A Shared Destiny Community Effects of Uninsurance (2003) / Chapter Skim
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Appendix D: Commissioned Papers
Appendix D: Commissioned Papers
Pages 203-235
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D Commissioned Papers 203
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Survey of Hospitals and Medicare Cost Reports. We estimate the impact of the uninsured rate on hospital margins and four measures of hospital service availability, i.e., capacity, services to vulnerable populations, community services, and high-tech services.
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Persons without health insurance have poorer heath outcomes for an episode of illness and higher overall mortality rates (Ayanian et al., 1993; Blustein et al., 1995; Canto et al., 2000; Roetzbeim et al., 2000~. While research has shown the persons who are uninsured face significant barriers to health care, little is known about how the overall percentage of those without health insurance, i.e., the uninsured rate, affects access to care for their community.
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Also, hospitals, physicians and other health care providers receive substantially less reimbursement for the care provided to uninsured patients compared to similar insured patients. Consequently, a high uninsured rate should reduce overall demand for health .
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CONCEPTUAL F12AMEWORK As stated above, we hypothesize that the uninsured rate is negatively related to the demand for hospital services. Specifically, as the uninsured rate increases, the overall demand for hospital services by insured patients decreases while the overall demand for hospital services by uninsured patients (i.e., charity or discount care)
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. uninsured rate Increases.
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beds, and beds devoted to patients diagnosed with alcoholism, drug abuse, or chemical dependency. Five services for vulnerable populations were examined: psychiatric outpatient services, psychiatric emergency room services, psychiatric inpatient services, outpatient, and rehabilitation services for persons diagnosed with alcoholism, drug abuse, or chemical dependency, and services for patients diagnosed with HIV-AIDS.
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METHODOLOGY We conducted MSA- and hospital-level analysis on three sets of variables: hospital beds, hospital services, and hospital margins. Beds In the MSA level analysis, we regressed beds per capita for total beds, medicalsurgical beds, beds in intensive care units, psychiatric inpatient beds, and beds for treatment of alcohol and chemical dependency on the percent of uninsured residents in the MSA, the other MSA characteristics, (i.e., percent Medicaid, percent Medicare, percent HMO enrollment, level of hospital competition, hospital wage index, and population density)
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The independent variables in this model were the uninsured rate, the other MSA characteristics, and the hospital characteristics. Similar to the other hospital-level models, we estimated random effects controlling for unobserved hospital and time effects, weighting by hospital beds and calculating robust standard errors using the Huber-White correction.
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APPENDIX D TABLE D.1 Means and Standard Deviations for Percent Uninsured in MSA and Dependent Variables 213 Unweighted Weighted Variable N Mean SD N Mean SD Percent Uninsured in MSA 340 14.6 Beds per 100,000 Population 5.3 Total 340 316.2 106.6 Medical-Surgical 340 173.2 78.0 ICU 340 29.7 10.3 Psychiatric 340 18.5 12.1 Alcohol and chemical 340 3.9 4.3 dependence % % % % Services for Vulnerable Populations Psychiatric inpatient 340 39.6 18.1 340 59.2 21.6 Psychiatric emergency 340 40.5 19.4 340 58.4 22.1 Psychiatric outpatient 340 32.5 16.7 340 49.3 21.8 Alcohol and chemical 340 25.8 16.7 340 37.8 22.4 dependence AIDS 340 54.1 21.0 340 73.7 18.9 High Technology Services Trauma 340 22.3 13.8 340 38.5 19.8 NICU 340 25.8 12.6 340 42.9 17.9 Transplant 340 16.5 11.2 340 32.2 17.3 Burn 340 5.2 4.9 340 11.1 11.0 MINI 340 47.2 20.6 340 66.2 23.3 Radiation therapy 340 37.2 15.3 340 61.0 18.5 Angioplasty 340 34.2 14.9 340 60.4 18.8 SPECT 340 41.2 16.8 340 57.3 19.4 ESWL 340 14.5 10.7 340 26.0 19.0 Community Services Community outreach 255 56.9 17.8 255 75.4 17.5 Transportation 255 24.8 15.6 255 33.7 22.0 Meals on Wheels 255 12.3 12.7 255 14.2 15.7 Margin 340 3.4 4.8
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b a p |
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Margin 6459 0.027 (0.059) a p |
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An increase in the uninsured rate of 5.3 percentage points, one standard deviation, is associated with a 4.5 percent decrease in beds overall, a 6.1 percent decrease in medical-surgical beds, a 17.5 percent decrease in psychiatric beds, and 25.8 percent decrease in alcohol and chemical dependence beds at the mean level of beds per capita. Services for Vulnerable Populations With respect to services for vulnerable populations, AIDS services are the most common.
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Because these services were more likely to be offered by larger hospitals, the proportion of beds in hospitals offering these services varied from 42.9 percent for NICU to 11.1 percent for burn care. Among these four services, in the MSA-level regressions, trauma services are less likely to be available in communities with higher uninsured rates, a finding observed in both the unweighted and weighted regressions.
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We observe no statistically significant association in either the MSA or hospital-level regressions of margin on uninsured rates. DISCUSSION In our analysis, we find inconsistent results between the MSA and hospitallevel models.
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We find this association in our MSA- and hospital-level analyses of beds and services. We find some evidence of an association of uninsured rates and the provision of trauma services and community outreach services by hospitals and weaker evidence of an impact on burn services and Meals on Wheels.
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ADDENDUM 85 LARGEST U.S. METROPOLITAN STATISTICAL AREAS Akron, OH Albany, NY Albuquerque, NM Allentown, PA Ann Arbor, MI Atlanta, GA Austin-San Marcos, TX Bakersfield, CA Baltimore, MD Bergen-Passaic, N} Birmingham, AL Boston, MA-NH Buffalo-Niagara, NY Charlotte, NC-SC Greenville, SC Harrisburg, PA Hartford, CT Honolulu, HI Houston, TX Indianapolis, IN Jacksonville, FL Jersey City, NJ Kansas City, MO-KS Knoxville, TN La Vegas, NV-AZ Los Angeles, CA Louisville, KY-IN Orlando, FL Philadelphia, PA-NJ Phoenix-Mesa, AZ Pittsburgh, PA Portland, OR-WA Providence, RI-MA Raleigh, NC Richmond, VA Riverside-San Bernardino, CA Rochester, NY Sacramento, CA Salt Lake City, UT San Antonio, TX Memphis, TN-AR-MS San Diego, CA Chicago, IL Miami, FL San Francisco, CA Cincinnati, OH-KY-IN Middlesex, N} San Jose, CA Cleveland, OH Milwaukee, WI Seattle, WA Columbus, GA-AL Columbus, OH Dallas, TX Dayton, OH Denver, CO Detroit, MI E1 Paso, TX Fort Lauderdale, FL Fort Worth, TX Fresno, CA Grand Rapids, MI Greensboro, NC Minneapolis, MN-WI Monmouth, N} Nashville, TN Nassau-Suffolk, NY New Orleans, LA New York, NY Newark, NJ Norfolk, VA-NC Oakland, CA Oklahoma City, OK Omaha, NE-IA Orange County, CA St.
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Data from the Medicare Cost Reports and American Hospital Association's (AMA) Survey of Hospitals were used to estimate the impact of the uninsured rate on hospital margins and four measures of hospital service availability, i.e., capacity, services to vulnerable populations, community services, and high-tech services.
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In addition, the availability of services for vulnerable populations and community services and the propensity for hospitals to offer these services was negatively associated with the uninsured rate. In this study, we examine the effect of uninsurance on rural hospitals.
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Detailed data on the number of uninsured persons or the uninsured rate at the county or hospital market level are not available. (See Appendix B of this report for further discussion of data and measurement issues for local uninsured rates.)
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In some markets, there are safety-net hospitals that provide a disproportionate share of the care to the uninsured while other hospitals provide less than their proportionate share of the market for uninsured patients. In such a market, an increase in the uninsured rate would have a larger effect on safety-net hospitals than on other hospitals, if the safety-net hospitals absorbed the increase in the demand for care for uninsured patients.
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FIGURE D.1 The impact of uninsurance rate on the demand and supply of hospital services. DATA Data for this study come from four sources: · state hospital discharge data from seven states · the AHA Annual Survey of Hospitals · the Medicare Cost Reports and · the Area Resource File compiled by the Bureau of Health Professions We used hospital discharge data from California, Massachusetts, New Jersey, New York, Pennsylvania, Washington, and Wisconsin for 1991, 1994, and 1996.
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We used four measures of hospital service availability: hospital capacity, services to vulnerable populations, community services, and high-tech services. To measure capacity we used the number of hospital beds, medical-surgical beds, psychiatric beds, ICU beds, and beds devoted to patients diagnosed with alcoholism, drug abuse, or chemical dependency.
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To facilitate the interpretation of the coefficients on the percentage of uninsured discharges, the main effect of the relative concentration ratio, and the interaction term, we centered the relative concentration ratio on its mean. We examine the overall effect of percent of uninsured discharges in counties with low and high concentration of uninsured discharges by summing the coefficient on the percent uninsured discharges with the product of the coefficient on the interaction term and relative concentration ratio evaluated at the three distinct points.
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It equals total hospital revenues in the county minus total hospital expenses in the county divided by total revenues. The independent variables were the percent of uninsured discharges in the county, the percents Medicaid and Medicare discharges, the percents of public and for-profit hospitals in the county, hospital wage index, population density, and year categorical variables to control for fixed time effects.
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There is a statistically significant association of ICU beds with percent uninsured at all three levels of uninsured concentration tested. In addition, for psychiatric beds there is a statistically significant association of percent uninsured and bed supply at low levels of concentration of the uninsured (see Table D.6~.
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Psychiatric emergency services are available in approximately 35 percent of hospitals (with 37 percent of beds) , while psychiatric inpa
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Among these three services, transplant services are less likely to be available in communities with lower concentrations of uninsured and higher uninsured rates. For trauma and NICU services, while the coefficients on percent uninsured are negative, they are not statistically significant.
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0.34 Alcohol and chemical dependence 386 -0.17 (0.12) 0.10 Services for Vulnerable Populations Psychiatric inpatient 386 -0.91 (0 59)
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Regressions of margin include percent county Medicaid, percent county Medicare, percent county HMO, percent hospitals in county for-profit, percent hospitals in county public, Herfindahl index, ratio of uninsured Herfindahl index to total Herfindahl index (the uninsured concentration) , county population density, and dummies for years 1994, 1996, and 1999.
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The fact that we observe higher average rates of offering beds or services when care for the uninsured is more concentrated in counties may reflect strategic interactions among hospitals. This illustrates the variability among rural counties in their capacity to maintain hospital services and the impact of higher uninsured rates on hospitals in these counties.
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This strategy, while preserving a rural hospital's ability to serve its community in the short-term, has implications for hospital's ability to provide, maintain, and improve services in the future. Because of lower margins, rural hospitals in areas with high uninsured rates may have difficulty maintaining and replacing their physical plant, investing in new technologies, and expanding their scope of services to meet new community health needs.
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