TITLE: A Framework for Research and Evaluation Into the Effects of Managed Care on the Pharmaceutical Marketplace

ABSTRACT: The growing influence of managed care has had a profound effect on the pharmaceutical marketplace, and has highlighted a number of long-standing concerns among those involved in providing pharmaceutical services, including the industry, purchasers, providers, third-party payers and the government. The goal of this project, therefore, was to improve the quality and accessibility of information used to make decisions in the public and private sectors about how to deal with the revolutionary changes in the pharmaceutical marketplace and the impact of managed care on pharmaceutical services. The project also developed information on how managed care has affected consumer access to pharmaceutical services. The principal product of the project describes a framework for research and evaluation that serves the information needs of all the stakeholders, public and private, providing a common basis for discussion and decision making. The principal report is supported by a series of study papers that synthesize the best current research on the evolution of key elements of the health care delivery system. These study papers do not focus on solutions to problems or recommendations for change. Instead, their purpose is to analyze and synthesize the existing research into a comprehensive, balanced portrait of the system.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Kevin Hennessy

PHONE NUMBER: 202-690-7272

PIC ID: 6049

PERFORMER ORGANIZATION: The George Washington University and Urban Institute, Washington, D.C.
 

TITLE: Assessment of Access to Liability Insurance for Tribes and Tribal Organizations with Self-Determination Contracts/Compacts

ABSTRACT: This study examines issues surrounding tribal experiences with private liability insurance and the Federal Tort Claims Act (FTCA). The primary purposes of the study are to: (1) examine access to private liability insurance by tribes and tribal organizations operating programs under the Indian Self-Determination and Education Assistance Act (ISDEAA), and the coordination of that insurance with the immunity from tort liability for self-determination contractors and compactors and their employees provided under the FTCA; (2) identify barriers to the appropriate pricing of private liability insurance; and (3) recommend strategies that will assist tribes, tribal organizations, and other contractors and self-governance compactors to reduce the need for private liability insurance, as well as its cost. The grant of immunity from tort claims provided under the FTCA for P.L. 93-638 activities should have resulted in tribes and tribal organizations paying less for private insurance. However, a lack of awareness of the applicability of the FTCA and/or full understanding of its scope appear to have prevented some tribes from doing so. One of the most important steps that tribes can take to lower their private liability costs is to become better informed about the fundamentals of the FTCA and the types of commercial insurance they need to supplement the immunity from tort claims that the FTCA provides. The Federal government can assist tribes and tribal organizations by providing more accessible information about the FTCA in a form that is simple and useful to laypersons. Tribes and tribal organizations can help each other by sharing information about their experiences in obtaining appropriate and reasonably priced insurance.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Tom Hertz

PHONE NUMBER: 202-690-7779

PIC ID: 6345

PERFORMER ORGANIZATION: The George Washington University, Washington, D.C.
 

TITLE: Children's Health Insurance Expansions: State Experience in Developing Benefit Packages and Cost-Sharing Arrangements

ABSTRACT: This project reviews the experiences of nine States that either utilized Medicaid expansions or developed stand alone programs to expand health insurance for children prior to the enactment of Title XXI. The enactment of the State Children's Health Insurance Program (CHIP), under Title XXI of the Social Security Act, is providing $24 billion in funding to States over a five-year period to expand health insurance coverage to uninsured children. Under CHIP, States have the option of expanding their existing Medicaid programs, developing stand alone programs or some combination of the two. As States select their approaches, design of the benefit package, including cost-sharing features, is one of the critical considerations States are facing. While the legislation defines standards for benefit packages and limits the extent to which States can impose premiums or cost-sharing (i.e., deductibles and copayments), the States maintain a fair amount of flexibility in program design. The nine States interviewed for this study are divided into two broad categories: Medicaid expansion programs and stand alone insurance programs. Generally, the survey revealed that States debated over whether to provide a more limited insurance product for more children, or include inpatient benefits and therefore serve fewer children. In terms of cost sharing, results of the survey indicated that program directors believed that by instituting moderately priced premiums and copayments, families were more willing to enroll, and did not view the program as a form of welfare. Several States identified the affordability of employer-sponsored insurance as an important consideration in the implementation of mechanisms to limit crowd out. Related to issues of price sensitivity is the decision of whether to implement a flat fee premium for all participants, or one that is based on a sliding scale.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: George Greenberg

PHONE NUMBER: 202-690-7794

PIC ID: 6729.1

PERFORMER ORGANIZATION: The Lewin Group Fairfax, VA
 

TITLE: Children's Health Insurance Patterns: A Review of the Literature

ABSTRACT: Policymakers are currently considering a number of proposals aimed at reducing the number of children without health insurance. This report attempts to address the lack of information about the uninsured child population. This literature review focuses on (1) uninsured children: how many there are, their characteristics, how long are they uninsured, and why are they uninsured; and (2) Medicaid eligibility, enrollment, participation rates, program dynamic, and measurement issues. The review found that: (1) the uninsured are found in every age group of children, even among the very young supposedly covered by past expansion efforts under Medicaid; (2) over two-thirds of uninsured children live in families with a family income of less than 200 percent of poverty; (3) about 70 percent live in two-parent families and 64 percent have one parent working full-time; (4) the vast majority (80 percent) of uninsured children have one parent who is also uninsured; (5) even though a majority of uninsured children are white, minorities (especially Hispanics) are disproportionately represented; (6) uninsured children include a disproportionate number of noncitizens (10 percent versus 4 percent in the general population of children); and (7) there are inconsistencies in the research concerning how long children are insured. Also identified are topics for further investigation. (Final report 72 pages.)

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Caroline Taplin

PHONE NUMBER: 202-690-7906

PIC ID: 6721

PERFORMER ORGANIZATION: Mathematica Policy Research, Inc. Plainsboro, NJ
 

TITLE: Deriving State Level Estimates from Three National Surveys: A Statistical Assessment and State Tabulations

ABSTRACT: This report assesses the statistical issues involved in the production of State-level estimates related to health and welfare issues from three national surveys: the Current Population Survey (CPS), the Survey of Income and Program Participation (SIPP), and the National Health Interview Survey (NHIS). With the devolution of many welfare programs from the Federal Government to the States, there is a strong interest in being able to track the health and welfare of the population in each State. This would allow for examination of the effects of various State welfare initiatives that are to be implemented in the next few years. Ideally, the CPS, SIPP and NHIS would be able to provide "direct" estimates of adequate precision for every State, as opposed to the "indirect" estimates derived from statistical models. The surveys, however, are not large enough to produce accurate direct estimates for every State, and there are great disparities in sample size. The relevant statistical issues involved in making State-level estimates from the three surveys include State stratification, non-sampling errors and precision of the estimates. For this report, the most current databases for two of the three surveys were examined: March 1996 for the CPS and the 1993 panel for the SIPP. In 1995, the NHIS sample was completely redesigned, so examining the 1994 data would yield little information on the ability of future years to provide State-level estimates. For all three surveys, the allocation of sample size to the States is made with the aim of balancing the precision requirements of both State and national estimates. As a result, disparities exist. Approaches to overcome the sample size limitations of these surveys include the following: (1) increase State samples, (2) combine data from multiple years of the same survey, and (3) combine data from two or more surveys. These methods can both increase the size, and improve the accuracy of, State samples.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: George Greenberg

PHONE NUMBER: 202-690-7794

PIC ID: 6380

PERFORMER ORGANIZATION: The Lewin Group Fairfax, VA
 

TITLE: Examining Substitution: State Strategies to Limit Crowd Out in the Era of Children's Health Insurance Expansions

ABSTRACT: In recent years, State initiatives to provide health insurance for low-income children have raised a new set of concerns regarding the actual and potential impact of employer and individual-based substitution. As a number of States elected to expand Medicaid in the late 1980s, researchers began to explore the possibility that Medicaid was substituting private coverage. As Federal and State governments seek to increase the proportion of people with health coverage, it is critical to understand the nature and extent of substitution. Concerns focus on the potential that, if Medicaid and other public expansions are responsible for shifting individuals from employer-sponsored insurance to public programs, the effectiveness of public funds to expand insurance coverage might be limited. As programs minimize the effects of substitution, States will then have the ability to target funding specifically to children who do not have access to affordable health coverage. Several States have suggested that the coverage issue, in most cases, is not employers dropping coverage, rather individuals choosing to opt out of private insurance coverage for State subsidized programs. Research has attempted to assess the amount of substitution, suggested ways to limit its effects, and weighed the benefits and costs of expanding Medicaid with the potential of crowding out private insurance. State strategies to address substitution include nine mechanisms that either purposefully or inadvertently limit two types of substitution: individual-based and employer-based. The extent to which States deliberately institute mechanisms limiting substitution varies by program and State.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Cheryl Austein-Casnoff

PHONE NUMBER: 202-690-6102

PIC ID: 6729

PERFORMER ORGANIZATION: The Lewin Group Fairfax, VA
 

TITLE: Public Health Laboratories and Health System Change

ABSTRACT: All fifty States and the District of Columbia operate their own Public Health Laboratories (PHLs). Changes in the private health care delivery system, especially the growth of managed care organizations (MCOs), hospital consolidations, and large commercial laboratories, are causing public health professionals to examine the viability of publicly funded laboratories. The study identifies aspects of the public health infrastructure critical for developing assessment and evaluation tools. The report includes a literature review, interviews with stakeholders, an informal poll of state PHL directors and detailed case studies of three States that have PHLs and relationships with MCOs and/or private laboratories. The report concludes that: (1) PHLs are part of the broader public health infrastructure and must respond to changes in the health care marketplace; (2) services that are not commercially viable within the private sector, and those that are critical to identifying emerging diseases, should remain in the domain of PHLs; (3) assurance of quality and consistency of laboratory testing are critical functions of PHLs; and (4) policy development in laboratories needs to address the growth of managed care and changes in the health care delivery system. The study recommends increased Federal guidance in: (1) assessing the regionalization of laboratory services, (2) supporting information infrastructure development, and (3) facilitating communication between private and public sectors. (Final report variously paginated.)

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Cheryl Austein-Casnoff

PHONE NUMBER: 202-690-6102

PIC ID: 6458

PERFORMER ORGANIZATION: The Lewin Group Fairfax, VA
 

TITLE: Resource Evaluation of the FDA Food Additive Petition Review Process Executive Summary

ABSTRACT: This project analyzes the food additive petition process in the Food and Drug Administration (FDA) to determine the resources needed to achieve a petition processing time frame of 180 days. The Food Additives Amendment to the Food, Drug and Cosmetics Act requires the Food and Drug Administration to provide premarket approval for food additives prior to inclusion in food. Premarket approval is sought via the petition process and the statute requires the FDA to complete its petition review within 90 days of filing, with a possible extension of another 90 days and an extended processing period of 180 days. The FDA had been unable to consistently meet these statutory time frames. This project quantifies the resources required for each of the Office of Premarket Approval's (OPA's) various responsibilities, and details the impact of competing requirements on the petition review system. Conclusions state that the statutory time frames are unrealistic for most petitions. The ability to meet the time frames is not a question of staffing or personnel availability. The only way to address the statutory time frames is to either change the time frames, or completely rethink the entire functioning of OPA and the types of review it should be performing.

AGENCY SPONSOR: Office of Health Policy

FEDERAL CONTACT: Laina Bush

PHONE NUMBER: 202-205-5271

PIC ID: 6342

PERFORMER ORGANIZATION: Research Triangle Institute, Research Triangle Park, NC