Dynamics of Macroeconomy, Medicaid, and State Fiscal Conditions: A Role of Medicaid Expansion.

Background: One of the main concerns of state governments about Medicaid expansion is the potential increase in state fiscal burden following the rise in enrollments. In previous literature, limited attention has been paid to the effect of macroeconomic changes, which are closely linked to Medicaid enrollments, in understanding the impact of Medicaid expansion on a state. To narrow the gap, this study establishes a synthetic model to represent the transmission channel from an unemployment shock to the Medicaid program and state expenditures. Methods: The panel vector autoregression (VAR) model is adopted for the empirical analysis using annual data from 2010 to 2019 for 50 US states and D.C. The unit root and Granger causality tests are conducted to check the model's appropriateness. The estimated results are analyzed by using impulse response functions. Results: A sudden increase in the unemployment rate will raise the number of Medicaid enrollees and the state Medicaid expenditure, but the impact on the overall state budget is not clear. States that adopt Medicaid expansion will encounter surges in enrollment and increasing Medicaid expenditure during the economic recession, while the non-expansion states will only have moderate enrollment increases. However, an increased budgetary burden per new enrollees will not be significant at its level. Conclusion: Medicaid expansion will allow more people to benefit from the public health insurance program during an economic recession while the impact on states' fiscal burden will be moderate.

What Makes NPOs Sustainable in an Emergency? Examining the Effect of Person-Organization Fit and Generation on Volunteer Activities During the COVID-19 Pandemic.

Purpose: Despite the unprecedented challenges caused by the COVID-19 pandemic, nonprofit organizations (NPOs) continued providing services, thereby contributing to overcoming the pandemic. What enabled NPOs to sustain their service provision during this global emergency? This study attempts to answer this question by focusing on one of the essential pillars supporting the operation of NPOs: volunteers. More specifically, we aim to investigate how person-organization (P-O) fit and generation, particularly the Millennial generation, are related to engagement in voluntary activities during the COVID-19 pandemic. Methods: We collected data through an online survey conducted in March 2021. This US national survey was completed by 2307 respondents, yielding the US Census balanced data regarding gender, age, race, education, and income. To analyze the data, we employed the two-stage Heckman selection model. Results: Relying on P-O fit theory and generational theory, the study identifies what led existing volunteers to continue engaging in volunteer activities at their NPO during the COVID-19 pandemic despite the risks. We found that P-O fit mattered in volunteers' decision to continue engaging. In addition, our study uncovered that when existing volunteers were Millennials, the relationship between P-O fit and engagement in voluntary activities strengthened during the pandemic. Conclusion: This study contributes to expanding the explanatory power of the P-O fit theory by testing it in an emergency and extends the generational theory by clarifying under what conditions Millennials (aka Generation Me) transform themselves into Generation We. In addition, linking NPO management and emergency management, this study provides NPO managers with practical implications for securing reliable volunteers who will sustain the capacity of the NPO in a crisis.

The impact of price transparency and competition on hospital costs: a research on all-payer claims databases.

BACKGROUND: Public reporting has been considered effective in reducing health care costs by mitigating information asymmetry in the market as payers have incorporated publicly available information mandates into pay-for-performance programs and value-based purchasing. Therefore, hospitals have faced increasing pressures to provide price transparency. Despite the widespread promotion of healthcare transparency, the effectiveness of public reporting has not yet been sufficiently understood. This study analyzed the impact of transparency policy and competition on hospital costs by taking the state operations of all-payer claims databases (APCDs) as a case of interest. METHODS: We employed a fixed-effects regression, which allows the generation of hospital-specific effects, in accordance with the suggestion by the Hausman test. The study samples comprise nonprofit and for-profit general acute care hospitals in the United States for 2011-2017. The finalized dataset ranges from 3547 observations in 2011 to 3405 observations in 2015 after removing missing values. RESULTS: We found that hospitals in the states with APCDs tend to bear higher average operating expenses than those without APCDs, which may indicate that states maintaining higher healthcare expenditures are more attentive to a price transparency initiative and tend to adopt APCDs. With regard to competition, the results showed that weak market competition is significantly associated with higher operating costs, supporting the traditional competition theory. However, the combined effect of APCDs and competition did not indicate a significant association with operating expenses. Further investigation showed a continued tendency for a weak intensity of competition to be linked to lower hospital operating costs in states without APCDs. For those located in non-APCD adopted states, market consolidation helped hospitals coordinate care more effectively, economize operating costs, and enjoy economies of scale due to their large size. Similar trends did not appear in APCD-adopted states except for in 2015. CONCLUSIONS: This study observed limited evidence of the impact of APCDs and market competition. Our findings suggest that states need to make multifaceted efforts to contain hospital costs, not solely depending on the rollout of cost information or market competition. Market concentration may lead to coordinated care or cost economization in some cases. Still, the existing literature also demonstrates some potentially harmful impacts of increased concentration in the healthcare market, such as inefficient use of resources, unilateral market power, and deterrence of innovation. The introduction of a price transparency tool may require additional policy actions that take market competition into consideration.

The Veterans Choice Act and Technical Efficiency of Veterans Affairs (VA) Hospitals.

The Veterans Health Administration (VHA), responsible for providing 9 million veterans with quality healthcare, is not insulated from concerns about efficiency. In the aftermath of the Veterans Affairs (VA) hospital scandal in 2014, Congress passed the Veterans Choice Act of 2014, which allows eligible veterans to use non-VA hospitals instead of VA hospitals. After analyzing 118 or 119 VA hospitals each year from 2012 through 2017 in the U.S, this paper evaluates the efficiency scores of VA hospitals and examines how the 2014 Act has influenced their technical efficiency over time. Slack analysis shows that inefficient VA hospitals can improve efficiency by reallocating input resources, and regression analysis demonstrates that the overall technical efficiency of VA hospitals decreased by 0.164 after the implementation of the Act. This means that as more veterans used non-VA hospitals under the 2014 Act, the technical efficiency of VA hospitals decreased considerably. Given that a substantial portion of veterans' demands for healthcare transferred out to non-VA hospitals, the VHA should evaluate whether the current capacity of VA hospitals is appropriate and try to reduce wasted input resources to improve efficiency.

The Impact of Public Reporting Schemes and Market Competition on Hospital Efficiency.

In the wake of growing attempts to assess the validity of public reporting, much research has examined the effectiveness of public reporting regarding cost or quality of care. However, relatively little is known about whether transparency through public reporting significantly influences hospital efficiency despite its emerging expectations for providing value-based care. This study aims to identify the dynamics that transparency brought to the healthcare market regarding hospital technical efficiency, taking the role of competition into account. We compare the two public reporting schemes, All-Payer Claims Database (APCD) and Hospital Compare. Employing Data Envelopment Analysis (DEA) and a cross-sectional time-series Tobit regression analysis, we found that APCD is negatively associated with hospital technical efficiency, while hospitals facing less competition responded significantly to increasingly transparent information by enhancing their efficiency relative to hospitals in more competitive markets. We recommend that policymakers take market mechanisms into consideration jointly with the introduction of public reporting schemes in order to produce the best outcomes in healthcare.

Multifaced Evidence of Hospital Performance in Pennsylvania.

As health care costs and demands for health care services have been rising for decades in the United States, health care reforms have focused on increasing the performance of health care delivery. Competition has been considered as a mechanism to improve the quality of health care services and operational performance. Evidence on health care performance and market competition, however, has not sufficiently been reported to track its progress. The purpose of this study is twofold: First, we measure hospital performance over nine years, using the Malmquist Productivity Index. Second, we examine the impact of market competition on hospital efficiency in Pennsylvania, using a two-stage estimation procedure. The bootstrapped Malmquist productivity indices resulted in noticeable performance improvements. However, no steady performance trends were found during the course of nine years. In examining the impact of market competition, the bootstrapped panel Tobit analysis was applied after computing the efficiency scores with Data Envelopment Analysis. The results of the Tobit model found that hospitals run more efficiently in less competitive regions than in more competitive regions. The finding implies that hospitals underperforming in productivity growth should benchmark best practices of efficient hospitals to improve their productivity level. Another implication is that market competition would not be the best approach to effect the improvement of hospital efficiency in delivering health care services.

The Dynamics of Cross-Sector Collaboration in Centralized Disaster Governance: A Network Study of Interorganizational Collaborations during the MERS Epidemic in South Korea.

The debate continues as to which governance structure is most appropriate for collaborative disaster response, particularly between centralization and decentralization. This article aims to contribute to this debate by analyzing the structural characteristics of a multisectoral network that emerged and evolved under strong state control during the 2015 outbreak of Middle East respiratory syndrome-coronavirus (MERS) in South Korea. This study particularly focuses on the evolution of intra- and inter-sectoral collaboration ties in the network. The data for the study were collected through a content analysis of government documents and news articles. Using social network analysis, the authors found that the network evolved into a centralized structure around a small number of governmental organizations at the central level, organizing the ties between participating organizations rather hierarchically. The network displayed a preponderance of internal ties both among health and non-health organizations and among public and nonpublic health organizations, but under different influences of structural characteristics. This tendency was intensified during the peak period. Based on these findings, the authors conclude that the centralization of disaster management may not or only marginally be conducive to cross-sector collaboration during public health disasters, calling for a careful design of governance structures for disaster response.

Expelled uninsured patients in a less-competitive hospital market in Florida, USA.

BACKGROUND: This research evaluates the effect of hospital competition on inward and outward patient transfers for different types of payers including the uninsured. Although it is a less spotlighted issue, an equally important topic is the likelihood of inter-hospital patient transfers of the insured and the uninsured. This study attempts to fill a gap in the research about the relationship between hospital competition and patient transfers. METHODS: By developing the payer-specific level of hospital competition, this research evaluates the effect of hospital competition on inward and outward patient sharing (or patient transfers) for different types of payers including the uninsured. For patient transfers, instead of focusing on whether a patient is transferred from one hospital to another hospital at the patient level, we measure the numbers of patient transfers between hospitals (both inward and outward) at the hospital level. These dependent variables-the numbers of outward and inward patient transfers by the principal payers-are count variables, and we employ either a Poisson regression model or a negative binomial regression model. RESULTS: Controlling for hospital characteristics, when the uninsured Hirschman-Herfindahl Index (HHI) increased by 0.01, the uninsured were 593 % more likely to be transferred to another hospital. When a hospital dominates its market, it tends to expel uninsured patients to other hospitals. CONCLUSION: If patient transfers are medically unnecessary and primarily due to financial incentives, health administrators and policymakers should minimize such events. Since the uninsured who are admitted to a hospital that dominates its hospital market are likely to be much more vulnerable in their access to health care services, the state government of Florida needs to move toward increased health insurance coverage for eligible Floridians.

Closure of a local public hospital in Korea: focusing on the organizational life cycle.

Just as living organisms have a creation-maintenance-extinction life cycle, organizations also have a life cycle. Private organizations will not survive if they fail to acquire necessary resources through market competition. Public organizations, however, continue to survive because the government has provided financial support in order to enhance public interest. Only a few public organizations in Korea have closed. With the introduction of new public management since the economic crisis in 1997, however, public organizations have had to compete with private organizations. Public hospitals are not free to open or close their business. They are also controlled by the government in terms of their prices, management, budgets, and operations. As they pursue public interest by fulfilling the government's order such as providing free or lower-priced care to the vulnerable population, they tend to provide a lower quality of care and suffer a financial burden. Employing a case study analysis, this study attempts to understand the external environment that local public hospitals face. The fundamental problem of local public hospitals in Korea is the value conflict between public interest and profitability. Local public hospitals are required to pursue public interest by assignment of a public mission including building a medical safety net for low-income patients and managing nonprofitable medical facilities and emergent health care situations. At the same time, they are required to pursue profitability by achieving high-quality care through competition and the operation of an independent, self-supporting system according to private business logic. Under such paradoxical situations, a political decision may cause an unexpected result.

Has competition increased hospital technical efficiency?

Hospital competition and managed care have affected the hospital industry in various ways including technical efficiency. Hospital efficiency has become an important topic, and it is important to properly measure hospital efficiency in order to evaluate the impact of policies on the hospital industry. The primary independent variable is hospital competition. By using the 2001-2004 inpatient discharge data from Florida, we calculate the degree of hospital competition in Florida for 4 years. Hospital efficiency scores are developed using the Data Envelopment Analysis and by using the selected input and output variables from the American Hospital Association's Annual Survey of Hospitals for those acute care general hospitals in Florida. By using the hospital efficiency score as a dependent variable, we analyze the effects of hospital competition on hospital efficiency from 2001 to 2004 and find that when a hospital was located in a less competitive market in 2003, its technical efficiency score was lower than those in a more competitive market.

To whom do bureaucrats need to respond? Two faces of civil society in health policy.

The South Korean government implemented a law that separates the dispensing and prescribing (SDP) of drugs in July 2000. It was one of the most controversial issues in the Korean healthcare delivery system. Drawing on the conflict-cycle view and stakeholder analysis, which was used to examine how multiple stakeholders influenced this policymaking process, this study examines 1) the role of Korean civil society (i.e., civic and special interest groups) in SDP reform and 2) why SDP reform led to unintended consequences. We argue that bureaucrats in the Ministry of Health and Welfare (MoHW) should have played a central role in accommodating the public interest. Because they failed to do so, civic groups assumed major mediating and moderating roles. Due to the civic groups' lack of technical knowledge and professional experience, however, they played a limited role. In finalizing the proposal, therefore, bureaucrats were captured by strong interest groups, leading to unintended consequences, such as the increased use of non-covered services and higher healthcare expenditures. To ensure that the government serves the authentic public interest rather than special interest groups, bureaucrats should be responsible to the public rather than these interest groups. Moreover, civic groups should be strengthened (in relation to strongly organized interest groups) and included systematically in creating health policy.

The association between managed care enrollments and potentially preventable hospitalization among adult Medicaid recipients in Florida.

BACKGROUND: The intent of adopting managed care plans is to improve access to health care services while containing costs. To date, there have been a number of studies that examine the relationship between managed care and access to health care. However, the results from previous studies have been inconsistent. Specifically, previous studies did not demonstrate a clear benefit of Medicaid managed care. In this study we have examine whether Medicaid managed care is associated with the probabilities of preventable hospitalizations. This study also analyzes the spillover effect of Medicaid managed care into Medicaid patients in traditional FFS plans and the interaction effects of other patient- and county-level variables on preventable hospitalizations. METHODS: The study included 254,321 Medicaid patients who were admitted to short-term general hospital in the 67 counties in Florida. Using 2008 hospital inpatient discharge data for working-age adult Medicaid enrollees (18-64 years) in Florida, we conduct multivariate logistic regression analyses to identify possible factors associated with preventable hospitalizations. The first model includes patient- and county-level variables. Then, we add interaction terms between Medicaid HMO and other variables such as race, rurality, market-level factors, and resource for primary care. RESULTS: The results show that Medicaid HMO patients are more likely to be hospitalized for ambulatory care sensitive conditions (ACSCs) (OR = 1.30; CI = 1.21, 1.40). We also find that market structure (i.e., competition) is significantly associated with preventable hospitalizations. However, our study does not support that there are spillover effects of Medicaid managed care on preventable hospitalizations for other Medicaid recipients. We find that interactions between Medicaid managed care and race, rurality and market structure are significant. CONCLUSIONS: The results of our study show that the Medicaid managed care program in Florida was associated with an increase in potentially preventable hospitalizations for Medicaid enrollees. The results suggest that lower capitation rate has been associated with a greater likelihood of preventable hospitalizations for Medicaid managed care patients. Our findings also indicate that increased competition in the Medicaid managed care market has no clear benefit in Medicaid managed care patients.

Application of revised nursing work index to hospital nurses of South Korea.

PURPOSE: Based on the Revised Nursing Work Index (NWI-R), this research aimed to develop a Korean Hospital General Inpatient Unit-Nursing Work Index (KGU-NWI). This study also aimed to compare the common points and differences between the subfactors of the KGU-NWI and the subfactors from previous studies. METHODS: Based on opinions from 3,151 nurses in Korean hospital general inpatient unit, this research used 57 items of NWI-R and the principal axis factor analysis for deriving subfactors. We evaluated the convergent validity through factor analysis and the content validity of KGU-NWI in terms of the association between nurses' job outcome and the subfactors derived. RESULTS: Six subfactors and 26 items for KGU-NWI were derived from NWI-R. Among them, 'physician-nurse relationship', 'adequate nurse staffing' and 'organizational support and management of hospital' were the same with results from previous studies. In addition, two subfactors, 'participation of decision-making processes' and 'education for improving quality of care', which were similar with results from previous Korean studies, were newly added by using Korean hospital cases. In contrast to previous Korean studies, a unique subfactor this study found was 'nursing processes'. This research confirmed that the six subfactors were highly correlated with job satisfaction, intention to leave, and quality of health care, which represented a nurse's job outcome. CONCLUSION: KGU-NWI including six subfactors and 26 items is an applicable instrument to investigate nurse work environment in Korean hospital general inpatient unit.

Serving distinct populations: performance in Medicaid HMOs and commercial HMOs.

The objective of this study was to compare the preventable emergency department (ED) admissions of Medicaid health maintenance organization (HMO) beneficiaries and commercial HMO beneficiaries in the state of Florida, in addition to analyzing the effect of HMO market conditions in relation to these admissions. Paired and unpaired t tests and 10 regression equations were estimated using ED hospital admission data to examine the differences between Medicaid and commercial HMOs in 5 commonly recognized preventable hospitalization conditions. For the same preventable ED admissions, Medicaid and commercial HMO beneficiaries had statistically different rates of admission. In 3 of 5 conditions, Medicaid HMO beneficiaries had more preventable ED admissions than did commercial HMOs for the same conditions. HMO market conditions did not have a statistically significant association with preventable ED admissions for either beneficiary group, whereas teaching status and the percentage of females admitted to the hospital under a given HMO payer type had the greatest effect on preventable ED admissions. Whereas uncontrolled comparisons of preventable ED admissions are statistically different between Medicaid and commercial HMO beneficiaries, controlling for hospital and patient characteristics, market conditions do not affect the rate of preventable ED admissions.

The association between hospital ownership and technical efficiency in a managed care environment.

This study assessed the association between hospital ownership and technical efficiency in a managed care environment. Hospital technical efficiency scores were calculated via the data envelopment analysis (DEA) method, employing four input variables and three output variables from the American Hospital Association Hospital Survey Data for acute care general hospitals in Florida. By utilizing the hospital technical efficiency scores as a dependent variable, we determined that non-profit hospitals were more efficient than for-profit hospitals for all 4 years examined in this study. In particular, for-profit hospitals with between 100 and 249 beds and those with more than 400 beds had lower technical efficiency scores as compared to their nonprofit peers. Another finding was that teaching hospitals were more efficient than non-teaching hospitals in 2001-2003, but not in 2004. Those variables associated with managed care, namely "number of HMO contracts" and "contracted with HMO", however, were not shown to be statistically significant.

Perceived service quality among outpatients visiting hospitals and clinics and their willingness to re-utilize the same medical institutions.

OBJECTIVES: This study was to determine how the perception and the satisfaction of outpatients who utilized clinics and hospitals are structurally related with their willingness to utilize the same institution in the future. METHODS: Three hundred and ten responses (via convenient sampling) were collected from 5 hospitals and 20 clinics located in Seoul listed in the "Korea National Hospital Directory 2005". Service quality was utilized as the satisfaction measurement tool. For analysis, we used a structural equation modeling method. RESULTS: The determining factors for general satisfaction with medical services are as follows: medical staff, reasonability of payment, comfort and accessibility. Such results may involve increased competition in the medical market and increased demands for quality medical services, which drive the patients to visit hospitals on their own on the basis of changed determining factors for satisfaction. CONCLUSIONS: The structural equation model showed that the satisfaction of outpatients with the quality of medical services is influenced by a few sub-dimensional satisfaction factors. Among these sub-dimensional satisfaction factors, the satisfaction with medical staff and payment were determined to exert a significant effect on overall satisfaction with the quality of medical services. The structural relationship in which overall satisfaction perceived by patients significantly influences their willingness to use the same institution in the future was also verified.

A strategy for enhancing financial performance: a study of general acute care hospitals in South Korea.

In this study, the determinants of hospital profitability were evaluated using a sample of 142 hospitals that had undergone hospital standardization inspections by the South Korea Hospital Association over the 4-year period from 1998 to 2001. The measures of profitability used as dependent variables in this study were pretax return on assets, after-tax return on assets, basic earning power, pretax operating margin, and after-tax operating margin. Among those determinants, it was found that ownership type, teaching status, inventory turnover, and the average charge per adjusted inpatient day positively and statistically significantly affected all 5 of these profitability measures. However, the labor expenses per adjusted inpatient day and administrative expenses per adjusted inpatient day negatively and statistically significantly affected all 5 profitability measures. The debt ratio negatively and statistically significantly affected all 5 profitability measures, with the exception of basic earning power. None of the market factors assessed were shown to significantly affect profitability. In conclusion, the results of this study suggest that the profitability of hospitals can be improved despite deteriorating external environmental conditions by facilitating the formation of sound financial structures with optimal capital supplies, optimizing the management of total assets with special emphasis placed on inventory management, and introducing efficient control of fixed costs including labor and administrative expenses.

Determinants of hospital choice of rural hospital patients: the impact of networks, service scopes, and market competition.

Among 10,384 rural Colorado female patients who received MDC 14 (obstetric services) from 2000 to 2003, 6,615 (63.7%) were admitted to their local rural hospitals; 1,654 (15.9%) were admitted to other rural hospitals; and 2,115 (20.4%) traveled to urban hospitals for inpatient services. This study is to examine how network participation, service scopes, and market competition influences rural women's choice of hospital for their obstetric care. A conditional logistic regression analysis was used. The network participation (p < 0.01), the number of services offered (p < 0.05), and the hospital market competition had a positive and significant relationship with patients' choice to receive obstetric care. That is, rural patients prefer to receive care from a hospital that participates in a network, that provides more number of services, and that has a greater market share (i.e., a lower level of market competition) in their locality. Rural hospitals could actively increase their competitiveness and market share by increasing the number of health care services provided and seeking to network with other hospitals.

The effects of case mix on hospital costs and revenues for medicare patients in California.

Hospital competition and managed care have negatively affected hospital profitability. In the current turbulent health care environment in the U.S., hospitals in California have argued that the rate of increase in hospital costs is faster than the rate of increase in hospital revenues. By employing Medicare case mix indexes (CMIs) as a primary policy variable, this study found that the coefficients for CMIs in hospital costs for Medicare patients were smaller than those in hospital revenues in the years of 1986, 1989 and 1998. However, the coefficients for CMIs in hospital costs for Medicare patients were greater than those in hospital revenues in the years of 1992 and 1995. Although there were some differences between the coefficients for CMIs in hospital costs and revenues for Medicare patients, those differences found to be statistically insignificant. In spite of claims on behalf of Californian hospitals, the rate of increase in hospital costs for Medicare patients had not been greater than that of hospital revenues for Medicare patients.

The impact of payer-specific hospital case mix on hospital costs and revenues for third-party patients.

Competition among hospitals and managed care have forced hospital industry to be more efficient. With higher degrees of hospital competition and managed care penetration, hospitals have argued that the rate of increase in hospital cost is greater than the rate of increase in hospital revenue. By developing a payer-specific case mix index (CMI) for third-party patients, this paper examined the effect of hospital case mix on hospital cost and revenue for third-party patients in California using the hospital financial and utilization data covering 1986-1998. This study found that the coefficients for CMIs in the third-party hospital revenue model were greater than those in the hospital cost model until 1995. Since 1995, however, the coefficients for CMIs in the third-party hospital revenue model have been less than those in hospital cost models. Over time, the differences in coefficients for CMIs in hospital revenue and cost models for third-party patients have become smaller and smaller although those differences are statistically insignificant.