Christopher J. Conover

Does Removing Certificate-of-Need Regulations Lead to a Surge in Health Care Spending?

This study assesses the impact of certificate-of-need (CON) regulation for hospitals on various measures of health spending per capita, hospital supply, diffusion of technology, and hospital industry organization. Using a time series cross-sectional methodology, we estimate the net impact of CON policies on costs, supply, technology diffusion, and industry organization, controlling for area characteristics, the presence of other forms of regulation, such as hospital rate-setting, and competition. Mature CON programs are associated with a modest (5 percent) long-term reduction in acute care spending per capita, but not with a significant reduction in total per capita spending. There is no evidence of a surge in acquisition of facilities or in costs following removal of CON regulations. Mature CON programs also result in a slight (2 percent) reduction in bed supply but higher costs per day and per admission, along with higher hospital profits. CON regulations generally have no detectable effect on diffusion of various hospital-based technologies. It is doubtful that CON regulations have had much effect on quality of care, positive or negative. Such regulations may have improved access, but there is little empirical evidence to document this.

Improving health outcomes among individuals with HIV, mental illness, and substance use disorders in the Southeast

Abstract Providing behavioral treatment for mental health and substance use disorders among HIV-infected individuals is critical because these disorders have been associated with negative outcomes such as poorer medication adherence. This study examines the effectiveness of an integrated treatment model for HIV-infected individuals who have both substance use and mental disorders. Study participants (n = 141) were recruited through routine mental health and substance abuse screening at tertiary Infectious Disease clinics in North Carolina. The study participants received integrated mental health and substance abuse treatment for one year and were interviewed at three-month intervals. Using linear regression analyses, we detected statistically significant decreases in participants’ psychiatric symptomatology, illicit substance use, alcohol use, and inpatient hospital days. Participants also reported fewer emergency room visits and were more likely to be receiving antiretroviral medications and adequate psychotropic medication regimens at follow-up. No changes in sexual risk, physical health, or medical adherence were detected after treatment participation. This integrated treatment model offers an option for treating HIV-infected individuals with mental health and substance use disorders that can be adapted for use in a variety of psychiatric and medical treatment settings.

Utilization of mental health and substance abuse care for people living with HIV/AIDS, chronic mental illness, and substance abuse disorders.

Objective:To examine the effects of race/ethnicity, insurance, and type of substance abuse (SA) diagnosis on utilization of mental health (MH) and SA services among triply diagnosed adults with HIV/AIDS and co-occurring mental illness (MI) and SA disorders. Data Source:Baseline (2000 to 2002) data from the HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study. Study Design:A multiyear cooperative agreement with 8 study sites in the United States. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was administered by trained interviewers to determine whether or not adults with HIV/AIDS had co-occurring MI and SA disorders. Data Collection/Extraction Methods:Subjects were interviewed in person about their personal characteristics and utilization of MH and SA services in the prior 3 months. Data on HIV viral load were abstracted from their medical records. Principal Findings:Only 33% of study participants received concurrent treatment for MI and SA, despite meeting diagnostic criteria for both: 26% received only MH services, 15% received only SA services, and 26% received no services. In multinomial logistic analysis, concurrent utilization of MH and SA services was significantly lower among nonwhite and Hispanic participants as a group and among those who were not dependent on drugs and alcohol. Concurrent utilization was significantly higher for people with Veterans Affairs Civilian Health and Medical Program of the Uniformed Services (VA CHAMPUS) insurance coverage. Two-part models were estimated for MH outpatient visits and 3 SA services: (1) outpatient, (2) residential, and (3) self-help groups. Binary logistic regression was estimated for any use of psychiatric drugs. Nonwhites and Hispanics as a group were less likely to use 3 of the 5 services; they were more likely to attend SA self-help groups. Participants with insurance were significantly more likely to receive psychiatric medications and residential SA treatment. Those with Medicaid were more likely to receive MH outpatient services. Participants who were alcohol dependent but not drug dependent were significantly less likely to receive SA services than those with dual alcohol and drug dependence. Conclusion:Among adults with HIV/AIDS and co-occurring MH and SA disorders, utilization of MH and SA services needs to be improved.

The impact of ancillary services on primary care use and outcomes for HIV/AIDS patients with public insurance coverage

To better understand the impact of ancillary services on access to primary care, utilization of health services, costs and health status of HIV/AIDS patients, we studied adult HIV/AIDS patients eligible for public insurance for low-income people (Medicaid) in eastern North Carolina. Using primary data from a 1997 survey of such patients linked to Medicaid claims, multivariate logit analysis was used to estimate the effect of receiving housing, legal services and substance abuse treatment and of self-reported failure to obtain transportation and child care services on: (a) adequacy and use of primary care; (b) CD-4 counts; (c) viral load; and (d) self-rated health status. Between two-thirds and four-fifths of patients needing ancillary services obtain them. Receipt of housing and legal services were found to have a positive relationship with access to primary care. Difficulties in obtaining transportation and receipt of substance abuse services had a negative relationship with receipt of adequate primary care. On balance, these findings provide some support for continued public funding for various ancillary services to improve patient access to needed primary care. At current funding levels, not all patients needing help appear able to obtain such services.

Antecedents of Hospital Ownership Conversions, Mergers, and Closures

This study assesses the determinants of conversions in hospital ownership from 1986 through 1996. To place such changes in context, we also analyze causes of hospital mergers and closures, which are often alternatives to hospital ownership conversion. A consistent result from our analysis is that an important antecedent of ownership conversions is a low profit margin. Conversions from private nonprofit or government ownership to for-profit status are preceded by chronically low margins and high debt-to-asset ratios. By contrast, conversions from for-profit ownership occur quickly following declines in margins. Many mergers seem motivated by a desire to increase market power—a consideration not evident for conversions.

Impact of gene patents and licensing practices on access to genetic testing for inherited susceptibility to cancer: comparing breast and ovarian cancers with colon cancers.

Genetic testing for inherited susceptibility to breast and ovarian cancer can be compared with similar testing for colorectal cancer as a “natural experiment.” Inherited susceptibility accounts for a similar fraction of both cancers and genetic testing results guide decisions about options for prophylactic surgery in both sets of conditions. One major difference is that in the United States, Myriad Genetics is the sole provider of genetic testing, because it has sole control of relevant patents for BRCA1 and BRCA2 genes, whereas genetic testing for familial colorectal cancer is available from multiple laboratories. Colorectal cancer-associated genes are also patented, but they have been nonexclusively licensed. Prices for BRCA1 and 2 testing do not reflect an obvious price premium attributable to exclusive patent rights compared with colorectal cancer testing, and indeed, Myriads per unit costs are somewhat lower for BRCA1/2 testing than testing for colorectal cancer susceptibility. Myriad has not enforced patents against basic research and negotiated a Memorandum of Understanding with the National Cancer Institute in 1999 for institutional BRCA testing in clinical research. The main impact of patenting and licensing in BRCA compared with colorectal cancer is the business model of genetic testing, with a sole provider for BRCA and multiple laboratories for colorectal cancer genetic testing. Myriads sole-provider model has not worked in jurisdictions outside the United States, largely because of differences in breadth of patent protection, responses of government health services, and difficulty in patent enforcement.

Life transitions and health insurance coverage of the near elderly.

OBJECTIVES This study addresses three issues. (1) What are demographic wealth, employment, and health characteristics of near-elderly persons losing or acquiring health insurance coverage? Specifically, (2) what are the effects of life transitions, including changes in employment status, health, and marital status? (3) To what extent do public policies protect such persons against coverage loss, including various state policies recently implemented to increase access to insurance? METHODS The authors used the 1992 and 1994 waves of the Health and Retirement Study to analyze coverage among adults aged 51 to 64 years. RESULTS One in five near-elderly persons experienced a change in insurance coverage from 1992 to 1994. Yet, there was no significant change in the mix of coverage as those losing one form of coverage were replaced by others acquiring similar coverage. CONCLUSIONS Individuals whose health deteriorated significantly were not more likely than others to suffer a subsequent loss of coverage, due to substitution of retiree or individual coverage for those losing private coverage and acquisition of Medicaid and Medicare coverage for one in five uninsured. State policies to increase access to private health insurance generally did not prevent individuals from losing coverage or allow the uninsured to gain coverage. Major determinants of the probability of being insured were education, employment status of person and spouse, and work disability status. Other measures of health and functional status did not affect the probability of being insured, but had important impacts on the probability of having public coverage, conditional on being insured.

Does distance affect utilization of substance abuse and mental health services in the presence of transportation services

Abstract Long travel times have been identified as a significant barrier to accessing mental health and other critical services. This study examines whether distance to treatment was a barrier to receiving outpatient mental health and substance abuse care for HIV-positive persons when transportation was provided. Data from a cohort of HIV-positive persons who participated in a year-long substance abuse and mental health treatment programme were examined longitudinally. Transportation, which included buses, taxis, and mileage reimbursement for private transportation, was provided free of charge for participants who needed this assistance. Nearly three-quarters (74%) of participants utilized the transportation services. No statistically significant differences in retention in, or utilization of, the mental health and substance abuse treatment programme were identified by distance to the treatment site. This analysis demonstrated that increased distance to care did not decrease utilization of the treatment programme when transportation was provided to the client when necessary. These results provide preliminary evidence that distance to substance abuse and mental health services need not be a barrier to care for HIV-positive individuals when transportation is provided. Such options may need to be considered when trying to treat geographically dispersed individuals so that efficiencies in treatment can be attained.

Effects of Tennessee Medicaid Managed Care on Obstetrical Care and Birth Outcomes

A comparative study was conducted in two neighboring states, Tennessee and North Carolina, to determine whether Medicaid managed care (implemented in Tennessee as TennCare) affected prenatal care, care patterns at labor-delivery, and birth outcomes. A pre- and post-design coupled with a difference-in- difference approach--using North Carolina as a control--was used to assess TennCares effects for all births and for three categories of high-risk mothers (under age eighteen, unwed, or living in high poverty areas). Data from 328,296 singleton births in birth files and matched birth-death files for 1993 and 1995 in both states were used to analyze a number of variables related to maternal behavior during pregnancy, utilization of care before and after labor-delivery, patterns of obstetrical care at delivery, and birth outcomes. Under TennCare, Tennessee mothers were relatively more likely to obtain no prenatal care or to wait and initiate third trimester care as compared to those in North Carolina. Relative utilization of specific prenatal procedures declined, Apgar scores fell very slightly, and birth abnormalities increased in the poverty subsample. TennCare had no significant effect on infant mortality. Utilization reductions in obstetrical services were achieved with apparent spillovers to non-TennCare births, but without adverse effects overall. TennCare was neither a panacea nor an unmitigated disaster. It is a model worth examining, but not uncritically.

Hospital credentialing and quality of care.

The purpose of this study was to evaluate the impact of hospital credentialing standards on surgical outcomes for selected procedures. The study used hospital credentialing practices from a 1996 survey of North Carolina community hospitals, with surgical outcomes derived from a statewide database of inpatient surgical discharges in 1995. Hospital mortality, complications and elevated lengths of stay were used as outcome indicators in an analysis of 6 surgical procedures. Multivariate logit analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on outcomes, controlling for patient demographic characteristics, type of admission, severity of illness and hospital characteristics. Teaching hospitals adopted more stringent credentialing practices, with almost no difference between metropolitan and nonmetropolitan nonteaching facilities in their use of various credentialing policies. Surgical outcomes typically were not related to stringency of the hospital credentialing environment. Generally, the effect of specific practices was inconsistent (associated with improved outcomes for certain procedures and significantly worse outcomes for others) or counterintuitive (showing worse outcomes for selected surgical procedures where effects were statistically significant). More stringent hospital credentialing does not appear likely to improve patient outcomes.