Managed care in rural markets: availability and enrollment.

The objective of this research was to test the hypothesis that urban-rural differences in managed care availability and enrollment are primarily due to differences in population socioeconomic and health system characteristics rather than geographic location, population size, or density. These two groups of variables were entered into a regression equation to determine which group could best account for the variance in managed care availability and enrollment. In general, the results of these analyses indicated that socioeconomic and health system characteristics did a much better job of explaining differences in managed care availability and enrollment. Therefore, focusing on factors such as adjacency to metropolitan areas or population size or density in making managed care policy decisions may be less productive than focusing on the socioeconomic and health system characteristics of an area.

Risk equalization, competition, and choice: a preliminary assessment of the 1993 German health reforms.

Risk adjustment and/or equalization has become a central issue in the health care reform initiatives of many countries, including Germany, Switzerland, the Netherlands, Israel, the U.K. and the U.S. Risk adjustment is widely seen as essential to prevent cream skimming and to promote fair competition. In this vein, the 1993 German health reforms require implementation of a risk-based contribution rate equalization scheme by 1996. This paper provides a preliminary assessment of the risk equalization methodology currently proposed for Germany. Recent research in the U.S. and the Netherlands is used to examine whether the sociodemographic factors being used in Germany are likely to be effective. Research findings from both countries indicate that risk formulas based only on socio-demographic factors predict only one-tenth to one-fourth of the maximum possible explainable variance. If the current formula is used, sickness funds with higher concentrations of high risk groups are likely to be substantially under compensated, and to face serious enrollment and financial problems. The authors conclude that improvements in the formula through measures based on diagnosis and prior hospitalization, disability status, and regional variations in utilization and cost are urgently needed before the system is implemented. The German experience is also relevant to other countries that have relied to date on socio-demographic measures for risk adjustment.

HIV/AIDS in the rural United States: epidemiology and health services delivery.

This integrated research review addresses the epidemiology of rural human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and the organization, financing, and delivery of health services for rural persons living with HIV or AIDS (PLWHIVs, PLWAs). Several abstracting services, indexing services, and bibliographies were searched. An annotation form served as the guideline for data extraction. Several conclusions emerged from this review. Epidemiological evidence indicates that there has been a dramatic increase in the relative proportion of rural HIV/AIDS incident cases over the past 5 years. Explanations for the rural increase focus on injection drug use, heterosexual behavior, and sexually transmitted disease levels. Dramatically elevated rates of infection in rural Black women are indicated. Rural areas experience important levels of in-migration of HIV/AIDS-infected individuals. The health services literature suggests that rural providers and institutions have limited resources and little experience with PLWHIVs or PLWAs.

Stratification, competition and risk distribution: health insurance in Germany and the United States.

Issues of unequal risk distribution among sickness funds are given increasing attention in the current discussions on the reform of the statutory health insurance system in Germany. This paper examines the structural determinants of risk distribution and points toward the links between social stratification, competition, health risk and insurance status. A model showing the links between basic structural determinants is presented. Using health survey data from Germany and the U.S., statistical analyses are conducted. The results support the model and indicate its applicability for both health care systems. The paper concludes by indicating the relevance of such findings for health policy and future research.

Universal health insurance and high-risk groups in West Germany: implications for U.S. health policy.

Access to West Germany's broad-based health-insurance system is geared to the country's occupational structure. People who qualify, however, may seek coverage from alternative sources, including local "sickness funds." The changing nature of the German job market is leading to concentration of high-risk groups in the local funds, some of which could in turn face serious financial problems. Proponents of a universal health-insurance program for the United States need to take account of the growing segmentation of risk groups in the current German experience, which may ultimately threaten the concept of solidarity on which the system is founded.

The use of research in national health policy: an assessment and agenda.

This article provides an assessment of health services research contributions to national health policy. An examination of disciplinary-based research identifies many of the shortcomings of such research and the need for a different structure for relating research to health policy. Some definitions are offered for such terms as "applied research," "disciplinary research," "policy analysis," and "policy research." A policy research model of sequential steps in problem-solving is suggested as a useful approach. A review of the federal role in health policy is developed to set the context for viewing past contributions as well as to suggest a strategy for maximizing the relevance and usefulness of research.