Back to school: a health care strategy for youth.

School-based health centers (SBHCs) are a policy innovation designed to increase health care access among youth. The centers offer primary and acute care, often to underserved populations. We describe SBHCs, trace their history, and analyze the three great political challenges they face: moral opposition triggered by concern about reproductive health services in schools; funding in a managed care era; and partisan state politics. We show how the centers have been meeting these challenges. Finally, we consider the prospect of this innovation going to scale across the nation.

Medicare's Choice explosion? Implications for beneficiaries.

Medicare+Choice was established under the Balanced Budget Act of 1997 to expand the range of health plan options available to beneficiaries and to encourage plans to compete on the basis of price and quality, with potential savings to beneficiaries and the program. However, it is unclear whether the envisioned positive outcomes will occur. This paper reviews the rationale for expanding choices under Medicare. It considers how the rapidly changing health insurance market poses uncertainties for beneficiaries and concludes with a discussion of safeguards that may be necessary to assure that the program continues to work well for beneficiaries with diverse needs and circumstances.

Medicare HMO withdrawals: what happens to beneficiaries?

More than 400,000 Medicare beneficiaries had to seek other insurance arrangements when their health maintenance organization (HMO) withdrew from Medicare at the end of 1998. According to a new survey of 1,830 involuntarily disenrolled Medicare beneficiaries, two-thirds subsequently enrolled in another Medicare HMO; one-third experienced a decline in benefits, and 39 percent reported higher monthly premiums. One in seven lost prescription drug coverage; about one in five had to switch to a new primary care doctor or specialist. Those with traditional Medicare by itself or with Medigap, the disabled under age sixty-five, the oldest old, and the near-poor experienced the greatest hardship after their HMO withdrew.

Price controls: on the one hand ... and on the other.

Controlling health care costs requires that limits be placed either on prices, quantities of services, or both. Prices are measurable and more easily controlled than is quantity and, consequently, health care cost containment has frequently focused on mechanisms for controlling prices. Regulatory approaches, however, may create market distortions and change access patterns. An alternative approach to controlling prices is to restructure the market for health services to encourage greater price competition among providers. Because this type of health reform has not previously been attempted, there is much more uncertainty about the outcome of market-oriented approaches than for direct regulatory control over prices.

Managed care in the United States: promises, evidence to date and future directions.

In the United States, health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have proliferated during the past decade. To a great extent, their growth has been based on the perceived promise of these organizations to reduce health care costs without compromising quality of care and introduce a level of competition into the health care market that would result in a more efficient and effective health care system. This paper examines the promise of managed care as delivered through HMOs and PPOs, the evidence to date on the extent to which their promise has been met, and recent developments in the organization of managed care systems.

Economic consequences for Medicaid of human immunodeficiency virus infection.

Medicaid is currently a major source of financing for health care for those with acquired immunodeficiency syndrome (AIDS) and to a lesser extent, for those with other manifestations of human immunodeficiency virus (HIV) infection. It is likely to become even more important in the future. This article focuses on the structure of Medicaid in the context of the HIV epidemic, covering epidemiological issues, eligibility, service coverage and use, and reimbursement. A simple methodology for estimating HIV-related Medicaid costs under alternative assumptions about the future is also explained.

Structure and performance of health maintenance organizations: a review.

During the past decade, the number of and enrollment in health maintenance organizations (HMOs) have grown dramatically. In 1980, 236 HMOs served 9 million members. By 1989, there were 591 HMOs with over 34 million enrollees. New HMOs are very different in organizational structure and arrangements than the HMOs that were operating in the 1970s, and the health care markets they serve also have changed substantially with the increasing supply of physicians and declining hospital admissions. Consequently, the accepted research findings on HMO performance in the 1970s may have only limited usefulness in understanding the role of HMOs and their effect on today's market for health services. This is of particular concern as the Health Care Financing Administration considers the further expansion of managed care options available to Medicare and Medicaid beneficiaries. In this article, the author reviews evidence on the relationship between HMO organizational arrangements and performance, and the trends within the HMO industry toward new organizational structures. The implications for Medicare and Medicaid risk contracting are also examined.

Evaluation of the Medicare competition demonstrations.

A summary of findings from the Evaluation of the Medicare Competition Demonstrations is presented in this article. The purpose of this evaluation was to examine the implementation and operational experiences of the 26 health maintenance organizations that operated as demonstrations from 1983 to 1985, their experiences in marketing their plans, the factors that affected beneficiaries' decisions to join or not join a plan, the extent to which beneficiaries were satisfied with their choice of plans, the quality of care provided by the plans, and the impact of the demonstrations on Medicare beneficiaries' use and cost of services.

Patient satisfaction among elderly enrollees and disenrollees in Medicare health maintenance organizations. Results from the National Medicare Competition Evaluation.

More than 1 million Medicare beneficiaries have enrolled in health maintenance organizations (HMOs) and competitive medical plans under a new program in which beneficiaries can freely enroll in a risk-based HMO in their area or remain in the fee-for-service sector under Medicare. Based on a randomly selected nationwide sample of beneficiaries, we analyzed differences in patient satisfaction between 2091 beneficiaries who were continuously enrolled in an HMO plan for 1 year and 1000 beneficiaries in the fee-for-service sector. We also studied the reasons for disenrollment. No significant difference in overall satisfaction was found between HMO enrollees and fee-for-service beneficiaries. However, HMO enrollees expressed less satisfaction compared with fee-for-service beneficiaries regarding the professional competence of their health care providers and the willingness of the HMO staff to discuss problems. On the other hand, HMO enrollees were more satisfied than fee-for-service beneficiaries with waiting times and claims processing. Approximately half of the disenrollment from an HMO within 1 year was attributed to misunderstanding the terms of enrollment.

Disenrollment patterns in Medicare HMOs: a preliminary analysis.

This paper examines disenrollment patterns of 17 Medicare Competition Demonstration HMOs during 1984. Characteristics of HMO disenrollees for a sample of Medicare beneficiaries from two surveys conducted in early 1985 and 1986 are also examined. These data provide a preliminary, descriptive analysis of the nature and the implications of Medicare HMO disenrollment.

Comparison of "rollovers" and "switchers" among enrollees of Medicare HMOs.

Individuals who are able to enroll in an HMO and retain the physician-patient relationship they had developed under fee-for-service arrangements ("rollovers") may differ on average in health status and other characteristics from those who changed physicians to join an HMO ("switchers") and those who did not have a regular physician prior to joining. If such differences exist, they could have important implications for the relative performance of IPA-model HMOs, which tend to enroll significant numbers of rollovers, and staff model HMOs, which primarily enroll switchers and individuals without a regular physician. This study uses survey data on Medicare beneficiaries who enrolled in 17 HMOs under the Medicare competition demonstrations to compare rollovers to both switchers and enrollees who previously had no regular physician. The findings indicate that rollovers are very similar to each of the other categories of enrollees on demographic and socioeconomic characteristics as well as self-reported health status.

Effects of community characteristics on young physicians' decisions regarding rural practice.

The supply of physicians has increased rapidly during the past decade. To examine the impact of this expanding supply on the geographic distribution of physicians in rural areas, we examined the location patterns of 1974-78 medical school graduates practicing in 1983 in rural areas. Of 2,112 rural counties, 58 percent gained at least one 1974-78 graduate; 31 percent of the least populous rural counties gained physicians; and 92 percent of most populous counties gained physicians. When Health Manpower Shortage Areas were examined separately, it was found that only 45 percent of the HMSAs that consisted of an entire county gained a young physician compared with 61 percent of non-HMSA counties. Characteristics of counties that gained a young physician were compared with characteristics of counties that did not attract a young physician. Results of the multivariate analysis indicated that the probability that a county would attract a young physician is positively related to population, the supply of physicians, the proportion of white collar employment, and the presence of a college. Higher levels of farm population are associated with a lower probability that a county would attract a young physician. These findings suggest that diffusion of young physicians into rural areas is occurring as the supply of physicians increases. However, young physicians are attracted to communities with particular characteristics. Those counties with fewer attractive characteristics may continue to have difficulty gaining physicians to serve their communities.

Early experience of health maintenance organizations under Medicare competition demonstrations.

Between 1982 and 1985, health maintenance organizations (HMO's) entered the Medicare market under the Medicare competition demonstrations. The status and experience of these HMO's, their market areas,, and the benefit packages they offered are presented. Information from case studies of 20 of these HMO's is used to discuss the planning process through which the organizations prepared to enter the Medicare market. Data from administrative reports, submitted by the HMO's, are used to describe the operational experience, including enrollments, utilization, and financial performance.