Defining geographic areas to adjust payments to physicians, hospitals, and HMOs.

Defining geographic areas for the purpose of paying health care providers has been difficult and is an issue that Congress continues to address. Employment-based insurance programs are starting to face this same issue in paying HMOs. Because input prices are related to population density, payment levels could be related to density. This paper offers a new measure of density that represents the population density for the average person. Using zip-code-level data, this measure calculates density of a county weighted by the population of the zip code. Payment areas can be devised by using the measure to categorize counties. This approach can be applied to paying physicians, hospitals, and HMOs.

Patterns of sealant delivery under variable third party requirements.

Despite evidence indicating dental sealants to be effective in preventing caries on the pit and fissure surfaces of teeth, only 8 percent of school-aged US children had received sealants as of 1986-87. While many rationales have been suggested and scientifically answered for this low level of utilization, issues of cost and cost effectiveness remain considerable barriers to many insurers and public programs. This study reports dentist behavior when sealants were added with few restrictions as a new benefit to an existing third party system of care. Results are compared to another third party program with stricter reimbursement policies. Overall, sealants were provided in a reasonable fashion to both groups of patients, relative to teeth selected for sealing and costs. Only a small proportion of patients receiving sealants were under age six or above age 19. Even under the most liberal program, sealants were predominantly targeted to teeth at highest risk to decay. Still, for both groups, a significant proportion of the sealants were placed in teeth at points in time quite distant from expected eruption patterns and, thus, their periods of highest risk to decay. Overall, dentists appeared to use sealants only minimally in their practices. These data suggest that sealants can be added to third party dental programs with little overall risk of inappropriate use or abuse. They also suggest that specific efforts are merited to educate providers as to the most effective times at which to provide sealants for preventing the maximum amount of decay in a population.

A sliding scale for hospital reimbursement.

Reimbursement by governmental agencies and by third party payors of general and voluntary hospitals currently does not take cognizance of the special financial burdens of inner city teaching hospitals. It is proposed that a formulation, previously described, be used to provide a sliding scale for reimbursement purposes which would ameliorate the situation in an auditable, justifiable, and fair manner.