Bradford H. Gray

Churning in Medicaid Managed Care and Its Effect on Accountability

There is concern that churning in Medicaid excludes children from the accountability system for managed care because they may not meet the one-year continuous enrollment requirement. This study explores the effect of churning in measuring childhood immunization coverage rates under the current accountability system. Data were collected from administrative databases at the Centers for Medicaid and Medicare Services and 12 states with high Medicaid managed care penetration. On average in the 12 states only 39% of the children enrolled in one specific managed care plan met the continuous enrollment requirement. However, Centers for Medicaid and Medicare Services data showed that 78% of children were enrolled in Medicaid (but not the same plan) continuously for 12 months. Both plan-specific rates and overall Medicaid rates varied greatly across the states. Policies that result in churning mean that many vulnerable children fall outside of the accountability structure intended to assure that they receive necessary services.

Complexities of Informed Consent

Informed consent has emerged as an issue both of great importance and substantial uncertainty and confusion. This paper examines some of the conceptual and practical complexities of informed consent and suggests some impli cations of our empirical knowledge about consent. Among the issues considered are the purposes of informed consent, ethical versus legal functions of informed consent, the dis tinction between informed consent and consent forms, and whether informed consent is an ideal that can never be achieved. It is argued that informed consent is presently not a reliable method of protecting subjects and patients from harm because of limited commitment of professionals to the concept of informed consent, the tendency for procedures to be substituted for substance, the dependence of the quality of consent on many factors, including the characteristics of the subjects or patients, and the tendency of human subjects review committees to confine their attention to consent forms rather than to the process by which consent is sought.

Racial and Ethnic Disparities in the Use of High-Volume Hospitals

Differences in the source of care could contribute to racial and ethnic disparities in health status. This study looks at a major metropolitan area and examines racial and ethnic differences in the use of high-volume hospitals for 17 services for which there is a documented positive volume-outcome relationship. Focusing on the hospitalizations of New York City area residents in the periods 1995-1996 and 2001–2002, we found, after controlling for socioeconomic characteristics, insurance coverage, proximity of residence to a high-volume hospital, and paths to hospitalization, that minority patients were significantly less likely than whites to be treated at high-volume hospitals for most volume-sensitive services. The largest disparities were between blacks and whites for cancer surgeries and cardiovascular procedures.

Aging without Medicare? Evidence from New York City

Medicare and Social Security often are assumed to provide universal coverage for the population age 65 and older. Evidence from New York City raises doubts. Data from the Statewide Planning and Research Cooperative System, the Centers for Medicare and Medicaid Services, the Social Security Administration, and the U.S. Bureau of the Census provide evidence that 16% to 20% of New York City residents age 65 and older lack such coverage. Noncoverage is not unique to this city, but it may be particularly common there. Noncoverage is pronounced in, but not limited to, certain immigrant groups. Because the population share covered by Medicare increases with age and most hospitalizations not covered by Medicare are paid by Medicaid, Medicaid gradually may be replacing Medicare as the payer for hospitalizations for a substantial share of the 65+ population in New York City.

American Primary Care Physicians’ Decisions to Leave Their Practice Evidence From the 2009 Commonwealth Fund Survey of Primary Care Doctors

The status of the primary care workforce is a major health policy concern. It is affected not only by the specialty choices of young physicians but also by decisions of physicians to leave their practices. This study examines factors that may contribute to such decisions. We analyzed data from a 2009 Commonwealth Fund mail survey of American physicians in internal medicine, family or general practice, or pediatrics to examine characteristics associated with their plans to retire or leave their practice for other reasons in the next 5 years. Just over half (53%) of the physicians age 50 years or older and 30% of physicians between age 35 and 49 years may leave their practices for these reasons. Having such plans was associated with many factors, but the strongest predictor concerned problems regarding time spent coordinating care for their patients, possibly reflecting dissatisfaction with tasks that do not require medical expertise and are not generally paid for in fee-for-service medicine. Factors that predict plans to retire differ from those associated with plans to leave practices for other reasons. Provisions of the Patient Protection and Affordable Care Act that reduce the number of uninsured patients as well as innovations such as medical homes and accountable care organizations may reduce pressures that lead to attrition in the primary care workforce. Reasons why primary care physicians’ decide to leave their practices deserve more attention from researchers and policy makers.

Periods of Unmanaged Care in Medicaid Managed Care

Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure in Medicaid managed care has received less attention. Recent reports indicate that childrens tenures in health plans are far shorter than tenures in Medicaid itself, but explanations for the difference are not given. In the research reported here, we conducted case studies in five states to determine difference in tenure and reasons for the difference. Our investigation showed that children were enrolled in Medicaid two to four months longer than in specific Medicaid health plans. The major reasons for the gap were retroactive enrollment in Medicaid and delays in selecting a health plan. Frequent and burdensome Medicaid renewal processes exacerbate the problem, resulting in breaks in enrollment and the need to reenroll. The task of managing the care of Medicaid children is difficult without adequate tenures in health plans.

Coverage for undocumented migrants becomes more urgent.

The outcome of the presidential election has put immigration reform back on the national agenda. Once the coverage expansions of the Patient Protection and Affordable Care Act take effect in the st...

The Accountability of Nonprofit Hospitals: Lessons from Maryland's Community Benefit Reporting Requirements

Under Internal Revenue Service requirements, nonprofit hospitals will begin filing new community benefit reports in 2010. Maryland has had similar requirements since 2004. This paper, based on interviews at 20 hospitals, describes how Marylands requirements affected hospitals and their activities. Increases in reported community benefit expenditures since the program began are due to both changes in activities and better data capture. Charity care accounts for one-third of community benefit dollars. A key distinction concerns whether hospitals take an accounting or managerial approach to community benefit. The Maryland experience suggests the issues that will arise when the national requirements are implemented.

European Policies on Healthcare for Undocumented Migrants

This chapter describes how access to healthcare is organized for undocumented migrants (UDMs) in European health systems. Undocumented migrants include individuals who have entered a country without documentation, peo- ple whose legal basis (e.g. a visa, residence, or work permit) for being in the country has expired or become invalidated, and those who have been unsuccessful in obtaining asylum. Although ‘undocumented’ is most com- mon, ‘illegal’, ‘irregular’, or ‘unauthorized’ is also used in European literature (Woodward et al., 2013). Estimates of the number of undocumented migrants in the European Union (EU) countries (Croatia not yet included) range from 1.9 to 3.8 million people (European Commission, 2009). This is a substantial number but comparatively low to some other regions of the world, including the United States, which has an estimated 11.8 million undocumented migrants.

Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments.

Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.