tradeoffs, and to national health insurance.     

Competition and physician-enabled demand: The role of managed care

Recent organizational changes in the health care sector promote greater patient participation in their treatment decisions. How physicians respond to patient-initiated requests for treatment is an issue of considerable policy interest. To study this phenomenon, we introduce the notion of physician-enabled demand and examine empirically whether this behavior responds to competitive pressures in the market and financial incentives associated with different physician payment mechanisms.We find that physician-enabled demand increases with more competition under fee-for-service reimbursement, but decreases with greater competition under managed care. This asymmetric response is quite consistent with our conceptual framework and at odds with alternative interpretations.     

Cost of health care and quality outcomes of patients at nurse-managed clinics

Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs. Nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that nurse-managed clinics improve the use of preventative services, aid in the promotion of health, compliance of treatment and patient satisfaction, and reduce emergency room visits and rehospitalizations. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if nurse-managed clinics are to remain viable.     

Complex home care: Part I--Utilization and costs to families for health care services each year

As many as 120 persons per million people in the United States are dependent on the lifelong, complex, technology-based care of home parenteral nutrition (HPN) infusions. However, data for costs paid by families for HPN-related health care services and for non-reimbursed expenditures are rarely tabulated and most often underestimated. The goals of this study were to describe health care services used by families to manage HPN, report the frequency of each service used annually, and estimate the average annual non-reimbursed costs to families for these health services. The numerous and varied types of services reported and the time required to coordinate and access HPN services illustrates the challenges faced by patients and their family caregivers. The lack of a coordinated and efficient system for delivering complex chronic care results in poorer outcomes for HPN patients and their families on-reimbursed costs and the extensive amount of time required to coordinate multi-professional services negatively impacts the clinical outcomes and quality of life of complex chronic home care.     

Health Policy and Equity of Health Care Financing in Australia: 1973–2010

Using data from Australian Taxation Statistics and Household Expenditure Surveys we analyze the distribution of health care financing in Australia over almost four decades. We compute Kakwani Progressivity indices for four sources of health care financing: general taxation, Medicare Levy payments, Medicare Levy Surcharge payments, and direct consumer payments, and estimate the effects of major policy changes on them. The results demonstrate that the first three of these sources of health care financing are progressive in Australia, while the distribution of direct payments is regressive. Surprisingly, we find that neither the introduction of Medicare in Australia in 1984 nor the Extended Medicare Safety Net in 2004 had significant effects on the progressivity of health care financing in Australia. By contrast, the Lifetime Cover scheme—introduced in 2000 to encourage people to buy and hold private health insurance—had a progressive effect on health care financing.     

The impending reimbursement revolution: how to prepare for future APN reimbursement

Health care reimbursement reform is underway as part of a national effort to enhance quality outcomes and bring spiraling health care costs under control. Implications of pay-for-performance reimbursement are discussed along with ways to prepare for changes in APN reimbursement.     

Crossing the quality chasm: creating the ideal patient care experience

To create a health system that better meets patients' needs requires a fundamental redesign of our care delivery system and a new framework. Without a payment mechanism to reflect the value of care provided other than the face-to-face visit, adoption of advanced medical home principles will be challenging. The hand-off of the patient between providers and settings of care is a critical time for the patient and its effectiveness impacts patient care outcomes. The appropriate utilization of hospital and other health system resources is crucial, especially as hospitals, emergency departments, and other health care venues increasingly face capacity constraints and throughput challenges. It becomes the responsibility of the multidisciplinary team of providers to ensure that patients being discharged have an identified personal physician or team who will provide a medical home, and that the handoff to this medical home is thorough and well coordinated. An ideal patient care experience is one in which all systems and processes are geared to meet the needs of the patient: a safety-oriented system that provides standardized, evidence-based care supported by technology, but that recognizes and responds to individual needs.     

Resource based relative value scale: a new challenge and opportunity for health care cost management

Beginning in 1992, the use of resource based relative value scale (RBRVS) will greatly change the way physicians are reimbursed for services to Medicare patients. This new system will also have implications for trust funds and corporate providers of health care benefits.     

A nurse-run business to improve health care for nursing home residents

The costs of health care for the rapidly growing segment of our population over age 75 are staggering. EverCare is a nurse-run business that seeks to improve cost-effectiveness and quality of health care for nursing home residents enrolled in a health maintenance organization.     

Medicare payment generosity and access to care

All payments to physicians under Medicare Part B are adjusted to reflect geographic differences in practice costs. The methods used for this adjustment, and temporary price floors imposed by Congress, have created longstanding systematic under and overpayment across physicians, whereby some are routinely underpaid while others are routinely overpaid. Using a nationally representative 2008 survey of physicians, this study examines whether the relative generosity of Medicare influences beneficiary access to care. We find that in areas where Medicare payments are more generous physicians are more likely to accept new Medicare patients, whereas in less generous areas, they are less likely. Our estimated models suggest that if Medicare could eliminate the systematic biases inherent its payment formula, it would see a net improvement to access to care under Medicare Part B.     

Managed care, quality of care, and patient rights

The growth of managed care has been accompanied by calls for increased government regulation because HMOs and other forms of managed care are seen by the public as more concerned about controlling costs than with protecting the rights of patients to quality care. This paper applies a theory of health care rights and clinical evidence of managed care quality in an analysis of public opinion about managed care. The paper concludes that there is no persuasive evidence that managed care has resulted in a general deterioration in the quality of care and that, with one exception, restrictions imposed by managed care plans are consistent with a theory of health care rights. The paper concludes with the recommendation that public policy should dispense with attempts to fine tune managed care and address an unquestionable violation of health care rights, the failure to guarantee a minimum standard of care to some 43 million Americans.     

An interview with Senator John D. Rockefeller IV. Interview by Carmella Bocchino

Congress is faced with moving forward a pressing health care agenda while the federal deficit demands major budget cuts in Medicare. A pivotal player in this chess game is Senator John D. Rockefeller IV (D-WV). In this interview with Nursing Economic+, Sen. Rockefeller discusses catastrophic health insurance, Medicare, long-term care, and other health care issues.