Community, service, and policy strategies to improve health care access in the changing urban environment.

Urban communities continue to face formidable historic challenges to improving public health. However, reinvestment initiatives, changing demographics, and growth in urban areas are creating changes that offer new opportunities for improving health while requiring that health systems be adapted to residents' health needs. This commentary suggests that health care improvement in metropolitan areas will require setting local, state, and national agendas around 3 priorities. First, health care must reorient around powerful population dynamics, in particular, cultural diversity, growing numbers of elderly, those in welfare-workplace transition, and those unable to negotiate an increasingly complex health system. Second, communities and governments must assess the consequences of health professional shortages, safety net provider closures and conversions, and new marketplace pressures in terms of their effects on access to care for vulnerable urban populations; they must also weigh the potential value of emerging models for improving those populations' care. Finally, governments at all levels should use their influence through accreditation, standards, tobacco settlements, and other financing streams to educate and guide urban providers in directions that respond to urban communities' health care needs.

Access to care is the centerpiece in the elimination of socioeconomic disparities in health.

Many health care professionals have sustained an almost single-minded conviction that disparities in access to health care across socioeconomic groups are the key reason for the major discrepancies in health status between wealthy persons and poor persons. Others, however, have argued that a host of factors work to create major impediments and that reducing or eliminating financial barriers to health care in particular will do little to reduce discrepancies in health status. This paper, while acknowledging the spectrum of contributing factors, argues that the elimination of financially based differences in access is central to any effort to create equity in outcomes across socioeconomic groups. Through selected review of the many studies on health insurance, access, outcomes, and socioeconomic status, it establishes that a core links affected populations, their difficulty in financing health care, and the threat to their well-being. In so doing, it cites findings that strongly associate lack of insurance (especially for persons who live in poverty), inability to obtain services, and adverse health outcomes. It also uses the example of Medicaid and other coverage for HIV-infected persons in particular as an important positive instance in which leveling the discrepancies in health care across socioeconomic groups can move toward creating quality in access and outcomes. The competitive pressures in today's health care environment threaten to drive socioeconomic groups further apart, especially insured and uninsured persons. However, the recent enactment of state actions, especially the State Child Health Insurance Program, represent powerful examples of health insurance expansion that have lessons for policymakers at all levels for the monitoring and reduction of socioeconomic disparities.

The social and health characteristics of California cities.

This DataWatch presents information from nationally recognized sources on sociodemographic characteristics, crime, and hospitals for the sixteen largest cities in California. Recognizing that effective health system changes will require attention to these critical issues, the report identifies their status in a single year and documents changes since 1980. It also provides comparisons among these cities and for the 100 largest U.S. cities. Synthesis of information indicates a wide range in status among these cities for most characteristics but concludes that, on a number of specific measures, the largest California cities have lost ground compared with their U.S. city counterparts.

U.S. hospital care for HIV-infected persons and the role of public and private teaching hospitals: 1988-1991.

Hospitals are a major provider of resources for individuals with HIV-related conditions. With the changing nature of HIV, tracking the dependence on and impact of related care delivered in these institutions is critical to monitoring overall resource need. This report documents HIV inpatient care in U.S. hospitals during 1991 by surveying 1,931 acute care institutions (19% of all acute care institutions). In addition, this report documents changes in HIV care in 124 teaching hospitals between 1988 and 1991. Of the 1,081 hospitals completing the 1991 survey (56%), 773 reported treating at least one HIV inpatient and a total of 58,211 inpatients. Northeastern and public hospitals provided significantly more care. Public-related payer sources financed almost 90% of care in public institutions and > 60% in private institutions. Hospitals reported an average loss of $ 92,025 and an estimated total cost-based loss of $ 71.1 million among all responding institutions. The number of HIV inpatients increased 68% between 1988 and 1991. During these years, substantial increases in revenue and modest reductions in per patient use led to a decrease in total inpatient losses of $ 540,748 to $ 260,331 per hospital. Results show that HIV-associated inpatient care is extensive and increasing and that support for care has become a predominantly public sector responsibility. Teaching hospitals' increase in care suggests that they have become "magnets" for patients with HIV-related disease. However, treatment economies and reimbursement rate improvements have worked to lower losses. Any HIV financing policies should work to balance support for non-hospital care with the continuing need for inpatient treatment.

Comparisons of hospital care for patients with AIDS and other HIV-related conditions.

OBJECTIVE: To compare utilization and financing of inpatient care for persons with the acquired immunodeficiency syndrome (AIDS) (as defined by the Centers for Disease Control) and those with "other HIV [human immunodeficiency virus]-related illness." DESIGN: A mailed survey of the members of five national organizations representing public, teaching, children's, community, and Catholic hospitals. The survey requested information on demographics, service utilization, costs, and financing of care for AIDS and other HIV patients. Statistical analysis using paired t tests was conducted to evaluate differences between group means for AIDS and other HIV patients. Differences among categorical variables were evaluated by calculation of proportions and compared using chi 2 tests. PARTICIPANTS: Five hundred eighteen of 1158 hospitals surveyed responded to the AIDS and other HIV portions of the survey. RESULTS: Three hundred twenty-five hospitals reported treating at least one other HIV patient. These 325 hospitals treated 30% of all AIDS patients (16,213) estimated to have been alive during 1988, and provided care to over 11,000 other HIV patients. Service utilization by other HIV patients was found to comprise a substantial portion of the total HIV burden and related costs, representing 35% of all HIV-related admissions, 29% of all inpatient costs, and 35% of all inpatient losses. Demographic and mode of exposure analysis indicated that other HIV patients were more likely than AIDS patients to be intravenous drug users, female, nonwhite, and to have no source of public or private coverage for their health care. CONCLUSIONS: Our results demonstrate that accounting for only the utilization of services by persons with AIDS as defined by the Centers for Disease Control will understate significantly the total burden of the HIV epidemic on hospitals. The results suggest that the expanded definition proposed by the Centers for Disease Control would incorporate a large hospitalized HIV population.

Physician staffing in the emergency departments of public teaching hospitals: a national survey.

STUDY HYPOTHESIS: To evaluate factors influencing emergency physician staffing patterns in an important subset of US hospitals. DESIGN: Survey of emergency department directors and hospital administrators. PARTICIPANTS: Member institutions of the National Association of Public Hospitals and the Council of Teaching Hospitals. MEASUREMENTS: Of 498 hospitals enrolled, two mailings and telephone follow-up yielded 277 replies (56% response rate). To adjust for differences in ED size and volume, levels of staffing were converted to full-time equivalents (FTEs) per 10,000 annual ED visits. RESULTS: Responding institutions included 160 private and 115 public hospitals, 74 of which were Veterans Administration hospitals. Formal medical school affiliation was noted by 86% of responding institutions, and 82 (30%) supported emergency medicine residency programs. Full-time attending emergency physician staffing varied widely, from less than one to more than three FTEs per 10,000 visits; however, mean levels of staffing at public hospitals did not differ significantly from private institutions (2.7 +/- 1.6 vs 2.5 +/- 3.1, respectively; P = .50). Three of four hospitals reported using part-time emergency physician attending but only 33% used nurse practitioners or physicians' assistants. Two thirds of responding hospitals used rotating house officers-in-training. Of note, hospitals that supported emergency medicine residency programs reported significantly higher levels of staffing by housestaff (2.2 +/- 1.8 vs 1.0 +/- 1.2 FTEs/10,000 visits; P less than .0004), but levels of total staffing by full- and part-time attending physicians were virtually identical (2.69 +/- 1.6 vs 2.67 +/- 2.6 FTEs/10,000 visits; respectively; P = .95). Marked variability in levels and patterns of ED staffing at public and teaching hospitals currently exists, but the differences are not explained by hospital ownership. The reasons for such variations and their implications for patient care must be explored.

Emergency departments and crowding in United States teaching hospitals.

STUDY OBJECTIVES: To assess the extent and distribution of hospital and emergency department crowding nationally. DESIGN: The research design consisted of a mailed questionnaire disseminated in the fall of 1988 to the member institutions of the National Association of Public Hospitals (NAPH) and the Council of Teaching Hospitals (COTH). TYPE OF PARTICIPANTS: Study participants included hospital administrators and ED directors from 239 of the non-Veterans Administration, general acute care, US members of COTH and NAPH. MEASUREMENTS: Key measures of hospital and ED crowding including mean ED holding times for floor and ICU beds. MAIN RESULTS: Three fourths of responding hospitals reported increases in ED visits over the preceding three years. Mean ED holding times for admitted patients were 3.5 hours (median, 2.0 hours) for a floor bed and 2.9 hours (median, 1.5 hours) for an ICU bed. Half of all hospitals noted maximum waits for floor and ICU beds of ten hours or more and seven hours or more, respectively. Measures taken by hospitals to manage crowding during August 1988 included restricting access to some types of patients (mean, 3.6 days), actively transferring patients to other hospitals (mean, 2.2 days), transfer refusal (mean, 2.8 days), and total ambulance diversion (mean, 1.6 days). CONCLUSIONS: Our study strongly suggests that ED crowding is not an isolated phenomenon; ED crowding and its attendant problems appear to affect hospitals with similar adverse effects regardless of ownership. Although our results suggest that ED crowding is concentrated in metropolitan areas and in a smaller subset of hospitals, we found instances of crowding among hospitals nationwide.

The 1987 US hospital AIDS survey.

In 1987, the National Public Health and Hospital Institute conducted a national survey of 623 acute-care hospitals to obtain information relating to inpatient and outpatient care for persons with acquired immunodeficiency syndrome (AIDS). Two hundred seventy-six hospitals reported treating persons with AIDS; the average length of stay was 16.8 days. Average costs and revenues per inpatient day were $681 and $545, respectively, with a cost per patient per year of $17,910. Estimated cost for AIDS inpatient care during 1987 was $486 million; Medicaid represented the primary payer. Regional and ownership comparisons for this year and between 1985 and 1987 indicated significant differences in utilization, payer source, and financing. Results suggest major differences in reimbursement and losses related to payer source or lack of insurance, with many hospitals that serve large numbers of low-income persons with AIDS encountering moderate to severe financial shortfalls. We conclude that increasing concentrations of persons with AIDS in relatively few hospitals in large cities may make it more difficult to secure the broader political base necessary to obtain adequate support for treatment.

KIE: The National Public Health and Hospital Institute conducted a survey of 623 acute care hospitals to obtain information on inpatient and outpatient care of persons with AIDS (PWAs). This article summarizes and comments upon 1987 data from 322 responding hospitals. Participants answered questions in six categories: general inpatient utilization; demographic and risk-group characteristics; hospital organization and staffing of AIDS treatment programs; outpatient information; financial characteristics of inpatient and outpatient care; and specific treatments available for PWAs. Institutions also were asked to report cost, charge, and revenue per day for non-AIDS patients. The authors conclude that hospital losses due to financial shortfalls and the growing volume of PWA care reinforce the need for policy changes to insure that hospitals, particularly public hospitals, are adequately reimbursed for AIDS care, and to encourage the development of alternatives to inpatient treatment.

The provision and financing of medical care for AIDS patients in US public and private teaching hospitals.

The National Association of Public Hospitals and the Association of American Medical Colleges' Council of Teaching Hospitals conducted a detailed survey on hospital care to patients with acquired immunodeficiency syndrome (AIDS) in major US public and private teaching institutions in 1985. The 169 hospitals treating patients with AIDS that responded to the survey reported providing inpatient services to 5393 patients with AIDS. These patients accounted for 171,205 inpatient days and 8806 inpatient admissions, with an average length of stay of 19 days. The average costs and revenue for patients with AIDS per day were $635 and $482, respectively, with Medicaid representing the most frequent third-party payer. The average inpatient cost per patient per year was $20,320. Using Centers for Disease Control estimates of 18,720 patients diagnosed as having AIDS and alive during any part of 1985, we estimate that the total cost of inpatient care for patients with AIDS was $380 million for that year. We also found significant regional and ownership differences in source of payment for patients with AIDS and regional differences in revenues received for AIDS treatment. Results indicate that the costs of treating patients with AIDS will profoundly affect major public and private teaching institutions, but that public teaching hospitals in states with restrictive Medicaid programs will be most adversely affected.

KIE: The authors report the results of a survey by the National Association of Public Hospitals and the Association of American Medical Colleges' Council of Teaching Hospitals regarding the provision and financing of care for AIDS patients by 169 major U.S. public and private teaching hospitals. In 1985, the average costs and revenues per day reported were $635 and $482 respectively, with Medicaid the most frequent third-party payer. Private hospitals treated more insured and homosexual patients while public institutions cared for higher percentages of Medicaid and drug abuse patients. The authors conclude that the study strongly suggests that major teaching hospitals and large city public institutions bear a disproportionate burden of AIDS care. They recommend less reliance on the hospital as the primary or sole source of care and the development of more cost-effective community-based services.