Robert W. Broyles

The medically vulnerable: their health risks, health status, and use of physician care.

Employing the Andersen/Neuman model of health behavior, this research compares the medically vulnerable (elderly, poor, and uninsured) with their less vulnerable counterparts with regard to (1) health and disability status, (2) likelihood of physician use, and (3) (among users) amount of physician use. Data were from the Oklahoma Behavioral Risk Factor Surveillance Survey and the Area Resource File. Findings indicate that the medically vulnerable are more likely to be disabled and to experience poorer health than the nonmedically vulnerable. The uninsured are less likely to have seen a physician in the past year. Among those who have seen a physician in the past year, the uninsured and Medicare recipients without supplemental insurance experienced fewer physician visits. The results point to inequalities in the distribution of physician care that may be exacerbated by federal policies that are currently under consideration.

The determinants of hospital utilization under a universal public insurance program in Canada.

This study employs the individual as the unit of analysis to examine the relative importance of medical need, sociodemographic and economic factors in determining the use or non-use of hospital care and the volume of service consumed by those who experienced an episode of hospitalization during the study period. The data were derived from the Canada Health Survey which is a stratified, multistaged sample of the entire population. The results of the discriminant and weighted regression analyses indicate that the use or non-use of hospital care and the volume of service consumed are largely determined by medical need and not by income. The findings are supportive of the view that the national health insurance scheme in Canada has resulted in a more equitable distribution of hospital care

Access to long-term care: race as a barrier.

Race continues to impede access to health services, for acute as well as long-term care. Whites, for example, use disproportionately more days of nursing home care than nonwhites, not simply because they are more likely to be private payers and, therefore, are preferred over nonwhites: the difference in utilization persists even among those whose nursing home stays are covered by Medicare. Using data from a study of patients awaiting alternative placement in North Carolina acute care general hospitals in 1991, this article examines racial differences in discharge delay, that is, in the time between when a patient is medically ready for discharge to another form of care and when he or she actually is discharged. Logistic regression and ordinary least squares are used heuristically to identify patient characteristics associated with delay, and two-way analyses of variance are used to document the independent effect of race. The results indicate that race has substantial independent explanatory power. This finding is reinforced by the analysis of variance with controls for the patients payment source for long-term care, chronic condition or special care requirements, demographic attributes, family cooperativeness, whether the patient had a behavior problem that impeded the discharge planning process, and whether there was a financial problem in arranging for the patients discharge. The inescapable conclusion is that nursing homes discriminate on the basis of race in admitting patients. This practice is patently objectionable; it also is costly to hospitals, thus to society, since hospitals bear the direct costs of delayed discharges and hospitals do not keep costs to themselves. While research is needed to determine whether the North Carolina findings are replicable in other states, past research suggests that the problem is not confined to this state.

Short-term responses of hospitals to the DRG prospective pricing mechanism in New Jersey.

Short-term responses of hospitals to the New Jersey prospective payment system, which uses Diagnosis Related Groups (DRGs) to establish rates of compensation for all payers, were examined in this study. The sample consisted of 84 New Jersey hospitals that were subject to prospective payment and a comparison group of 76 hospitals. Hospitals comprising the comparison group located in eastern Pennsylvania, were reimbursed retrospectively. Regression equations, which included independent variables to control for market supply and demand conditions, were estimated for the cost per admission, cost per day, length of stay; and cases treated. The results indicate that increases in the cost per admission and cost per day were lower (P < 0.05) in hospitals subject to the all payer DRG system than in those institutions that were reimbursed retrospectively. In addition, the results suggest that most of the cost savings attributed to the New Jersey DRG system are due to a reduction in the average length of stay. The paper concludes with policy implications.

The Temporarily and Chronically Uninsured: Does Their Use of Primary Care Differ?

The purpose of this study is to examine differences in the use of preventive or early-detection services by the temporarily and chronically uninsured. The use of preventive care was measured by an index that depicts the use of nine preventive or early-detection services and the use or nonuse of each procedure on the index. Respondents whose lapse in insurance coverage was one year or more were identified as chronically uninsured, while those whose lapse in coverage was less than one year were identified as temporarily uninsured. The analysis indicates that the chronically uninsured and, to a lesser extent, the temporarily uninsured use significantly fewer preventive or early-detection services than their insured counterparts.

Factors associated with the likelihood of injury resulting from collisions between four-wheel drive vehicles and passenger cars

The specific effects of vehicular type on the likelihood of an injury occurring are relatively unexplored. This study sought to assess the relative risk of injury to occupants of four-wheel drive vehicles and their counterparts in passenger cars. Data for 1143 occupants from all of the 454 crashes in Oklahoma, in 1995 that involved a four-wheel drive vehicle were used. Multiple logistic regression analysis determined the association between potential predictive factors and vehicular injury. Odds ratios revealed occupancy in a passenger car to be a major predictor of the likelihood of injury. Other factors include the driver being female, driving too fast, travel on curved or level roadways, and being hit laterally or from the rear.

Factors contributing to the amount of vehicular damage resulting from collisions between four-wheel drive vehicles and passenger cars.

This study examines the vehicular damage resulting from motor vehicle crashes involving four-wheel drive vehicles and passenger cars in the state of Oklahoma. In particular, the focus of the analysis is on differences in vehicular damage to passenger cars and four-wheel drive vehicles. Results indicate that passenger cars sustain significantly greater vehicular damage than four-wheel drive vehicles. In addition, several other factors significantly influence the level of damage resulting from collisions between four-wheel drive vehicles and passenger cars. Driver behavior or unsafe acts, represented by the rate of travel prior to the collision, failure to yield, failure to obey a stoplight or a stop sign, the consumption of alcohol and the use of drugs, also contributed to the amount of vehicular damage. In addition, results also indicate that the level of damage was influenced significantly by environmental factors, represented by a reduced intensity of light, wet or slippery roadways and the type of collision. The findings reinforce the importance of a number of policy initiatives that may reduce the vehicular damage resulting from collisions involving four-wheel drive vehicles and passenger cars. For example, the study indicates a need to initiate legislation that lowers the speed limit during dark and twilight hours, commits additional resources to road maintenance to reduce unsafe road conditions, and stimulates improvements in automotive design that provide better lateral protection to vehicles.

A qualitative assessment of the medicare prospective payment system

This paper employs commonly accepted criteria to evaluate the potential outcomes of the Medicare pricing mechanism. The analysis suggests that the recent revisions in the Medicare payment system have less potential to contain increases in total hospital costs than those embodied in all-payer systems. In addition, this paper also suggests that the pricing mechanism will jeopardize the financial viability of many hospitals while exacerbating inequities that emanate from differential pricing policies. Finally, when viewed from the perspective of insured beneficiaries, it is reasonable to expect that the payment mechanism will reduce not only access to inpatient care but also the use of service once admitted.

Equity Concerns With the Use of Hospital Services by the Medically Vulnerable

This study assessed distributional inequities in access to care among a representative sample of adults residing in Oklahoma. Inequities were identified by comparing the medically vulnerable to the less vulnerable with respect to their use or nonuse of hospital care and, among those admitted, the number of days of care consumed. The behavioral model was employed to guide the analysis and the development of hypotheses. Controlling for need, enabling, and predisposing factors, the results indicate that the use of service by the poor, the elderly who lack supplemental insurance, and the uninsured is incongruent with their health status and that current methods of financing care may contribute to distributional inequities. The implications of these findings are discussed in the context of options that may improve access to care by the medically vulnerable.

Prospective payment based on case mix: will it work in nursing homes?

This article evaluates the potential efficacy of implementing a prospective payment system based on case mix in the nursing home industry. The analysis of structural differences between the nursing home and hospital industries suggests that the mechanism of compensating long-term care facilities should be based on functional health status rather than on diagnosis and that incentives to improve quality and access should be strengthened. The article assesses several systems of classifying patients that have been proposed as the basis for implementing a prospective payment system in the nursing home industry. The article concludes with a discussion of policy issues related to the appropriate unit of payment and the scope of regulatory authority.