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Why do we need "public policy" regarding specialty hospitals? What is the rationale for government involvement in decisions by the private sector to invest in specialty hospitals? Two possibilities are reduced access to services primarily by the uninsured (a fairness concern) and changes in the types of patients receiving care resulting from poor consumer information (an efficiency concern). The fairness argument faces logical and empirical difficulties, and even if it proved to be true, it is not clear that limiting the growth of specialty hospitals would be an efficient way to address the problem. However, there is some empirical evidence to support the efficiency concern, and if specialty hospitals result in the treatment of patients with lower expected net benefits from treatment, then it is possible that physician-owned facilities could result in an increasingly inefficient allocation of health care resources, higher insurance premiums, and higher rates of uninsurance.

Under the 1997 Balanced Budget Act, Medicare expanded coverage of colonoscopy and prostate-specific antigen tests from diagnostic and surveillance tests to preventive screenings. The preventive tests now are covered with no deductibles or copayments. Reducing out-of-pocket costs increases premiums, resulting in a subsidy to beneficiaries who use the service by nonusers, and by taxpayers who shoulder the bulk of Medicare's costs. Using Medicare fee-for-service claims and the Medicare Current Beneficiary Survey, we estimate the behavioral and financial consequences of these Balanced Budget Act coverage expansions. We find that fee-for-service Medicare-covered colonoscopies increased by 3.5 percentage points after the coverage expansion, and prostate-specific antigen tests increased by 6.8 percentage points. Beneficiaries with lower incomes, less education, and those lacking a usual source of care or supplemental insurance were less likely to use these tests. Therefore, they generally received much smaller net benefits from the coverage of colonoscopies than more advantaged beneficiaries.

Analysts interested in physician market concentration often have access to tax identification numbers (TINs), but not the number of truly independent negotiating units (NUs). Health plans do know the true number of NUs, and, using 2014 claims data for Minnesota physicians from a large midwestern health plan, we compare Herfindahl-Hirschman Index (HHI) measures of physician market concentration using TINs versus NUs at the county and metropolitan statistical area (MSA) levels for thirteen specialties. We found that HHIs computed using TINs versus NUs were similar across Minnesota. Two MSAs in Minnesota met the Department of Justice's definition of highly concentrated markets. There is reason to believe that the discrepancy between TIN and NU HHIs may vary by insurance product and region of the country, and so we encourage other researchers to work with health plans to replicate our study.

Employers' willingness to control costs is a critical aspect of pro‐competition strategies for the health‐care market. Here, we present some of the first quantitative evidence of what employers do to control health‐care costs. Our sample is 44 large private and public employers in Minnesota.We develop a theoretical model in which the employer chooses cost‐control "innovations"—along with wages, fringe benefits, and labor‐force size—to maximize profits. The role of innovations is to reduce unit costs of offering fringe benefits.Our data are from a 1982 survey. Eighty percent of the surveyed employers, representing nearly 200,000 employees, responded. Most respondents offer both indemnity insurance plans and health‐maintenance organizations (HMOs). Many firms and individual health‐insurance plans conduct cost‐control activities, but less than half of the firms which offer HMOs have adopted level‐dollar premium contributions for their family health‐insurance policies. Few plans have increased their coinsurance and deductible requirements in the past five years.We use probit equations to estimate the probability that a firm or a health plan will adopt cost‐control activities. Our analysis suggests that many firms may soon make major plan‐design changes to control health‐care costs, although they have not yet done so.

This article describes issues that should be considered in the development of a theory or theories about incentives from which testable hypotheses could be derived. Economic, psychological, and organizational theories are described, and issues that should be considered in hypothesis generation are presented. Psychological factors influencing incentives include decision framing, regret, heuristics, and reinforcements. Organizational factors influencing incentives include bundling of services or people, matching of incentive structure with work organization, and the incompletely contained hierarchical nesting of incentives. Finally, the dynamics of incentive change are considered, with a focus on describing the conditions under which physicians and physician organizations respond to incentive changes.

This study assesses whether Minnesota's high-risk insurance pool is successful at insuring those denied health insurance coverage because of preexisting medical conditions. Eight hundred and twenty-nine individuals who had been denied health insurance coverage were interviewed. At the time of the survey, 80 percent of the sample had obtained coverage, 22 percent through the state's high-risk insurance pool. Seventeen percent remained uninsured. Logistic regression was used to identify correlates of remaining uninsured. Younger age and less education were significantly associated with being uninsured versus enrolling in the high-risk pool. Younger age, less education, unemployment, being non-White, and having worse mental health were significantly associated with being uninsured versus having non-high-risk pool insurance. Despite the presence of a large high-risk pool in Minnesota, specific groups are identified as being at risk for remaining uninsured after being denied health insurance.

This article evaluates the effect of the Health Insurance Flexibility and Accountability (HIFA) demonstrations on uninsurance rates among children. HIFA could increase the probability that children would have health insurance either by directly enrolling a child into a HIFA program or by creating a "spillover" effect from adults onto children by making parents of children already eligible for public programs eligible for HIFA. Data were drawn from the Current Population Survey from 2000 to 2007. The estimation approach was a probit model using a difference-in-differences approach. The authors find that the HIFA wavier demonstrations had no measureable effect on the uninsurance rate among children, either through direct eligibility or through a "spillover" effect from parental eligibility. This suggests that public programs that integrate family insurance coverage into a single structure are likely to be more effective at reducing the rate of uninsurance than different programs for different members of the same family.

Medicare's Physician Quality Reporting System (PQRS) is the largest quality-reporting system in the U.S. health care system and a basis for the new value-based modifier system for physician payment. The PQRS allows health care providers to report measures of quality of care that include both the process of care and physiological outcomes. Using a multivariate difference-in-differences model, we examine the relationship of PQRS participation to three claims-computable measures of inappropriate utilization of health care services and risk-adjusted per capita Medicare expenditures. The data are a national random sample of PQRS-participating providers matched to nonparticipating providers by zip code and caseload. We found few significant relationships in the overall analysis. However, the magnitude and statistical significance of the desirable associations increased in subgroups of providers and beneficiaries more prone to overutilization (e.g., males, older beneficiaries, beneficiaries treated in larger medical practices or by nonphysicians, and practices in rural areas), and among beneficiaries with heart conditions, diabetes, and eye problems.

The effect of hospital organizational affiliation on perinatal outcomes is unknown. Using the 2004 American Hospital Association Annual Survey and Healthcare Cost and Utilization Project State Inpatient Databases, the authors examined relationships among organizational affiliation, equipment and service availability and provision, and in-hospital mortality for 5,133 infants across five states born with very low and extremely low birth weight and congenital anomalies. In adjusted bivariate probit selection models, the authors found that government hospitals had significantly higher mortality rates than not-for-profit nonreligious hospitals. Mortality differences among other types of affiliation (Catholic, not-for-profit religious, not-for-profit nonreligious, and for-profit) were not statistically significant. This is encouraging as health care reform efforts call for providers at facilities with different institutional values to coordinate care across facilities. Although there are anecdotes of facility religious affiliation being related to health care decisions, the authors did not find evidence of these relationships in their data.

Since its inception, the Medicare Program has allowed for the participation of private health plans, but the relationship of private plans to the government-sponsored fee-for-service (FFS) plan has been the subject of debate. Increased payments to private plans, the introduction of regional preferred provider organizations (PPOs), and a mandated demonstration of price competition that includes FFS Medicare reflect an ongoing attempt to define the role of private plans. The purpose of this article is to explore the roles of private plans and FFS Medicare and to attempt to identify the advantages and disadvantages of each.