With the scaling back of public state psychiatric hospitals, general hospitals have become a major site of psychiatric inpatient care. While public hospitals play a disproportionate role in caring for Medicaid patients and the uninsured, data from the mid- 1980's show that nonprofit and for-profit general and psychiatric hospitals contributed substantially to the care of these patients. The changing market, notably the increase in competitiveness among insurers and health plans and aggressive negotiations by the plans of rates with hospitals has increased the financial pressures on hospitals and may be encouraging them to reduce the car they provide to Medicaid and uninsured patients. Prior studies of access to inpatient psychiatric care have not adequately addressed the question of whether this has occurred because they have aggregate hospital level data and overhead periods prior to those in which the greatest cost pressure occurred. Our research will use state patient discharge abstract data sets from 1987 to 1997 to: 1) determine the extent have relative admission rates and patient days per capita in different payer classes (including self-pay) changed over time; 2) determine whether, over time, self-pay and Medicaid patients have been shifted from private hospitals to public general hospitals and the pardon this imposes on these hospitals; and 3) determine whether the care self-pay and Medicaid pateints receive in hospitals differs from that of privately insured patients and whether differences in treatment are greater in private hospitals than public hospitals or have increased over time. We will examine the association of these changes to variations in the level of hospital competition, growth of managed care, and state policy change. WE will use discharge and financial data from California, Massachusetts, and Washington, augmented with data from the AHA and Census.
