This paper reports on a national survey of Medicaid managed care plans sponsored by safety-net pr... more This paper reports on a national survey of Medicaid managed care plans sponsored by safety-net provider organizations that have a mission of service to low-income populations. We identified ninety-nine safety-net plans and obtained data from eighty of them regarding their sponsorship, age and size, relationships to sponsors, managed care practices, and measures of success. Most plans engage in active managed care and have achieved at least some of their goals. However, 60 percent of plans lost money in 1997, and economic trends have been unfavorable.
To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surg... more To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surgical procedures with documented associations between volume and mortality. Cross-sectional regression analysis. New York City area hospital discharge data, 2001-2004. Adults from 4 racial/ethnic categories (white, black, Asian, and Hispanic) who underwent surgery for cancer (breast, colorectal, gastric, lung, or pancreatic resection), cardiovascular disease (coronary artery bypass graft, coronary angioplasty, abdominal aortic aneurysm repair, or carotid endarterectomy), or orthopedic conditions (total hip replacement). Treatment by a high-volume surgeon at a high-volume hospital. There were 133 821 patients who underwent 1 of the 10 procedures. For 9 of the 10 procedures, black patients were significantly (P < .05) less likely (after adjustment for sociodemographic characteristics, insurance type, proximity to high-volume providers, and comorbidities) to be operated on by a high-volum...
Inquiry : a journal of medical care organization, provision and financing, 2006
Medicare and Social Security often are assumed to provide universal coverage for the population a... more Medicare and Social Security often are assumed to provide universal coverage for the population age 65 and older. Evidence from New York City raises doubts. Data from the Statewide Planning and Research Cooperative System, the Centers for Medicare and Medicaid Services, the Social Security Administration, and the U.S. Bureau of the Census provide evidence that 16% to 20% of New York City residents age 65 and older lack such coverage. Noncoverage is not unique to this city, but it may be particularly common there. Noncoverage is pronounced in, but not limited to, certain immigrant groups. Because the population share covered by Medicare increases with age and most hospitalizations not covered by Medicare are paid by Medicaid, Medicaid gradually may be replacing Medicare as the payer for hospitalizations for a substantial share of the 65+ population in New York City.
Schedule H collects expenditures for charity care and &amp;amp;quot;certain other community b... more Schedule H collects expenditures for charity care and &amp;amp;quot;certain other community benefits,&amp;amp;quot; including unreimbursed costs of Medicaid and other means-tested programs, as well as expenses for community health improvement, health professions education, subsidized health services, research, ...
European countries have smaller shares of undocumented migrants than does the United States, but ... more European countries have smaller shares of undocumented migrants than does the United States, but these individuals have substantial needs for medical care and present difficult policy challenges even in countries with universal health insurance systems. Recent European studies show that policies in most countries provide for no more than emergency services for undocumented migrants. Smaller numbers of countries provide more services or allow undocumented migrants who meet certain requirements access to the same range of services as nationals. These experiences show it is possible to improve access to care for undocÂumented migrants. Strategies vary along three dimensions: (1) focusing on segments of the population, like children or pregnant women; (2) focusing on types of services, like preventive services or treatment of infectious diseases; or (3) using specific funding policies, like allowing undocumented migrants to purchase insurance.
Inquiry : a journal of medical care organization, provision and financing, 2014
Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose ... more Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.
Research has shown that the United States lags many other countries in the adoption of electronic... more Research has shown that the United States lags many other countries in the adoption of electronic health records (EHRs). The U.S. has now embarked on a major effort to achieve "meaningful use" of health information technology by clinicians and hospitals. This issue brief describes the extent of meaningful use in three countries with very high levels of health information technology adoption—Denmark, New Zealand, and Sweden. While all three have achieved high levels of meaningful use, none has reached 100 percent in all categories. The brief find[sic] high levels of meaningful use for EHR items and substantial information-sharing with other organizations or health authorities, although less information is shared with patients. Insights that may prove useful to the United States include providing economic incentives to encourage adoption and designating an organization to take responsibility for standardization and interoperability.
... Recent research has focused on the rapid proliferation of international joint ventures intran... more ... Recent research has focused on the rapid proliferation of international joint ventures intransformational economies (those in transition from cen ... Virtually no research on the relation-ships among bargaining power, control, and performance in joint ventures in China has been ...
Health plans formed by safety-net providers serve large numbers of Medicaid beneficiaries. Throug... more Health plans formed by safety-net providers serve large numbers of Medicaid beneficiaries. Through a series of case studies, we examined the care management tools used by leading safety-net plans. These plans do not rely on the coercive, command-style tools of managed care. They rely instead on tools that emphasize partnership with provid- ers: sharing data about practice patterns, using provider
Case studies suggest that important changes in the composition and structure of boards of trustee... more Case studies suggest that important changes in the composition and structure of boards of trustees of non-profit organisations have occurred in recent decades. The nature of these changes, and how they may vary across industry and locale, are not well documented. This pilot study compares changes in structure and board membership of three elite non-profit organisations in two cities at three points in time: 1925, 1955 and 1985. This study focuses on governing boards of the major art museum, largest non-profit hospital and local United Way of Boston and Cleveland. Board members' biographical data are used to assess models of board diversification based on environmental pressures and changes in local elites. We find evidence that trusteeship varies historically, regionally and across industries, and we set the stage for broader-based empirical comparative work on changes in non-profit boards of trustees.
The authors argue that declining legitimacy of the nonprofit sector in American society can be tr... more The authors argue that declining legitimacy of the nonprofit sector in American society can be traced to a limited public understanding of nonprofit enterprise. In this article, they explore the nature and correlates of ownership-related expectations in medical care. Data from a new national survey document that most Americans believe that ownership affects medical care. However, about a third of the public does not understand ownership; those who do not have decidedly less favorable attitudes toward nonprofits. Expectations for nonprofits are more positive among those who feel vulnerable to bad outcomes in medical care, but are substantially more negative among minority groups. Using an experimental design incorporated into the survey, the authors demonstrate that having additional information about ownership improves expectations about nonprofit performance but to varying degrees, depending on the content of the explanation, the particular dimension of performance, and the level of prior understanding.
Journal of Urban Health: Bulletin of the New York Academy of Medicine, 2002
This article provides new empirical data about the viability and the care management activities o... more This article provides new empirical data about the viability and the care management activities of Medicaid managed-care plans sponsored by provider organizations that serve Medicaid and other low-income populations. Using survey and case study methods, we studied these "safety-net" health plans in 1998 and 2000. Although the number of safety-net plans declined over this period, the surviving plans were larger and enjoying greater financial success than the plans we surveyed in 1998. We also found that, based on a partnership with providers, safety-net plans are moving toward more sophisticated efforts to manage the care of their enrollees. Our study suggests that, with supportive state policies, safety-net plans are capable of remaining viable. Contracting with safety-net plans may not be an efficient mechanism for enabling Medicaid recipients to "enter the mainstream of American health care," but it may provide states with an effective way to manage and coordinate the care of Medicaid recipients, while helping to maintain the health care safety-net for the uninsured.
The status of the primary care workforce is a major health policy concern. It is affected not onl... more The status of the primary care workforce is a major health policy concern. It is affected not only by the specialty choices of young physicians but also by decisions of physicians to leave their practices. This study examines factors that may contribute to such decisions. We analyzed data from a 2009 Commonwealth Fund mail survey of American physicians in internal medicine, family or general practice, or pediatrics to examine characteristics associated with their plans to retire or leave their practice for other reasons in the next 5 years. Just over half (53%) of the physicians age 50 years or older and 30% of physicians between age 35 and 49 years may leave their practices for these reasons. Having such plans was associated with many factors, but the strongest predictor concerned problems regarding time spent coordinating care for their patients, possibly reflecting dissatisfaction with tasks that do not require medical expertise and are not generally paid for in fee-for-service medicine. Factors that predict plans to retire differ from those associated with plans to leave practices for other reasons. Provisions of the Patient Protection and Affordable Care Act that reduce the number of uninsured patients as well as innovations such as medical homes and accountable care organizations may reduce pressures that lead to attrition in the primary care workforce. Reasons why primary care physicians&amp;amp;amp;amp;amp;amp;#39; decide to leave their practices deserve more attention from researchers and policy makers.
Journal of Health Care for the Poor and Underserved, 2005
Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure ... more Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure in Medicaid managed care has received less attention. Recent reports indicate that children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s tenures in health plans are far shorter than tenures in Medicaid itself, but explanations for the difference are not given. In the research reported here, we conducted case studies in five states to determine difference in tenure and reasons for the difference. Our investigation showed that children were enrolled in Medicaid two to four months longer than in specific Medicaid health plans. The major reasons for the gap were retroactive enrollment in Medicaid and delays in selecting a health plan. Frequent and burdensome Medicaid renewal processes exacerbate the problem, resulting in breaks in enrollment and the need to reenroll. The task of managing the care of Medicaid children is difficult without adequate tenures in health plans.
This paper reports on a national survey of Medicaid managed care plans sponsored by safety-net pr... more This paper reports on a national survey of Medicaid managed care plans sponsored by safety-net provider organizations that have a mission of service to low-income populations. We identified ninety-nine safety-net plans and obtained data from eighty of them regarding their sponsorship, age and size, relationships to sponsors, managed care practices, and measures of success. Most plans engage in active managed care and have achieved at least some of their goals. However, 60 percent of plans lost money in 1997, and economic trends have been unfavorable.
To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surg... more To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surgical procedures with documented associations between volume and mortality. Cross-sectional regression analysis. New York City area hospital discharge data, 2001-2004. Adults from 4 racial/ethnic categories (white, black, Asian, and Hispanic) who underwent surgery for cancer (breast, colorectal, gastric, lung, or pancreatic resection), cardiovascular disease (coronary artery bypass graft, coronary angioplasty, abdominal aortic aneurysm repair, or carotid endarterectomy), or orthopedic conditions (total hip replacement). Treatment by a high-volume surgeon at a high-volume hospital. There were 133 821 patients who underwent 1 of the 10 procedures. For 9 of the 10 procedures, black patients were significantly (P < .05) less likely (after adjustment for sociodemographic characteristics, insurance type, proximity to high-volume providers, and comorbidities) to be operated on by a high-volum...
Inquiry : a journal of medical care organization, provision and financing, 2006
Medicare and Social Security often are assumed to provide universal coverage for the population a... more Medicare and Social Security often are assumed to provide universal coverage for the population age 65 and older. Evidence from New York City raises doubts. Data from the Statewide Planning and Research Cooperative System, the Centers for Medicare and Medicaid Services, the Social Security Administration, and the U.S. Bureau of the Census provide evidence that 16% to 20% of New York City residents age 65 and older lack such coverage. Noncoverage is not unique to this city, but it may be particularly common there. Noncoverage is pronounced in, but not limited to, certain immigrant groups. Because the population share covered by Medicare increases with age and most hospitalizations not covered by Medicare are paid by Medicaid, Medicaid gradually may be replacing Medicare as the payer for hospitalizations for a substantial share of the 65+ population in New York City.
Schedule H collects expenditures for charity care and &amp;amp;quot;certain other community b... more Schedule H collects expenditures for charity care and &amp;amp;quot;certain other community benefits,&amp;amp;quot; including unreimbursed costs of Medicaid and other means-tested programs, as well as expenses for community health improvement, health professions education, subsidized health services, research, ...
European countries have smaller shares of undocumented migrants than does the United States, but ... more European countries have smaller shares of undocumented migrants than does the United States, but these individuals have substantial needs for medical care and present difficult policy challenges even in countries with universal health insurance systems. Recent European studies show that policies in most countries provide for no more than emergency services for undocumented migrants. Smaller numbers of countries provide more services or allow undocumented migrants who meet certain requirements access to the same range of services as nationals. These experiences show it is possible to improve access to care for undocÂumented migrants. Strategies vary along three dimensions: (1) focusing on segments of the population, like children or pregnant women; (2) focusing on types of services, like preventive services or treatment of infectious diseases; or (3) using specific funding policies, like allowing undocumented migrants to purchase insurance.
Inquiry : a journal of medical care organization, provision and financing, 2014
Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose ... more Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.
Research has shown that the United States lags many other countries in the adoption of electronic... more Research has shown that the United States lags many other countries in the adoption of electronic health records (EHRs). The U.S. has now embarked on a major effort to achieve "meaningful use" of health information technology by clinicians and hospitals. This issue brief describes the extent of meaningful use in three countries with very high levels of health information technology adoption—Denmark, New Zealand, and Sweden. While all three have achieved high levels of meaningful use, none has reached 100 percent in all categories. The brief find[sic] high levels of meaningful use for EHR items and substantial information-sharing with other organizations or health authorities, although less information is shared with patients. Insights that may prove useful to the United States include providing economic incentives to encourage adoption and designating an organization to take responsibility for standardization and interoperability.
... Recent research has focused on the rapid proliferation of international joint ventures intran... more ... Recent research has focused on the rapid proliferation of international joint ventures intransformational economies (those in transition from cen ... Virtually no research on the relation-ships among bargaining power, control, and performance in joint ventures in China has been ...
Health plans formed by safety-net providers serve large numbers of Medicaid beneficiaries. Throug... more Health plans formed by safety-net providers serve large numbers of Medicaid beneficiaries. Through a series of case studies, we examined the care management tools used by leading safety-net plans. These plans do not rely on the coercive, command-style tools of managed care. They rely instead on tools that emphasize partnership with provid- ers: sharing data about practice patterns, using provider
Case studies suggest that important changes in the composition and structure of boards of trustee... more Case studies suggest that important changes in the composition and structure of boards of trustees of non-profit organisations have occurred in recent decades. The nature of these changes, and how they may vary across industry and locale, are not well documented. This pilot study compares changes in structure and board membership of three elite non-profit organisations in two cities at three points in time: 1925, 1955 and 1985. This study focuses on governing boards of the major art museum, largest non-profit hospital and local United Way of Boston and Cleveland. Board members' biographical data are used to assess models of board diversification based on environmental pressures and changes in local elites. We find evidence that trusteeship varies historically, regionally and across industries, and we set the stage for broader-based empirical comparative work on changes in non-profit boards of trustees.
The authors argue that declining legitimacy of the nonprofit sector in American society can be tr... more The authors argue that declining legitimacy of the nonprofit sector in American society can be traced to a limited public understanding of nonprofit enterprise. In this article, they explore the nature and correlates of ownership-related expectations in medical care. Data from a new national survey document that most Americans believe that ownership affects medical care. However, about a third of the public does not understand ownership; those who do not have decidedly less favorable attitudes toward nonprofits. Expectations for nonprofits are more positive among those who feel vulnerable to bad outcomes in medical care, but are substantially more negative among minority groups. Using an experimental design incorporated into the survey, the authors demonstrate that having additional information about ownership improves expectations about nonprofit performance but to varying degrees, depending on the content of the explanation, the particular dimension of performance, and the level of prior understanding.
Journal of Urban Health: Bulletin of the New York Academy of Medicine, 2002
This article provides new empirical data about the viability and the care management activities o... more This article provides new empirical data about the viability and the care management activities of Medicaid managed-care plans sponsored by provider organizations that serve Medicaid and other low-income populations. Using survey and case study methods, we studied these "safety-net" health plans in 1998 and 2000. Although the number of safety-net plans declined over this period, the surviving plans were larger and enjoying greater financial success than the plans we surveyed in 1998. We also found that, based on a partnership with providers, safety-net plans are moving toward more sophisticated efforts to manage the care of their enrollees. Our study suggests that, with supportive state policies, safety-net plans are capable of remaining viable. Contracting with safety-net plans may not be an efficient mechanism for enabling Medicaid recipients to "enter the mainstream of American health care," but it may provide states with an effective way to manage and coordinate the care of Medicaid recipients, while helping to maintain the health care safety-net for the uninsured.
The status of the primary care workforce is a major health policy concern. It is affected not onl... more The status of the primary care workforce is a major health policy concern. It is affected not only by the specialty choices of young physicians but also by decisions of physicians to leave their practices. This study examines factors that may contribute to such decisions. We analyzed data from a 2009 Commonwealth Fund mail survey of American physicians in internal medicine, family or general practice, or pediatrics to examine characteristics associated with their plans to retire or leave their practice for other reasons in the next 5 years. Just over half (53%) of the physicians age 50 years or older and 30% of physicians between age 35 and 49 years may leave their practices for these reasons. Having such plans was associated with many factors, but the strongest predictor concerned problems regarding time spent coordinating care for their patients, possibly reflecting dissatisfaction with tasks that do not require medical expertise and are not generally paid for in fee-for-service medicine. Factors that predict plans to retire differ from those associated with plans to leave practices for other reasons. Provisions of the Patient Protection and Affordable Care Act that reduce the number of uninsured patients as well as innovations such as medical homes and accountable care organizations may reduce pressures that lead to attrition in the primary care workforce. Reasons why primary care physicians&amp;amp;amp;amp;amp;amp;#39; decide to leave their practices deserve more attention from researchers and policy makers.
Journal of Health Care for the Poor and Underserved, 2005
Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure ... more Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure in Medicaid managed care has received less attention. Recent reports indicate that children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s tenures in health plans are far shorter than tenures in Medicaid itself, but explanations for the difference are not given. In the research reported here, we conducted case studies in five states to determine difference in tenure and reasons for the difference. Our investigation showed that children were enrolled in Medicaid two to four months longer than in specific Medicaid health plans. The major reasons for the gap were retroactive enrollment in Medicaid and delays in selecting a health plan. Frequent and burdensome Medicaid renewal processes exacerbate the problem, resulting in breaks in enrollment and the need to reenroll. The task of managing the care of Medicaid children is difficult without adequate tenures in health plans.
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Papers by Bradford Gray