Health risk influence on medical care costs and utilization among 2,898 municipal employees.

INTRODUCTION: Although worksite health promotion programs are credited with stabilizing medical benefits costs, research is needed to characterize the medical costs of cohorts with selected health risk factors. The purpose of this study was to compare medical cost outcomes in City of Birmingham, Alabama, employees who differ on selected health risk factors. METHODS: Health risk appraisal and medical claims cost data were examined in 2,898 employees participating in health screening during 1992 and 1993. Probit analysis was employed to test the null hypotheses that there are no differences in (1) probability of medical service utilization and (2) probability of medical service cost quartile (high, moderate, and low) between groups characterized by risks. Age, gender, race, education, marital status, and diabetes were included as covariates in each model examined. In addition, smoking habits was included as a covariate in models involving risk taking behavior and psychosocial risk. RESULTS: Significant differences in medical care utilization and costs were found between risk groups based on psychosocial risk, cardiovascular disease risk, and total risk. No association was found between risk-taking behavior and utilization and costs. CONCLUSION: Subjects reporting psychosocial, cardiovascular disease, and total risk factors were more likely to use medical services and to be in the high or high/moderate cost categories.

Teaching and maintaining behavior management skills with nursing assistants in a nursing home.

This article describes a nursing staff training program in basic behavior management skills and a formal staff management system to encourage the application of these basic skills on the nursing unit. Behavioral skills training consists of a 5-hour in-service followed by three weeks of on-the-job training to ensure accurate application of behavior management skills. Following training, a staff management system is used to facilitate long-term use of the skills. Components of the staff management system include supervisory monitoring of the nursing assistants (NAs) by licensed practical nurses (LPNs), NA self-monitoring, verbal and written performance feedback, and incentives.

Effects of tobacco excise taxes on the use of smokeless tobacco products in the USA.

Data from the September 1985 Current Population Survey are used to estimate the effects of tobacco excise taxes and state laws restricting smoking in public places on the likelihood of current use of cigarettes or smokeless tobacco (ST) products (moist snuff or chewing tobacco) among males in the USA. The results indicate that higher ST excise tax rates are associated with a reduced probability of ST use, whereas higher cigarette excise tax rates are associated with an increased probability of ST use, holding other factors constant. State laws restricting smoking have no apparent effect on ST use.

Access to neonatal intensive care for low-birthweight infants: the role of maternal characteristics.

OBJECTIVES: This study assessed the impact of mother's race, insurance status, and use of prenatal care on very low birthweight infant delivery in or transfer to hospitals with neonatal intensive care units (ICUs). METHODS: Multivariate analysis of Alabama vital statistics records between 1988 and 1990 for infants weighing 500 to 1499 g was conducted, comparing hospital of birth and maternal and infant transfer status, and controlling for infant birthweight and for maternal pregnancy history and demographic characteristics. RESULTS: With other factors adjusted for, non-White mothers with early prenatal care were more likely than White mothers to deliver their very low birthweight infants in hospitals with neonatal ICUs without transfer. Among the mothers who presented first at hospitals without such facilities, those who had late prenatal care were less likely than those with early care to be transferred to hospitals with neonatal ICUs before delivery. Medicaid coverage increased the likelihood of antenatal transfer for White women. Likelihood of infant transfer was not associated with these maternal characteristics. CONCLUSIONS: Maternal race, prenatal care use, and insurance status may influence the likelihood that very low birthweight infants will have access to neonatal intensive care. Interventions to improve perinatal regionalization should address individual and system barriers to the timely referral of high-risk mothers.

Health care reform: public views of problems and solutions.

Public opinion surveys have found growing discontent with the health care system. In response, major reform legislation has been introduced in Washington and in many statehouses as well. Nonetheless, very few, if any, state-level public opinion surveys examining health care have been conducted in the South. During November of 1991, a statewide survey of 1,250 Alabamians was conducted to collect information on a wide range of health care issues. The survey is perhaps the largest and most complete survey on health care issues ever conducted in a southern state. Major findings of the survey are as follows: (1) Two-thirds of Alabamians believe the health care system needs fundamental change or needs to be completely rebuilt; however, there is little consensus on the shape of this new health care system. (2) Over 50 percent of Alabamians believe that rising health care costs are the most important issue facing the country. Yet, only about one-third support managed-care mechanisms as a means of controlling personal health care costs. (3) Four of ten Alabamians believe access to care is a critical health care issue. Nonetheless, only 16 percent are willing to pay more than $100 in additional annual taxes to guarantee health care for everyone. This survey yields a set of conflicting conclusions. Policy makers and elected officials should be aware of these issues as they attempt to forge health care reform legislation.

Can a poor state afford not to expand Medicaid?

Some advocates of the uninsured support expansion of Medicaid programs, while others say that expansions are simply unaffordable, especially in poor states. State-level analyses of the costs and consequences of these expansion programs are infrequent. This study evaluates three programs to expand eligibility for Alabama's Medicaid program. The first two programs would raise the Aid to Families with Dependent Children (AFDC) eligibility threshold to 50 and 100 percent, respectively, of the federal poverty level. The third program, currently not available to the states without a federal waiver, would drop all categorical eligibility requirements and base eligibility solely on whether income is below the federal poverty level. Only 10.7 and 18.3 percent, respectively, of Alabama's uninsured would gain health care coverage under the first two programs. The third program would increase the proportion of Alabamians with health coverage to nearly 50 percent. For all of these programs, front-end state costs would be largely countered by federal funding and offsets, such as reductions in uncompensated hospital care and savings realized by former uninsureds from reductions in out-of-pocket expenditures for health services.

Consequences of alternative programs to cover the uninsured in central southern states.

The lack of health insurance represents a significant barrier to timely, preventive medical services. In addition, certain providers risk financial viability as their uncompensated care burdens worsen. These issues are particularly troublesome in southern states because the population is disproportionately represented by greater numbers of poor uninsured individuals. This study examines the consequences of three alternative proposals to reduce the number of uninsureds in five southern states. Program 1 raises the AFDC income eligibility threshold to the federal poverty level. Program 2 drops Medicaid categorical eligibility requirements in favor of a poverty-level income standard. Program 3 requires employers to insure all employees, and their dependents, who work 25 hours or more per week. Surprisingly, Program 1 produces a modest 16 percent reduction in the uninsured. Programs 2 and 3, however, reduce the uninsured population by 41 and 57 percent, respectively. Nonetheless, these last two programs reach very different income groups. Program 2 captures all the poor uninsureds whereas Program 3 includes 40 percent of this same population. From this analysis it is clear that a combination of these programs would be necessary to effectively cover the uninsured.

What is the dentist's occupational risk of becoming infected with hepatitis B or the human immunodeficiency virus?

Surveys have shown that dentists are reluctant to treat persons infected with the human immunodeficiency virus (HIV). However, dentists are much more willing to treat patients with infectious hepatitis B virus (HBV). This study shows that the annual cumulative risk of infection from routine treatment of patients whose seropositivity is undisclosed is 57 times greater from HBV than from HIV, and that the risk of dying from HBV infection is 1.7 times greater than the risk of HIV infection, for which mortality is almost certain.

How restrictive are Medicaid's categorical eligibility requirements? A look at nine Southern states.

Medicaid, as an existing program with federal matching dollars, remains attractive to state legislatures looking for a means to address the problems of the uninsured. However, the extent to which states can maximize coverage of the poor uninsured under Medicaid's present eligibility criteria is unknown. Surprisingly, this study of nine Southern states shows a modest 14.8% reduction in the uninsured population when the AFDC income eligibility threshold is moved up to the federal poverty level. This threshold is twice as high as the national mean and three times greater than the mean income eligibility threshold for the nine states that were the focus of this study. In sharp contrast, elimination of the categorical eligibility requirements under the same poverty-level threshold reduces the uninsured population by nearly 40%.

Perceived need for dental care among persons living with acquired immunodeficiency syndrome.

Compromised oral health holds significant implications for the general health of medically vulnerable, HIV infected individuals. Past studies have reported that these individuals frequently suffer from oral opportunistic infections and have a tendency to develop severe periodontal disease. This study extends past research by examining the prevalence of oral infections according to patient characteristics and by reporting, for the first time, the level of perceived dental need in a large, multi-site sample of individuals with symptomatic HIV disease. Data for this study come from a survey of 857 clients of the Robert Wood Johnson Foundation's AIDS Health Services Program in 9 U.S. cities. More respondents (52%) reported a need for dental care than for any other service need. Multivariate analysis showed that clients who were white, in low-income groups, used intravenous drugs, or had a past history of oral opportunistic infections were more likely to report dental need. Relations between age, gender, insurance status, or disease status and perceived need were statistically nonsignificant. Forty-seven percent of the clients reported they had an oral opportunistic infection, the second outcome variable examined in this study. Statistically significant differences (P less than 0.05) were found in the prevalence of oral opportunistic infections among race and disease severity groups. Whites and the more severely ill were more likely to report an infection than their respective counterparts.

Access to appropriate dental care.

For this review, publications were considered in the context of a broad definition of access to dental care, including the ability to gain available, appropriate services as determined by personal, economic, cultural, geographic, and other factors. None of the studies fully integrated the multiple dimensions explicit in this definition. Nonetheless, it is clear that certain segments (ie, the poor and members of racial and ethnic minoritites) of the US population use dental services less frequently. When these people do use the system, they are less likely to receive preventive services and more likely to have a dental emergency. The availability of services to poor populations through Medicaid programs is compromised due to low provider participation, which is attributed to dissatisfaction with reimbursement rates and limitations in the breadth of covered services. Concerning the appropriateness of care, it is shown that practices with homogenous patient populations vary widely in the rates of the types of services provided.

Methodological considerations in the analysis of cost effectiveness in dentistry.

Cost-effectiveness analysis is a technique applied with increasing frequency to help make rational decisions in health care resource allocation. This article reviews the ten general principles of cost-effectiveness analysis outlined by the Office of Technology Assessment of the US Congress and describes a model for such analyses used widely in medicine, but only recently applied in dentistry. The imperative for the formulation of the best current information on both the effectiveness of dental practices and their costs is made more urgent because of the now universally recognized belief that resources available to meet the demands for health care are limited. Today's environment requires critical allocation decisions within categorical health problems, across diseases, or relative to other health problems. If important health benefits or cost savings are to be realized, then these analytic approaches must become widely understood, accepted, and appropriately applied by key decision makers in the dental health sector.

The dentist's role in access to dental care by Medicaid recipients.

This study uses a decision analytic approach to assess the dentist's role in access to care by Medicaid recipients. The question of whether a private dentist, when given the choice, will schedule a Medicaid or non-Medicaid patient is examined. The model considers factors frequently reported to influence dentist's decisions over whether to accept Medicaid recipients into their practices. Factors include reimbursement rates, probability of broken appointments, and likelihood of reimbursement. The model permits calculation of the expected benefits in dollars for comparable treatment of Medicaid and non-Medicaid patients. Under a variety of conditions, it is shown that the strategy to schedule a non-Medicaid patient dominates alternative strategies in which Medicaid recipients are scheduled. Policy implications of these results are discussed.

The impact of insurance on charges for dental care.

This study assesses the effect of insurance on charges for dental care. It is hypothesized that dental practices with higher percentages of insured patients will have higher average charges for dental visits, all other things being equal. An econometric model and ordinary least squares analysis are used to test the hypothesis, based on data from the American Dental Association's 1985 Survey of Dental Practice. For the sake of homogeneity, the study is confined to solo general practitioners. Within this group, the model is applied to two practice types categorized by whether or not the practice employed a hygienist. In solo general practices with and without hygienists, a positive association between the prevalence of insureds within a practice and charges for dental care visits is shown. Hypothetical cases are used to demonstrate that an additional 18 percent of insureds within a practice results in a 6 percent increase in the average charge for a dental visit. The analysis uncovers associations between other variables and dental charges. Of particular note is the curvilinear relation between a dentist's years of experience and his or her charges for dental care.