Accessibility of addiction treatment: results from a national survey of outpatient substance abuse treatment organizations.
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OBJECTIVES: This study examined organization-level characteristics associated with the accessibility of outpatient addiction treatment. METHODS: Program directors and clinical supervisors from a nationally representative panel of outpatient substance abuse treatment units in the United States were surveyed in 1990, 1995, and 2000. Accessibility was measured from clinical supervisors' reports of whether the treatment organization provided "treatment on demand" (an average wait time of 48 hours or less for treatment entry), and of whether the program turned away any patients. RESULTS: In multivariable logistic models, provision of "treatment on demand" increased two-fold from 1990 to 2000 (OR, 1.95; 95 percent CI, 1.5 to 2.6), while reports of turning patients away decreased nonsignificantly. Private for-profit units were twice as likely to provide "treatment on demand" (OR, 2.2; 95 percent CI, 1.3 to 3.6), but seven times more likely to turn patients away (OR, 7.4; 95 percent CI, 3.2 to 17.5) than public programs. Conversely, units that served more indigent populations were less likely to provide "treatment on demand" or to turn patients away. Methadone maintenance programs were also less likely to offer "treatment on demand" (OR, .65; 95 percent CI, .42 to .99), but more likely to turn patients away (OR, 2.4; 95 percent CI, 1.4 to 4.3). CONCLUSIONS: Although the provision of timely addiction treatment appears to have increased throughout the 1990s, accessibility problems persist in programs that care for indigent patients and in methadone maintenance programs. (+info)
How much medical care do the uninsured use, and who pays for it?
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With the number of uninsured people exceeding forty-one million in 2001, insuring the uninsured is again a major policy issue. This analysis establishes benchmarks for the inevitable debate over the cost of expanding coverage: How much is being spent on care for the uninsured, and where does the money come from? This information is essential for assessing how much new money will be required for expanded coverage, how much can be reallocated from existing sources, and how a new financing system would redistribute the burden of subsidizing care for the uninsured from private to public sources. (+info)
Hospital tiers in health insurance: balancing consumer choice with financial incentives.
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Variations in efficiency and market power are generating wide variations in the prices charged by hospitals to health insurance plans. Insurers are developing new network structures that expose the consumer to some of the cost differences, to encourage but not mandate differential use of the more economical facilities. The three leading designs include hospital "tiers" within a single broad network, multiple-network products, and the replacement of copayments by coinsurance in HMO as well as PPO products. This paper describes the new network designs and evaluates the challenges they face in influencing consumers' behavior, incorporating information on clinical quality, and supporting medical education and uncompensated care. (+info)
Professional monopoly, social covenant, and access to oral health care in the United States.
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Lack of access to oral care is a severe problem in the United States with over one-third of the population lacking dental insurance. In this group, 32 million people lack dental insurance and access to public dental services (Medicaid or Medicare), and 7 million of them need dental care. In some high-risk populations, such as Native Americans, two-thirds have unmet dental needs. Only 1 percent of Medicaid-eligible babies have a dental examination before twelve months of age. In this paper the social covenant of the dental profession is examined and suggestions made for improving access to care through improved efficiency. It is proposed that 1) private dentists should accept 5 percent per annum of their patients for indigent care funded by improved efficiency from utilizing allied dental providers (ADP) in new roles, and 2) ADP should have their own independent state boards. If dentists refuse to honor their social covenant, then ADP should be allowed to practice independently, breaking the professional monopoly. (+info)
Care for the uninsured in general internists' private offices.
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This paper examines the care of uninsured patients in general internists' private practices. More than two-thirds of internists provide at least some charity care, usually to their existing patients who have become uninsured. They appear to be filling a need for people who are moving between coverage, by helping bridge coverage intervals. Approximately two-thirds of all internists accommodate uninsured patients by reducing the charge or creating a payment plan, with internists who are practice owners much more likely to do so. This care to the uninsured is important, especially with growing unemployment rates, because the safety net would not be able to absorb these patients. (+info)
The urban safety net: can it keep people healthy and out of the hospital?
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There is much discussion and debate over the relative vulnerability and capacity of the health care safety net to care for the growing numbers of uninsured and disenfranchised persons in urban poor communities. In this study, we present findings from a community-based survey of 248 adults identified at eight safety net provider sites in Baltimore, Maryland, to contextualize recent findings that described Baltimore's safety net capacity as having more hospital- and intensive service-based interventions, with higher proportions of the population reportedly unable to get care when needed compared with other cities. The average age of respondents was 41.2 years, most (87.3%) were African American, unemployed (75.8%), homeless (57.0%), and with at least one chronic medical problem (77.8%). Almost one half (47.6%) also reported a chronic mental health condition, and 51.2% reported having difficulty accessing health care services in the past. Overall, 76.9% reported accessing additional community sites for daily sustenance needs, with most of these sites community non-profit or faith-based organizations. In the multiple logistic regression model, only individuals with chronic mental health conditions were significantly more likely to report difficulties accessing health care. The lack of a Community Access Program or other structured efforts to facilitate integration of services among providers in Baltimore and an "all-payer" system that reimburses uncompensated care only for hospital admissions are postulated as two structural elements that may contribute to these findings. (+info)
Characteristics of emergency departments serving high volumes of safety-net patients: United States, 2000.
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OBJECTIVE: This report describes hospital, community, and patient factors associated with emergency departments (EDs) whose case loads are driven by "safety-net" populations. The study also explores the relationship between safety-net burden and receipt of Medicaid Disproportionate Share Hospital (DSH) Program funds. METHODS: Linked data were analyzed from the 2000 National Hospital Ambulatory Medical Care Survey (NHAMCS), Area Resource File, and reports of Medicaid DSH payments to hospitals. NHAMCS ED visit data were aggregated to the hospital ED level (n = 376). Hospital sampling weights were used to produce national estimates of hospital EDs. Hospitals were classified into high vs. low safety-net burden based on the percent of ED visits where the expected source of payment was Medicaid or uninsured (self-pay or no charge). High- and low-burden EDs were compared along five domains: hospital characteristics; community factors; patient mix; diagnosis mix using Billings' profiling algorithm; and condition severity, visit content, and outcome. RESULTS: Approximately one-third (36.1 percent) of U.S. EDs were classified as high safety-net burden provides. Hospitals located in the South were more likely to have a high ED safety-net burden (61.3%). High-burden EDs saw a higher percentage of cases that were either nonurgent or emergent, but primary care treatable. EDs high in uninsured burden were not necessarily high in Medicaid burden. Fewer than half of high-burden EDs received DSH payments. CONCLUSIONS: High safety-net burden is not necessarily offset by public funding. The vast majority of EDs that serve high proportions of uninsured patients do not receive such compensation. (+info)
Emergency care in California: robust capacity or busted access?
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Licensed emergency department (ED) capacity is a static measure that is inadequate to evaluate a system that the public and policymakers expect to respond dynamically to individual patients in a timely manner. Government mandates on hospital-based providers, undersupply of trained and willing personnel, and private market imperatives all curtail the functional capacity of the emergency care system. Although most Californians still live within a few miles of the closest hospital, many ambulance patients are diverted much further because of ED crowding. Many ambulatory patients are delayed so long in waiting rooms that they return home without ever being seen. (+info)