Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments.

Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.

Quality information and fragmented markets: patient responses to hospital volume thresholds.

Over the last two decades, information dissemination policies to improve patient hospital choice have emerged. But during this same period, policy makers have also generally adopted a market-oriented approach vis-à-vis hospitals, with limited regulation of facility expansion and few restrictions on hospital mergers and ownership changes. These policies may be in tension, and this analysis examines whether there have been changes over time in patient responses to information about the value of high-volume hospitals and the degree to which hospital market changes may have limited these patient responses. The results indicate modest changes consistent with an increase in quality-seeking behavior for several services for which research indicates a volume-outcome relationship. At the same time, there are services for which trends have been moving in the opposite direction--toward greater local-care seeking--and changes for the remaining services have been fairly small. Even for services with a trend toward greater patient sensitivity to volume as a marker for quality, however, hospital market changes have reduced the change over time in high-volume hospital use. These results highlight some of the limitations of market-oriented strategies for increasing patient use of high-quality hospitals.

Reducing racial disparities in coronary angiography.

Racial disparities in cardiac services are well documented; however, policies to close these gaps have not been studied. This paper evaluates a New Jersey certificate-of-need reform to reduce disparities in diagnostic coronary angiography. The number of angiography facilities in New Jersey doubled following reform, and a large black-white disparity was eliminated-a trend not observed in nearby states. Surprisingly, increases in service to African American patients following reform were concentrated in hospitals licensed before reform, while the newly licensed facilities contributed relatively little to reducing disparities. We hypothesize that added hospital competition contributed to the reduction in disparities.

Managed care regulation in the States: the impact on physicians' practices and clinical autonomy.

While the states engaged in an extended period of adopting and revising laws regulating managed care during the 1990s, there has been to date only limited empirical assessment of the impacts of these laws. For this analysis, we constructed a data set using information on state laws combined with survey responses of physicians. We distinguish regulations with a typology based on whether they affect the context or content of care and the target group of the regulation (consumer or provider). Our findings indicate that the context of care appears to be more efficaciously regulated than the content of care. Provisions concerning consumer access and contractual relationships lead to greater reported physician ability to obtain referrals and services, improved quality of clinical interactions, and greater perceived clinical autonomy. Regulations intended to enhance professional autonomy are associated with lower reported levels of utilization constraints and higher reported quality of clinical interactions. In contrast, consumer protection provisions, including procedures for appeals from plan decisions, appear to have had little impact on most physicians' practices. Despite structural and legal constraints on the potential effectiveness of these regulations, state managed care legislation appears to have provided some protections against managed care restrictions on physicians' clinical autonomy.

Assessing changes in high-volume hospital use: hospitals, payers, and aggregate volume trends.

The relationship between higher procedure volumes and medical outcomes has generated recommendations for greater use of high-volume hospitals, with research and advocacy on this issue intensifying during the 1990s. Despite this interest, the trends presented here showed only limited changes between 1995 and 2002. For a number of services, less than half of patients received care at high-volume hospitals, and for several services, there was a surprising decline in the proportion at high-volume hospitals. Trends in the rate of high-volume hospital use appeared to be associated with trends in aggregate volume, at the same time that there were only modest changes in either patient use of high-volume hospitals or the number of hospitals offering these services. These trends suggested the importance of research on factors that affect patient choices, hospital decisions, and payer incentives concerning hospital use, especially in the context of declining aggregate procedure volumes.

Enrolling children in public insurance: SCHIP, Medicaid, and state implementation.

The Balanced Budget Act of 1997 established federal grants to the states to create the State Children's Health Insurance Program (SCHIP). This presented the states with a number of implementation choices concerning administrative models for the new programs, as well as choices about eligibility standards, enrollment simplification, crowd-out, and cost sharing requirements. At the same time, the states were also implementing welfare reform. We describe the most important of these implementation choices, and using data from the Current Population Survey, we estimate the impacts of state policy on enrollment in this multiprogram environment. The results indicate that SCHIP programs that are administered as Medicaid expansions are more successful than either separate SCHIP plans or combination programs in enrolling children. States that remove asset tests and implement presumptive eligibility and self-declaration of income have higher enrollment levels. Continuous eligibility and adoption of mail-in applications have no effect on overall enrollment. Waiting periods and premiums reduce enrollment. Stringent welfare reform reduces children's enrollment, despite federal policy that was intended to protect children from the consequences of welfare reform. The negative impacts of a number of these policy reforms substantially reduce enrollment, potentially offsetting the more favorable impacts of other policy choices. We estimate that if all states adopted the policy options that facilitate program use, enrollment for children with family incomes less than 200 percent of the poverty line could be raised from the current rate of 42 percent to 58 percent.

Stigma and other determinants of participation in TANF and Medicaid.

We developed a conceptual framework to examine the association between stigma, enrollment barriers (e.g., difficult application), knowledge, state policy, and participation in the Temporary Assistance to Needy Families (TANF) and adult Medicaid programs. Survey data from 901 community health center patients, who were potential and actual participants in these programs, indicated that while images of the Medicaid program and its recipients were generally positive, stigma associated with welfare stereotypes reduced both TANF and Medicaid enrollment. Expectations of poor treatment when applying for Medicaid, enrollment barriers, and misinformation about program rules were also associated with reduced Medicaid enrollment. States that enacted strict welfare reform policies were potentially decreasing TANF participation, while states with more simplified and generous programs were potentially increasing Medicaid participation. The results suggest that the image of the adult Medicaid program remains tied to perceptions about welfare and provides guidance to policymakers about how to improve participation rates.

Simplifying children's Medicaid and SCHIP.

The states have implemented the State Children's Health Insurance Program (SCHIP) in a variety of ways. We describe these choices and estimate the resulting enrollment impacts. Many widely adopted policies, including mail-in applications and twelve-month continuous eligibility, have had limited impacts. Other policies that increase enrollment, including presumptive eligibility and self-declaration of income, have not been widely adopted. SCHIP programs administered as Medicaid expansions have been more successful in enrolling children than either separate SCHIP plans or combination programs. Waiting periods, premiums, and welfare reform have had important negative impacts on children's program enrollment.