On Reducing Information Asymmetry in U.S. Health Care

Information asymmetry is a significant issue facing the U.S. health care system. In this article, we investigate some methods of reducing this asymmetry. We trace the information asymmetry using the “wicked problem” of the health care distribution system. An information asymmetry reduction method requiring joint responsibilities among health care stakeholders is developed. It is argued that information asymmetry is a contributor to enormous health care inflation. Hence, any reduction in such asymmetry will reduce health care costs. Concepts from both signaling and corrective justice theories are integrated in this article to help reduce the information asymmetry that exists in the U.S. health care system. Getting health care costs in line with other “advanced” nations, is the long-term solution to the wicked problem that currently exists in the U.S. health care system. There is an immediate need for a centralized health care database with adequate provisions for individual privacy. Both processes as well as an outcome-based control system are essential for reducing information asymmetries in the U.S. health care system.     

A comparative analysis of stakeholder power in the Mexican and U.S. health care systems

The primary focus of this paper is to analyze the Mexican health care system and the forces driving its change. To facilitate this, the paper conducts an analysis of the key stakeholders in both the U.S. and Mexican health care systems. The Mexican system is dominated by an autocratic federal government that is gradually relinquishing its role as provider of health care in exchange for control of the reform efforts. The U.S. system is characterized by a relatively equal distribution of power among the key stakeholders, in which changes occur primarily through incrementalism. The results of the analysis indicate that the key differences lie in terms of relative stakeholder power and rate of change in the systems. Compared with the U.S.,Mexico is making rapid changes to its health care system and both countries are struggling with the same key issues: Cost, access, and quality.     

Health care service utilization of documented and undocumented hired farmworkers in the U.S.

This article analyzes issues related to U.S. hired farmworkers’ utilization of health care services and their specific choices among health care provider and health bill payment method options. Using data from the National Agricultural Workers Surveys for the years 2000–2012, this article employs propensity score matching and probit estimation techniques to examine the health care utilization of hired farmworkers. This study’s results indicate that undocumented hired farmworkers are 10.7 and 3% less likely to use U.S. and foreign health care, respectively, compared to documented farmworkers. Health insurance is found to significantly increase hired farmworkers’ use of U.S. health care by 22.3%. Notably, compared to their documented working peers, undocumented workers are much less likely to patronize private clinics. They are even less likely to rely on migrant health centers even when these providers are their most viable sources of health care service.     

Utilization of physician health care services in Mexico by U.S. Hispanic border residents

One of the most controversial topics in the U.S. is the issue of accessibility to health services by U.S. residents. This issue is most critical to U.S. Hispanic residents living along the U.S.-Mexico border who have been identified as having low health standards and low socio-economic conditions when compared to the rest of the state and the country. The availability of lower cost health services across the U.S. border in Mexico is, therefore, perceived as a viable economic alternative source of health care. This study is derived from a health needs assessment survey of 1,100 households residing in Laredo, Texas, the largest land port along the 2,000-miles long U.S.-Mexico border. The major result of this study indicates that about 41.2 percent of the Laredo U.S. Hispanic residents are utilizing cross border physician health care services in Mexico.     

U.S. medical students' attitudes about patients' access to care

OBJECTIVE: Accessing adequate medical services remains a major struggle for many Americans, but U.S. medical students' beliefs regarding access to care have not been thoroughly examined. METHODS: All medical students in the Class of 2003 at 16 U.S. schools were eligible to complete three questionnaires during their medical training: during freshman orientation, orientation to wards, and their senior year (n=2316, response rate=80.3%). Students responded to three questions about health care provision. RESULTS: Overall, 35% of students strongly agreed that "physicians have a responsibility to take care of patients regardless of their ability to pay;" only 5% disagreed. Only 8% disagreed that "access to basic health care is a fundamental human right." We found the same significant associations with opinions on access as we did with "responsibility to treat," although the associations tended to be stronger for access. Only 10% of students agreed that "Managed care, as it is now delivered, is a good way to deliver health care to the U.S. population." CONCLUSION: Most U.S. medical students support universal access to medical care, though variations in this support, its decline with additional years of medical education, and concerns about managed care are noteworthy, and have policy implications for America's health and health care workforce.     

A review of data on the U.S. health sector spring 2006.

This report presents information on the state of the U.S. health system in the spring of 2006. It includes data on the uninsured and underinsured and their access to health care, on socioeconomic inequality in health care, and on the rising costs of the U.S. health system. It also presents information on the role of corporate money in health care, focusing on the pharmaceutical industry, Medicare HMOs, and corporate-government conflicts of interest. The author includes a survey of recent public opinion polls on health care and health system reform and an update on the U.S. national health insurance legislation. The article ends by reviewing recent data on international health systems and international system comparisons.     

Measuring Tijuana residents' choice of Mexican or U.S. health care services

There is growing concern that the indigent health care burden in the southwestern United States may be caused partly by Mexican residents who cross the border to use U.S. health services. This article describes the first attempt to measure the extent of this use by border residents. It also compares factors associated with their use of health care services in both the United States and Mexico. Data were obtained from a household survey conducted in Tijuana, Mexico, near the California border, using a random, stratified analytic sample of 660 households that included a total of 2,954 persons. The dependent variables--extent and volume of contacts with health professionals--were examined according to sociodemographic characteristics, insurance coverage, payment modality, type of visit, and health care setting. The results indicate that 40.3 percent of the Tijuana population used health services exclusively in Mexico during a 6-month period, compared with only 2.5 percent who used services in the United States. Of the Mexican users of U.S. services, the largest proportion appeared to be older people, lawful permanent residents or citizens of the United States who are living in Mexico, and persons from high- or middle-income sectors. In addition to the low level of use of U.S. health services, the findings show that more than 84 percent of the visits were to providers in the private sector and, for 59 percent of the visits, a fee for services was implied. Overall, this border population does not seem to be a drain on the U.S. public health system.(ABSTRACT TRUNCATED AT 250 WORDS)     

Achieving U.S. Health information technology adoption: the need for a third hand

The U.S. health care information technology (HIT) market is broken; broad-scale adoption of HIT is not occurring despite considerable evidence of its impact on the quality of care and patient safety. Although adoption of HIT will not cure all that ails health care, it is an important step toward transformation of the U.S. health care delivery system. In this commentary I describe several critical issues pertaining to the HIT market failure and several ways in which the federal government may act as a deft and gentle "Third Hand" to assist the Invisible Hand of Adam Smith.     

Giving birth across the border: the San Diego-Tijuana connection.

Large immigration flows of young Mexican women to the U.S.-Mexico border are increasing the demand for maternity services in the Southwest. To date no attempt has been made to determine how U.S. births are distributed among stable, permanent residents and transient migrants, such as border residents of Mexico who enter the U.S. temporarily, yet long enough to use health services. This exploratory study examines factors associated with childbirth in California by border residents of Tijuana, Mexico. Data on 184 women, 15-44 years old, who gave birth between 1982-87, were examined using a household survey and focus group discussions. The findings indicate that 10.4% of the sample crossed the border to give birth in the United States. Socio-economic and legal status, spoken English proficiency, history of U.S. residency, annual visits across the border, single parenthood and primiparity were factors significantly associated with childbirth in the United States. These factors, in addition to social class differentials in attitudes towards U.S. obstetrical care and citizenship-by-birth need to be examined in future studies of cross-border utilization of services. The findings also demonstrate that most U.S. deliveries were in the private sector and paid for out of pocket, representing a very low public health burden. Changes in Medicaid legislation, which have extended maternity care coverage to the undocumented, may encourage deliveries in the public sector. These effects, coupled with the bridging effects that newly legalized immigrant networks exert on friends and relatives, familiarizing them with U.S. health care resources, will require monitoring to determine changes in demand for U.S. maternity care by this population.     

State-specific trends in U.S. live births to women born outside the 50 states and the District of Columbia--United States, 1990 and 2000

Persons born outside the 50 states and the District of Columbia (DC) comprised an estimated 11.1% (31.1 million) of the U.S. population in 2000, and approximately one fifth of all U.S. births in 2000 were to women in this population. Racial/ethnic disparities in U.S. health outcomes are of public health concern, and the increasing cultural and linguistic diversity of the U.S. population poses challenges to the delivery of maternal and child health services. This report presents state-specific comparisons of live births in 1990 and 2000 to women born outside the 50 states and DC and compares maternal characteristics and live-birth outcomes for these women with those of state-born mothers (i.e., women born inside the 50 states and DC). The findings indicate that women born outside the 50 states and DC had better birth outcomes than their state-born racial/ethnic counterparts. However, a larger percentage of these women began prenatal care later and had other problems accessing health care, which might reflect economic, cultural, and language barriers. The U.S. public health system and maternal healthcare providers should understand and address the health needs of an increasingly diverse population.     

Health information technology is a vehicle, not a destination: a conversation with David J. Brailer. Interview by Arnold Milstein

The first U.S. national health care information technology (IT) coordinator estimates that if the current rate of interoperable electronic health record (EHR) adoption is sustained through 2014, it would create a launchpad for quality gain and health care spending reduction in excess of 50 percent in the subsequent decade. But in this conversation with Leapfrog Group cofounder and U.S. health care purchasing innovator Arnold Milstein, David Brailer identifies several environmental changes as critical to the materialization of this dividend. These include providers' ceding control of clinical information to patients, universal public availability of provider performance comparisons, and moving health policy from a no-man's land between government and market control.     

FACTORS THAT PROMOTE AND PREVENT PREPARATION FOR FUTURE CARE NEEDS: PERCEPTIONS OF OLDER CANADIAN,GERMAN, AND U.S. WOMEN

The risk of needing help with household tasks or of requiring care in old age increases. Using semi-structured, qualitative interviews, beliefs about the usefulness versus uselessness of planning ahead for future care needs (FCN) were investigated in 23 East German, 10 U.S., and 10 Canadian elderly-community dwelling women ( S 65 years). Primary reasons in favor of planning for FCN were: gaining a feeling of security regarding the future, avoiding being a burden to potential helpers, and coping with one's present health conditions. Factors that prevent planning for FCN were: the difficulty foreseeing FCN, the lack of resources to plan, and low levels of perceived vulnerability. The women dealt with the contradictions between these factors that promote and prevent preparation by making general plans which could be adapted in the case of needing help by developing alternative plans or by avoidance of thinking about possible future health crises.     

The Role of Patient-Reported Outcome Measures in Value-Based Payment Reform

The U.S. health care system is currently experiencing profound change. Pressure to improve the quality of patient care and control costs have caused a rapid shift from traditional volume-driven fee-for-service reimbursement to value-based payment models. Under the 2015 Medicare Access and Children’s Health Insurance Program Reauthorization Act, providers will be evaluated on the basis of quality and cost efficiency and ultimately receive adjusted reimbursement as per their performance. Although current performance metrics do not incorporate patient-reported outcome measures (PROMs), many wonder whether and how PROMs will eventually fit into value-based payment reform. On November 17, 2016, the second annual Patient-Reported Outcomes in Healthcare Conference brought together international stakeholders across all health care disciplines to discuss the potential role of PROs in value-based health care reform. The purpose of this article was to summarize the findings from this conference in the context of recent literature and guidelines to inform implementation of PROs in value-based payment models. Recommendations for evaluating key perspectives and measurement goals are made to facilitate appropriate use of PROMs to best benefit and amplify the voice of our patients.     

Overcoming disparities in U.S. health care

Disparities in U.S. health care result from a complex mixture of systemic quality and access problems intertwined with historic injury. The many dimensions of health disparities include race, ethnicity, socioeconomic status, and geography. It is critically important for policymakers to define the problem correctly so that our solutions address their intended goal-health security for all regardless of socioeconomic characteristics. Further, U.S. efforts to eliminate disparities must also be part of a broader effort to transform health care and thus must focus, first and foremost, on improving the quality of care delivered to the individual patient.     

Looking abroad for changes to the U.S. health care system

With the U.S. health care system in crisis, policy-makers and analysts in this country are looking seriously at foreign systems for clues to how to restructure our own. And those experts are turning away from the centrally controlled Canadian and British health care systems as models for our own, and looking toward systems such as Germany's and Australia's, which offer greater choice and more diverse health care markets.     

The pricing of U.S. hospital services: chaos behind a veil of secrecy

Although Americans and foreigners alike tend to think of the U.S. health care system as being a "market-driven" system, the prices actually paid for health care goods and services in that system have remained remarkably opaque. This paper describes how U.S. hospitals now price their services to the various third-party payers and self-paying patients, and how that system would have to be changed to accommodate the increasingly popular concept of "consumer-directed health care."     

Adolescent Health: A Report to the U.S. Congress

This article reports findings from an assessment by the Office of Technology Assessment (OTA), an analytical arm of the U.S. Congress. In brief, OTA found the conventional wisdom that American adolescents as a group are so healthy that they do not require health and related services is not justified. Even more disturbing, U.S. adolescents often face formidable barriers in trying to obtain health care. OTA suggested that Congress could act to 1) increase adolescents' access to health care, most effectively by supporting school- or community-based comprehensive health services specifically for adolescents, 2) restructure and reinvigorate the federal role in adolescent health, most visibly by creating an office of adolescent health in the U.S. Executive branch, and 3) improve adolescents' social environments, by providing more support to the families of adolescents, limiting adolescents' access to firearms, supporting the expansion of recreational opportunities for adolescents, and further supporting opportunities for community service. Congressional actions taken since the release of OTA's report are summarized.     

Physical and mental health characteristics of U.S.- and foreign-born adults: United States, 1998-2003

OBJECTIVE: This report presents national prevalence estimates of selected measures of physical health status and limitations, health care access and utilization, and mental health status among the civilian noninstitutionalized population of U.S.- and foreign-born adults aged 18 years and over in four race-ethnicity groups in the United States. METHODS: The estimates in this report were derived from the Family Core and Sample Adult components of the 1998-2003 National Health Interview Surveys, conducted annually by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). Estimates were generated and comparisons conducted using the SUDAAN statistical package to account for the complex survey sample design. Data were age adjusted to the 2000 U.S. standard population. RESULTS: In general, the foreign-born population was younger, less likely to have a high school diploma, more likely to be poor, heavily concentrated in the central cities of metropolitan areas, and more likely to live in large families, compared with their U.S.-born counterparts. Hispanic immigrants were the least likely to have health insurance or to have a usual source of health care compared with other immigrant groups. Non-Hispanic black and Hispanic adults, regardless of nativity, were more likely to be obese than non-Hispanic white and non-Hispanic Asian adults. However, non-Hispanic black and Hispanic immigrant adults were significantly less likely to be obese than their U.S.-born counterparts. Hispanic immigrants were more likely to be obese the longer they lived in the United States. Foreign-born nonHispanic black and Hispanic immigrant adults experienced fewer symptoms of serious psychological distress compared with their U.S.-born counterparts. CONCLUSIONS: There are significant differences in physical health status and mental health status among U.S.-born and foreign-born adults. Foreign-born adults enjoy considerable advantages over their U.S.-born counterparts for many health measures despite limited access to health care and unfavorable sociodemographic characteristics. Differences in the impact of length of stay in the United States on immigrant health suggest that the role of acculturation in understanding immigrant health is complex and may differ for various race/ethnicity groups.     

Employer-Sponsored Insurance, Health Care Cost Growth, and the Economic Performance of U.S. Industries

Objective. To estimate the effect of growth in health care costs that outpaces gross domestic product (GDP) growth ("excess" growth in health care costs) on employment, gross output, and value added to GDP of U.S. industries.
Study Setting. We analyzed data from 38 U.S. industries for the period 1987–2005. All data are publicly available from various government agencies.
Study Design. We estimated bivariate and multivariate regressions. To develop the regression models, we assumed that rapid growth in health care costs has a larger effect on economic performance for industries where large percentages of workers receive employer-sponsored health insurance (ESI). We used the estimated regression coefficients to simulate economic outcomes under alternative scenarios of health care cost inflation.
Results. Faster growth in health care costs had greater adverse effects on economic outcomes for industries with larger percentages of workers who had ESI. We found that a 10 percent increase in excess growth in health care costs would have resulted in 120,803 fewer jobs, US$28,022 million in lost gross output, and US$14,082 million in lost value added in 2005. These declines represent 0.17 to 0.18 percent of employment, gross output, and value added in 2005.
Conclusion. Excess growth in health care costs is adversely affecting the economic performance of U.S. industries.     

Report from the United States: the U.S. health crisis deepens amid rising inequality--a review of data, fall 2011

This report presents information on the state of the U.S. health system in late 2011. The authors include data on the uninsured and the underinsured and their access to health care, socioeconomic inequality in care, the rising costs of the U.S. health system, and the role of corporate money in health care, with special reference to the pharmaceutical industry and the hospice industry. They also provide updates on Medicaid and Medicare and on the new federal health care law. Some information on health care systems elsewhere in the world is also included.