A model of the transmission and control of genital herpes.

BACKGROUND: Mathematical modeling of herpes simplex virus type 2 transmission can provide insight into the behavior of the epidemic and the effects of control measures. GOAL: To examine parameter sensitivity and assess control strategies. STUDY DESIGN: The model simulates transmission in a young, sexually active, nonmonogamous population. The population is divided into compartments representing disease status (susceptible, exposed, primary infectious, asymptomatic, recurrent, vaccinated), and flows between compartments are described by differential equations. RESULTS: With a base set of parameter values, the basic reproduction rate (R0) is 1.79, indicating that ultimate prevalence in this population will be 44%. The course of the epidemic is most sensitive to changes in behavioral parameters (time nonmonogamous and partner-change rate) and to the probability of transmission during the asymptomatic stage. CONCLUSION: In the absence of behavior change, efforts to control the epidemic must focus on vaccine development and prevention of transmission during both symptomatic and asymptomatic phases.

Making health reform work without employer mandates.

Requiring employers to furnish health insurance may be a politically expedient way to expand coverage to the uninsured, but it will surely undermine economic competitiveness and contribute to greater unemployment at a time when the U.S. is struggling to regain its economic strength. In the present environment, a wiser course of action would require that individual households, not employers, become the entity responsible for obtaining health insurance. Under such a scenario, limits would be established on the percentage of after-tax income devoted to health insurance, subsidies would be granted to low-income individuals to purchase insurance, and a basic benefit package would be developed that limits payments to services meeting efficacy and cost-effectiveness criteria.

Universal access to health care: a practical perspective.

Policy disconnected from economic reality is bad policy. Neither government financed health insurance nor an employer mandated health insurance approach are in the national interest. Higher national priorities compel a reallocation of resources from consumption to investment. This need not, however, cause an abandonment of efforts to deal with the problems of the uninsured and other health reforms. Successful health care reform is achievable provided it is responsive to higher priorities for economic growth. A strong economy and the production of wealth are indispensable to economic justice. Toward this end, a program of universal access is proposed whereby families and individuals are required to pay for their own health insurance up to a fixed percentage of disposable personal income before public payments kick in. Government's chief role is to establish a standard package of cost-effective benefits to be offered by all insurance carriers, the cost of which is approximately 40 percent less than conventional insurance coverage because of the elimination of reimbursement for clinically non-efficacious and cost-ineffective services. Public financing is relegated to a residual role in which subsidies are targeted on the needy. Much of the momentum for cost control is transferred to consumers and private insurers, both of whom acquire a vested interest in obtaining value for money. Uniform rules for underwriting, eligibility, and enrollment practices guard against socially harmful practices such as experience rating and exclusion of preexisting conditions. The household responsibility and equity plan described herein could free up as much as $90 billion or more for public investment in economic growth and national debt reduction while assuring access to health care regardless of ability to pay. Economic revitalization will be assisted by changes in household savings. With health care no longer a free good and government social programs concentrated on the truly needy, individual propensity to save will increase, thereby enlarging the pool of capital for financing investments in economic growth. Putting more responsibility for health care financing on households with an ability to pay also serves to reinforce and expand the work ethic. Privatizing responsibility by severing health insurance from the workplace connection improves the geographic and occupational mobility of labor, diminishes employer tendencies to discriminate against hiring the disabled and older employees, and eliminates a major source of labor unrest.(ABSTRACT TRUNCATED AT 400 WORDS)

Exploring physician responses to patients' extramedical characteristics. The decision to hospitalize.

The influence of patients' extramedical characteristics on physician decisions to hospitalize patients is examined by use of the hypothetical case approach. In addition, physician and market condition characteristics are examined as possible correlates of physician responsiveness to patients' extramedical conditions. The findings provide additional evidence that, for at least some cases, the likelihood of a physician's admitting a patient to the hospital is influenced by the patient's living arrangements, travel time to the physician's office, and the extent to which medical care would cause a financial hardship for the patient. Variation in physician responsiveness to these extramedical conditions is quite large. This variation in responsiveness is not consistently related to physician specialty or hospital occupancy rates, but is correlated with physician time spent giving outpatient care.

The determinants of small-area variation in hospital utilization. The evidence from hospital discharge abstracts.

Small-area differences in hospital use were examined using hospital discharge abstract data for the populations of seven small service areas in Iowa that exhibited substantial variation in admission rates during 1980. The results indicate a marked difference in the age composition of the patient populations with older patients being more common among residents of high-use areas, higher age- and sex-adjusted discharge rates per 1000 in the high-use areas across many diagnostic categories, frequently higher average lengths of stay in high-use areas, a lack of conformity between discharge patterns for selected surgical procedures and diagnoses, and more readmissions to the same hospital during a 12-month period for residents of high-use areas. This data set comprises one part of a study of small-area differences that also employed household surveys, physician surveys, and other existing data sets. The findings illustrate the potential and limitations of hospital discharge abstracts as a data base for evaluating hospital discharge abstracts as a data base for evaluating hospital utilization differentials.

Visits to the physician: an evaluation of the usual-source effect.

Having a regular or usual source for medical care has frequently been found to be an important correlate of ambulatory visits to the physician. However, it remains unclear whether having a usual source is a determinant of visits, a consequence of visits, or both. This article addresses the question, how do these alternative theoretical relationships affect estimates of the relative impact of having a usual source on illness-related visits? The empirical results of a household interview survey generally support the significance of a usual-source variable as a determinant of illness-related visits, but they indicate that use of a single equation-estimation technique may overestimate the magnitude of this effect.