Employer-Sponsored Insurance, Ambulance Diversion and Heart Attack Deaths, and Massachusetts Heath Care Reform

ROCHESTER, NY (05/13/2010)(readMedia)-- Health care reform is now law, but concerns surrounding costs, premiums and effects on employers and employees remain. INQUIRY's spring issue offers policy-relevant articles that help inform these matters.

"Taking Up or Turning Down: New Estimates of Household Demand for Employer-Sponsored Health Insurance," by Jean Marie Abraham and Roger Feldman -- This study examined decisions to take health coverage offered by an employer, and found that for both one-person and multi-person households the probability of enrolling in employer-sponsored insurance (ESI) decreased as out-of-pocket premiums increased. Families with more children eligible for Medicaid or the Children's Health Insurance Program were even less likely to take up ESI, indicating the crowd-out effect of public insurance. Further investigating the behavior of low-income households, the authors concluded that substantial subsidies would be needed to make out-of-pocket premiums low enough for these families to take up ESI and thus have an impact on the overall number of the working uninsured.

"Workers on the Margin: Who Drops Health Coverage when Prices Rise?" by Edward N. Okeke, Richard A. Hirth, and Kyle Grazier – Also considering the relationship between premium costs and ESI take-up, this case study focused on one large employer---the University of Michigan---and employees' responses to actual changes in their health insurance premiums. Results showed that, on average, a 10% hike in an employee's out-of-pocket premium contribution increased by about 1% the probability that employee would drop health coverage. Married workers were more sensitive to price than single employees, with married female employees more likely to waive coverage than married male employees, suggesting the women had another source of coverage (such as through a spouse). Most responsive to premium increases were lower-paid workers, who were much more likely to drop coverage than higher-paid workers.

"Malpractice Premiums and the Supply of Obstetricians," by Daniel Polsky, Steven C. Marcus, and Rachel M. Werner -- Using hospital discharge data from Florida, Pennsylvania and New York for the 1998-2004 period, this study found that rising malpractice premiums increased the rate at which physicians dropped their obstetrics practice and reduced the rate of new obstetricians entering the labor market. In Florida and Pennsylvania, where premiums rose 20% each year from 2000 to 2004, the combined effect of exits and entries translated into a decline in the obstetrical workforce of 80 physicians, or 5.3% of the obstetrical labor supply. While the findings contradict most prior research in this area, the authors say their analysis employed more detailed data to identify practicing obstetricians.

"Physician Quality and Health Care for the Poor and Uninsured," by Lara Gardner and Sharmila Vishwasrao -- Looking at the characteristics of physicians at Florida hospitals in 2004, this study found uninsured and Medicaid patients were more likely to be treated by lower-quality physicians due to both the hospitals the patients attended and patient sorting within hospitals. While poor patients tended to receive treatment from physicians with less experience and no board certification within hospitals, discrimination was minor. Among nonprofit, for-profit and teaching hospitals, there was little difference in the likelihood that uninsured and Medicaid patients would be treated by a highly trained physician. However, at government hospitals, where the percentage of poor patients is high, patients had a much lower chance of being treated by a board-certified or top-trained physician than at the other types of hospitals.

"The Impact of Ambulance Diversion on Heart Attack Deaths," by Natalia Yankovic, Sherry Glied, Linda V. Green, and Morgan Grams -- This study looked at a year of hospital ambulance diversions in the five boroughs of New York City and found that high levels of ambulance diversion were associated with increased deaths from acute myocardial infarctions (AMIs), or heart attacks. The results differ from previous studies, which have shown no rise in deaths over a concomitant period of increasing ambulance diversion. The authors attribute the finding to their outcome measure of AMI deaths, a particularly time-sensitive condition. Also, rather than counting only deaths that occurred during transport, they included those that occurred in the emergency department (ED) or outside the hospital; this captured deaths that occurred while waiting for an ambulance, as well as those that occurred after transport and involved delays due to diversion and ED congestion.

Also featured in INQUIRY's spring issue are these open access articles:

"Regulation of Executive Compensation at Nonprofit Health Care Organizations: Coming Changes?" by David Albert Bjork -- In this McNerney Forum piece, Bjork, of Integrated Healthcare Strategies, discusses how recent efforts to regulate executive pay impacts nonprofit health care organizations. He recommends some changes that the boards of nonprofit health care providers and insurers might consider to minimize further scrutiny and regulation of their executive pay practices.

"The View from Here: What Happened in Massachusetts Didn't Stay in Massachusetts," by Alan C. Monheit – In this column, INQUIRY's editor takes a look at some of the political maneuvers used to promote and hinder health reform before its final approval.

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INQUIRY, the journal of health care organization, provision, and financing, is a peer-reviewed scholarly publication. Now in its 47th year, it is published quarterly by Excellus Health Plan, Inc. Press releases and article abstracts are available on the INQUIRY Web site at www.inquiryjournal.org under "Current Issue Table of Contents."