The cost of insuring the uninsured in the U.S.

Objectives: This study included two overarching objectives. Through a systematic review of the literature published between 1990 and 2012, the first objective aimed to assess whether insuring the uninsured would result in higher costs compared to insuring the currently insured. Studies that quantified the actual costs associated with insuring the uninsured in the U.S. were included. Based upon 2009 data from the Medical Expenditure Panel Survey (MEPS), the second objective aimed to assess and compare the self-reported health of populations with four different insurance statuses. The second part of this study involved a secondary data analysis of both currently insured and currently uninsured individuals who participated in the MEPS in 2009. The null hypothesis was that there were no differences across the four categories of health insurance status for self-reported health status and healthcare service use. The alternative hypothesis was that were differences across the four categories of health insurance status for self-reported health status and healthcare service use. Methods: For the systematic review, three databases were searched using search terms to identify studies that actually quantified the cost of insuring the uninsured. Thirteen studies were selected, discussed, and summarized in tables. For the secondary data analysis of MEPS data, this study compared four categories of health insurance status: (1) currently uninsured persons who will become eligible for Medicaid under the Patient Protection and Affordable Care Act (PPACA) healthcare reforms in 2014; (2) currently uninsured persons who will be required to buy private insurance through the PPACA health insurance exchanges in 2014; (3) persons currently insured under Medicaid or SCHIP; and (4) persons currently insured with private insurance. The four categories were compared on the basis of demographic information, health status information, and health conditions with relatively high prevalence. Chi-square tests were run to determine if there were differences between the four groups in regard to health insurance status and health status. With some exceptions, the two currently insured groups had worse self-reported health status compared to the two currently uninsured groups. Results: The thirteen studies that met the inclusion criteria for the systematic review included: (1) three cost studies from 1993, 1995, and 1997; (2) four cost studies from 2001, 2003, and 2004; (3) one study of disabilities and one study of immigrants; (4) two state specific studies of uninsured status; and (5) two current studies of healthcare reform. Of the thirteen studies reviewed, four directly addressed the study question about whether insuring the uninsured was more or less expensive than insuring the currently insured. All four of the studies provided support for the study finding that the cost of insuring the uninsured would generally not be higher than insuring those already insured. One study indicated that the cost of insuring the uninsured would be less expensive than insuring the population currently covered by Medicaid, but more expensive to insure than the populations of those covered by employer-sponsored insurance and non-group private insurance. While the nine other studies included in the systematic review discussed the costs associated with insuring the uninsured population, they did not directly compare the costs of insuring the uninsured population with the costs associated with insuring the currently insured population. For the MEPS secondary data analysis, the results of the chi-square tests indicated that there were differences in the distribution of disease status by health insurance status. As anticipated, with some exceptions, the uninsured reported lower rates of disease and healthcare service use. However, for the variable attention deficit disorder, the uninsured reported higher disease rates than the two insured groups. Additionally, for the variables high blood pressure, high cholesterol, and joint pain, the currently insured under Medicaid or SCHIP group reported a lower rate of disease than the two currently insured groups. This result may be due to the lower mean age of the currently insured under Medicaid or SCHIP group. Conclusion: Based on this study, with some exceptions, the costs for insuring the uninsured should not exceed healthcare-related costs for insuring the currently uninsured. The results of the systematic review indicated that the U.S. is already paying some of the costs associated with insuring the uninsured. PPACA will expand health insurance coverage to millions of Americans who are currently uninsured, as the individual mandate and insurance market reforms will require. Because many of the currently uninsured are relatively healthy young persons, the costs associated with expanding insurance coverage to the uninsured are anticipated to be relatively modest. However, for the purposes of construing these results, it is important to note that once individuals obtain insurance, it is anticipated that they will use more healthcare services, which will increase costs. (Abstract shortened by UMI.)^

Improving disclosure of medical errors: Including patients and family members in the disclosure process

Over the last decade, adverse events and medical errors have become a main focus of interest for the standards of quality and safety in the U.S. healthcare system (Weinstein & Henderson, 2009). Particularly when a medical error occurs, the disclosure of medical errors and its practices have become a focal point of the healthcare process. Patients and family members who have experienced a medical error might be able to provide knowledge and insight on how to improve the disclose process. However, patient and family member are not typically involved in the disclosure process, thus their experiences go unnoticed. ^ The purpose of this research was to explore how best to include patients and family members in the disclosure process regarding a medical error. The research consisted of 28 qualitative interviews from three stakeholder groups: Hospital Administrators, Clinical Service Providers, and Patients and Family Members. They were asked for their ideas and suggestions on how best to include patients and family members in the disclosure process. Framework Analysis was used to analyze this data and find prevalent themes based on the primary research question. A secondary aim was to index categories created based on the interviews that were collected. Data was used from the Texas Disclosure and Compensation Study with Dr. Eric Thomas as the Principal Investigator. Full acknowledgement of access to this data is given to Dr. Thomas. ^ The themes from the research revealed that each stakeholder group was interested and open to including patients and family members in the disclosure process and that the disclosure process should not be a "one-way" avenue. The themes gave many suggestions regarding how to best include patients and family members in the disclosure process of a medical error. Secondary aims revealed several ways to assess the ideas and suggestion given by the stakeholders. Overall, acceptability of getting the perspective of patients and family members was the most common theme. Comparison of each stakeholder group revealed that including patients and family members would be beneficial to improving hospital disclosure practices. ^ Conclusions included a list of recommendations and measureable appropriate strategies that could provide hospital with key stakeholders insights on how to improve their disclosure process. Sharing patients and family members experience with healthcare providers can encourage a shift in culture where patients are valued and active in participating in hospital practices. To my knowledge, this research is the very first of its kind and moves the disclosure process conversation forward in a patient-family member inclusion direction that will assist in improving disclosure practices. Future research should implement and evaluate the success of the various inclusion strategies.^

Estimates of hospital and physician costs of epilepsy in the United States for 1995 comparing the provider -based survey method and a patient -based medical charts and billing method

This investigation compares two different methodologies for calculating the national cost of epilepsy: provider-based survey method (PBSM) and the patient-based medical charts and billing method (PBMC&BM). The PBSM uses the National Hospital Discharge Survey (NHDS), the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS) as the sources of utilization. The PBMC&BM uses patient data, charts and billings, to determine utilization rates for specific components of hospital, physician and drug prescriptions. ^ The 1995 hospital and physician cost of epilepsy is estimated to be $722 million using the PBSM and $1,058 million using the PBMC&BM. The difference of $336 million results from $136 million difference in utilization and $200 million difference in unit cost. ^ Utilization. The utilization difference of $136 million is composed of an inpatient variation of $129 million, $100 million hospital and $29 million physician, and an ambulatory variation of $7 million. The $100 million hospital variance is attributed to inclusion of febrile seizures in the PBSM, $−79 million, and the exclusion of admissions attributed to epilepsy, $179 million. The former suggests that the diagnostic codes used in the NHDS may not properly match the current definition of epilepsy as used in the PBMC&BM. The latter suggests NHDS errors in the attribution of an admission to the principal diagnosis. ^ The $29 million variance in inpatient physician utilization is the result of different per-day-of-care physician visit rates, 1.3 for the PBMC&BM versus 1.0 for the PBSM. The absence of visit frequency measures in the NHDS affects the internal validity of the PBSM estimate and requires the investigator to make conservative assumptions. ^ The remaining ambulatory resource utilization variance is $7 million. Of this amount, $22 million is the result of an underestimate of ancillaries in the NHAMCS and NAMCS extrapolations using the patient visit weight. ^ Unit cost. The resource cost variation is $200 million, inpatient is $22 million and ambulatory is $178 million. The inpatient variation of $22 million is composed of $19 million in hospital per day rates, due to a higher cost per day in the PBMC&BM, and $3 million in physician visit rates, due to a higher cost per visit in the PBMC&BM. ^ The ambulatory cost variance is $178 million, composed of higher per-physician-visit costs of $97 million and higher per-ancillary costs of $81 million. Both are attributed to the PBMC&BM's precise identification of resource utilization that permits accurate valuation. ^ Conclusion. Both methods have specific limitations. The PBSM strengths are its sample designs that lead to nationally representative estimates and permit statistical point and confidence interval estimation for the nation for certain variables under investigation. However, the findings of this investigation suggest the internal validity of the estimates derived is questionable and important additional information required to precisely estimate the cost of an illness is absent. ^ The PBMC&BM is a superior method in identifying resources utilized in the physician encounter with the patient permitting more accurate valuation. However, the PBMC&BM does not have the statistical reliability of the PBSM; it relies on synthesized national prevalence estimates to extrapolate a national cost estimate. While precision is important, the ability to generalize to the nation may be limited due to the small number of patients that are followed. ^

Deep drilling of glaciers: Russian projects in the Arctic (1975-1995)

The data collection "Deep Drilling of Glaciers: Soviet-Russian projects in Arctic, 1975-1995" was collected by the following basic considerations: - compilation of deep (>100 m) drilling projects on Arctic glaciers, using data of (a) publications; (b) archives of IGRAN; (c) personal communication of project participants; - documentation of parameters, references. Accuracy of data and techniques applied to determine different parameters are not evaluated. The accuracy of some geochemical parameters (up to 1984 and heavy metalls) is uncertain. Most reconstructions of ice core age and of annual layer thickness are discussed; - digitizing of published diagrams (in case, when original numerical data were lost) and subsequent data conversion to equal range series and adjustment to the common units. Therefore, the equal-range series were calculated from original data or converted from digitized chart values as indicated in the metadata. For the methodological purpose, the equal-range series obtained from original and reconstructed data were compared repeatedly; the systematic difference was less then 5-7%. Special attention should be given to the fact, that the data for individual ice core parameters varies, because some parameters were originally measured or registered. Parameters were converted in equal-range series using 2 m steps; - two or more parameter values were determined, then the mean-weighted (i.e. accounting the sample length) value is assigned to the entire interval; - one parameter value was determined, measured or registered independently from the parameter values in depth intervals which over- and underlie it, then the value is assigned to the entire interval; - one parameter value was determined, measured or registered for two adjoining depth intervals, then the specific value is assigned to the depth interval, which represents >75% of sample length ; if each of adjoining depth intervals represents <75% of sample length, then the correspondent parameter value is assigned to both intervals of depth. This collection of ice core data (version 2000) was made available through the EU funded QUEEN project by S.M. Arkhipov, Moscow.

Vocation in the insertion of the university student and the graduate

The work plan aims at deepening the analysis of the theoretic assumptions which support the practice in Vocational Guidance: analyzing the incidence of endogenous and exogenous factors both in the election and studying of a particular course of study and in the occupational resolution of the graduate. This analysis enables the revision and the new theoretic conceptualization which is afterwards transferred to the course, and to different groups and provincial institutions where the practice of Vocational Guidance occurs, as well as to other schools in the Northwest provinces of Argentina. Semiotic analysis, statistical elaboration and the research-action approach which, while surveying data renders a service to the milieu, provide the base for the project. Said project focuses on the following individuals: 1) freshmen, who offer us the following aspects to be considered: a) factors which either favor or hinder the insertion of the students attending the first years of the course; b) the conditions making up the learning situation in each subject, from the teaching point of view; c) the influence of institutional dimension in the insertion process; 2) graduands: the characteristics of the situation following graduation from University, those of the labor field and the different ways of gaining access to it are investigated. This analysis is carried out in the courses of study of Psychology and English (education of Professionals in English and English for Professionals).

Perspectives on guidance and social inclusion in a global society

The world is changing rapidly. People today face numerous challenges in achieving a meaningful and fulfilling life. In many countries, there are enormous systemic barriers to address, such as: massive unemployment, HIV/AIDS, social disintegration, and inadequate infrastructure. One job for life is over. For many it never existed. Old metaphors and old models of career development no longer apply. New ways of thinking about careers are necessary, that take into account the context in which people are living, the reality of today's labour market, and the fact people's career-life journey contains many branching paths, barriers, and obstacles, but also allies and sources of assistance. Flexibility is important, as is keeping options open and making sure the journey is meaningful. Guidance professionals need to begin early, working with other professionals and those seeking assistance to develop attitudes that facilitate people taking charge of their own career-life paths. People need a vision for their life that will drive a purposeful approach to career-life planning and avoid floundering. Helping people achieve that direction can be most effectively accomplished when policy makers and practitioners work together to ensure that effective and accessible services are available for those who need them and when a large part of focus in on addressing the context in which marginalized people work and live.

Vocation in the insertion of the university student and the graduate

The work plan aims at deepening the analysis of the theoretic assumptions which support the practice in Vocational Guidance: analyzing the incidence of endogenous and exogenous factors both in the election and studying of a particular course of study and in the occupational resolution of the graduate. This analysis enables the revision and the new theoretic conceptualization which is afterwards transferred to the course, and to different groups and provincial institutions where the practice of Vocational Guidance occurs, as well as to other schools in the Northwest provinces of Argentina. Semiotic analysis, statistical elaboration and the research-action approach which, while surveying data renders a service to the milieu, provide the base for the project. Said project focuses on the following individuals: 1) freshmen, who offer us the following aspects to be considered: a) factors which either favor or hinder the insertion of the students attending the first years of the course; b) the conditions making up the learning situation in each subject, from the teaching point of view; c) the influence of institutional dimension in the insertion process; 2) graduands: the characteristics of the situation following graduation from University, those of the labor field and the different ways of gaining access to it are investigated. This analysis is carried out in the courses of study of Psychology and English (education of Professionals in English and English for Professionals).

Perspectives on guidance and social inclusion in a global society

The world is changing rapidly. People today face numerous challenges in achieving a meaningful and fulfilling life. In many countries, there are enormous systemic barriers to address, such as: massive unemployment, HIV/AIDS, social disintegration, and inadequate infrastructure. One job for life is over. For many it never existed. Old metaphors and old models of career development no longer apply. New ways of thinking about careers are necessary, that take into account the context in which people are living, the reality of today's labour market, and the fact people's career-life journey contains many branching paths, barriers, and obstacles, but also allies and sources of assistance. Flexibility is important, as is keeping options open and making sure the journey is meaningful. Guidance professionals need to begin early, working with other professionals and those seeking assistance to develop attitudes that facilitate people taking charge of their own career-life paths. People need a vision for their life that will drive a purposeful approach to career-life planning and avoid floundering. Helping people achieve that direction can be most effectively accomplished when policy makers and practitioners work together to ensure that effective and accessible services are available for those who need them and when a large part of focus in on addressing the context in which marginalized people work and live.

Vocation in the insertion of the university student and the graduate

The work plan aims at deepening the analysis of the theoretic assumptions which support the practice in Vocational Guidance: analyzing the incidence of endogenous and exogenous factors both in the election and studying of a particular course of study and in the occupational resolution of the graduate. This analysis enables the revision and the new theoretic conceptualization which is afterwards transferred to the course, and to different groups and provincial institutions where the practice of Vocational Guidance occurs, as well as to other schools in the Northwest provinces of Argentina. Semiotic analysis, statistical elaboration and the research-action approach which, while surveying data renders a service to the milieu, provide the base for the project. Said project focuses on the following individuals: 1) freshmen, who offer us the following aspects to be considered: a) factors which either favor or hinder the insertion of the students attending the first years of the course; b) the conditions making up the learning situation in each subject, from the teaching point of view; c) the influence of institutional dimension in the insertion process; 2) graduands: the characteristics of the situation following graduation from University, those of the labor field and the different ways of gaining access to it are investigated. This analysis is carried out in the courses of study of Psychology and English (education of Professionals in English and English for Professionals).

Perspectives on guidance and social inclusion in a global society

The world is changing rapidly. People today face numerous challenges in achieving a meaningful and fulfilling life. In many countries, there are enormous systemic barriers to address, such as: massive unemployment, HIV/AIDS, social disintegration, and inadequate infrastructure. One job for life is over. For many it never existed. Old metaphors and old models of career development no longer apply. New ways of thinking about careers are necessary, that take into account the context in which people are living, the reality of today's labour market, and the fact people's career-life journey contains many branching paths, barriers, and obstacles, but also allies and sources of assistance. Flexibility is important, as is keeping options open and making sure the journey is meaningful. Guidance professionals need to begin early, working with other professionals and those seeking assistance to develop attitudes that facilitate people taking charge of their own career-life paths. People need a vision for their life that will drive a purposeful approach to career-life planning and avoid floundering. Helping people achieve that direction can be most effectively accomplished when policy makers and practitioners work together to ensure that effective and accessible services are available for those who need them and when a large part of focus in on addressing the context in which marginalized people work and live.

(Table 1) Geochemical and geothermometry data from fibrous calcite vein fills in the Dabashan Fold Belt, China

Fibrous calcite veins with organic inclusions have been widely considered as indicators of oil and gas generation and migration under overpressure. Abundant fibrous calcite veins containing organic-bearing inclusions occur in faulted Lower Paleozoic through Triassic hydrocarbon source rocks in the Dabashan Foreland Belt (DBF). d13CPDB and d18OPDB values of the fibrous calcite range from - 4.8 to -1.9 to per mil and - 12.8 to - 8.4 per mil respectively, which is lighter than that of associated carbonate host rocks ranging from - 1.7 to + 3.1 per mil and - 8.7 to - 4.5 per mil. A linear relationship between d13CPDB and d18OPDB indicates that the calcite veins were precipitated from a mixture of basinal and surface fluids. The fibrous calcite contains a variety of inclusions, such as solid bitumen, methane bearing all-liquid inclusions, and vapor-liquid aqueous inclusions. Homogenization temperatures of aqueous inclusions range from 140 to 196° with an average of 179°. Salinities of aqueous inclusions average 9.7 wt% NaCl. Independent temperatures from bitumen reflectance and inclusion phase relationships of aqueous and methane inclusions were used to determine fluid pressures. Results indicate high pressures, elevated above typical lithostatic confining pressure, from 150 to 200 MPa. The elevated salinity and high temperature and pressure conditions of the fibrous calcite veins argue against an origin solely from burial overpressure resulting from clay transformation and dehydration reactions. Instead fluid inclusion P-T data and geochemistry results and regional geology indicate abnormally high pressures during fluid migration. These findings indicate that tectonic stress generated fracture and fault fluid pathways and caused migration of organic bearing fluids from the DBF during the Yanshan orogeny.

Effects of increasing levels of pea hulls in the diet on productive performance, development of the gastrointestinal tract, and nutrient retention of broilers from one to eighteeen days of age

The effects of inclusion of pea hulls (PH) in the diet on growth performance, development of the gastrointestinal tract and nutrient retention were studied in broilers from 1 to 18d of age. There were a control diet based on low fibre ingredients (69.3 total dietary fibre (16.1g crude fibre/kg)) and three additional diets that resulted from the dilution of the basal diet with 25, 50 and 75g PH/kg (81.2, 93.2, and 105.1g total dietary fibre/kg diet, respectively). Each treatment was replicated six times and the experimental unit was a cage with 12 chicks. Growth performance, development of the gastrointestinal tract and the coefficients of total tract apparent retention (CTTAR) of nutrients were recorded at 6, 12 and 18d of age. In addition, jejunal morphology was measured at 12 and 18d and the coefficients of apparent ileal digestibility (CAID) of nutrients at 18d of age. Pea hulls inclusion affected all the parameters studied. The inclusion of 25 and 50g PH/kg diet improved growth performance as compared to the control diet. The relative weight (g/kg body weight) of proventriculus (P≤0.01), gizzard (P≤0.001) and ceca (P≤0.05) increased linearly as the level of PH in the diet increased. The inclusion of PH affected quadratically (P≤0.01) villus height:crypt depth ratio with the highest value shown at 25g PH/kg. In general, the CTTAR and CAID of nutrients increased linearly and quadratically (P≤0.05) with increasing levels of PH, showing maximum values with PH level between 25 and 50g/kg diet. We conclude that the size of the digestive organs increases with increasing levels of PH in the diet. In general, the best performance and nutrient digestibility values were observed with levels of PH within the range of 25 and 50g/kg. Therefore, young broilers have a requirement for a minimum amount of dietary fibre. When pea hulls are used as a source of fibre, the level of total dietary fibre required for optimal performance is within the range of 81.2–93.2g/kg diet (25.6–35.0g crude fibre/kg diet). An excess of total dietary fibre (above 93.2g/kg diet) might reduce nutrient digestibility and growth performance to values similar to those observed with the control diet.

Growth response of broilers to lysine levels and hydrolyzed porcine digestive mucosa (Palbio) inclusion in diet from 1 to 21 d of age

Palbio (PAL, Palbio 50 RD, Bioibérica, Spain) is a protein concentrate based on hydrolyzed porcine digestive mucosa dried under a fluid bed system over a soybean carrier, currently used in piglet feeds. The digestibility of PAL is very high and the product may be an excellent source of protein for young chicks. An experiment was conducted with 1,280 straight-run one-d-old Ross 308 chicks to evaluate the growth response of broilers to dietary inclusion of PAL.

Survey and brain storming studies about machines, constructions, human and environmental risk consideration in the careers of the Universidad Politécnica of Madrid

The Universidad Politécnica of Madrid (UPM) includes schools and faculties that were for engineering degrees, architecture and computer science, that are now in a quick EEES Bolonia Plan metamorphosis getting into degrees, masters and doctorate structures. They are focused towards action in machines, constructions, enterprises, that are subjected to machines, human and environment created risks. These are present in actions such as use loads, wind, snow, waves, flows, earthquakes, forces and effects in machines, vehicles behavior, chemical effects, and other environmental factors including effects of crops, cattle and beasts, forests, and varied essential economic and social disturbances. Emphasis is for authors in this session more about risks of natural origin, such as for hail, winds, snow or waves that are not exactly known a priori, but that are often considered with statistical expected distributions giving extreme values for convenient return periods. These distributions are known from measures in time, statistic of extremes and models about hazard scenarios and about responses of man made constructions or devices. In each engineering field theories were built about hazards scenarios and how to cover for important risks. Engineers must get that the systems they handle, such as vehicles, machines, firms or agro lands or forests, obtain production with enough safety for persons and with decent economic results in spite of risks. For that risks must be considered in planning, in realization and in operation, and safety margins must be taken but at a reasonable cost. That is a small level of risks will often remain, due to limitations in costs or because of due to strange hazards, and maybe they will be covered by insurance in cases such as in transport with cars, ships or aircrafts, in agro for hail, or for fire in houses or in forests. These and other decisions about quality, security for men or about business financial risks are sometimes considered with Decision Theories models, using often tools from Statistics or operational Research. The authors have done and are following field surveys about risk consideration in the careers in UPM, making deep analysis of curricula taking into account the new structures of degrees in the EEES Bolonia Plan, and they have considered the risk structures offered by diverse schools of Decision theories. That gives an aspect of the needs and uses, and recommendations about improving in the teaching about risk, that may include special subjects especially oriented for each career, school or faculty, so as to be recommended to be included into the curricula, including an elaboration and presentation format using a multi-criteria decision model.

Methodological Proposal for Teamwork Evaluation in the field of training Project Management.

Teamwork, is one of the abilities that today is highly valued in the professional arena with a great importance for various personal and interpersonal skills associated with it. In this context, the Technical University of Madrid, is developing a coordinated educational innovation project, which main objective is to develop methodological and assessment tools for the acquisition of personal skills necessary to improve the employability of graduates and their skills for project management. Within this context, this paper proposes a methodology composed of various activities and indicators, as well as specific assessment instruments linked to the teamwork competence. Through a series of systematic steps it was allowed the design of an instrument and construction of a scale for measuring the competence of teamwork. The practical application of the methodology has been carried out in Projects lectures from different Schools of Engineering at the Technical University of Madrid, which results are presented in this document as a pilot experience. Results show the various aspects and methods that teachers should consider in evaluating the competence of the work, including analysis of the quality of results, through reliability and construct validity. On the other hand, show the advantages of applying this methodology in the field of project management teaching.