The Effects of Unemployment and Inflation On Hospital-Based Ambulatory Care SUSAN D. COHEN, MA, ALLEN S. GINSBERG, PHD, AND BRUCE C. VLADECK, PHD
This study was conducted to determine whether the depressed economic conditions of the mid-1970s, particularly the 3 per cent rise in unemployment, led to larger increases in hospital emergency room and clinic visits than would otherwise be expected, and whether such conditions caused shifts in the characteristics of hospital-based ambulatory care visits.
Methods Data about hospital ambulatory care utilization, unemployment, medical manpower, and population characteristics in the 147 major labor areas* of the United States were obtained from three sources: the tapes of the American Hospital Association's (AHA) Annual Survey from 1969 through 1975, the United States Department of Labor,' and the American Medical Association.2 The AHA tapes were "cleaned" by linear interpolation of missing data, and by editing for inconsistencies in the classification of total outpatient visits into emergency, clinic, and referred categories. The 147 major labor areas contained 2,440 community hospitals that reported emergency and/or clinic visits in one or more years from 1969 through 1974. Fifty-five per cent of the population of the United States, 85 per cent of all physicians in hospital-based practice, and 71 per cent of the physicians in officebased practice are located in these labor areas. Although hospitals in the major labor areas are, in general, representative of the 5,800 community hospitals nationwide, they are, on the whole, somewhat larger: while they comprise 42 per cent of the nation's community hospitals, they account for 62 per cent of the beds, 63 per cent of the emergency visits, and 79 per cent of the clinic visits. There are proportionately fewer state and local government hospitals *Major labor areas are defined by the U.S. Department of Labor as economically integrated geographical units within which workers may change jobs without changing their place of residence. Generally there is at least one central city with a minimum population of 50,000. From the Center for Community Health Systems, Columbia University. Address reprint requests to Dr. Allen S. Ginsberg, Deputy Director, Center for Community Health Systems, and Associate Professor of Public Health, Columbia University, 21 Audubon Avenue, New York, NY 10032. This paper, submitted to the Journal July 1, 1977, was revised and accepted for publication May 10, 1978. AJPH December 1978, Vol. 68, No. 12
in the major labor areas than in the entire country, 14 per cent versus 30 per cent. The data were examined to determine whether changes in outpatient utilization paralleled changes in unemployment rates when controlling for labor area characteristics such as rate of unemployment, degree of unemployment, and regional location, and by hospitals with different characteristics such as size, control, teaching status, and location. Utilization data were also lagged by one year to determine whether any relationships between indices of unemployment and visits might appear after this lapse of time. The relationship of changes in outpatient visits to changes in unemployment rates was emphasized,** rather than static correlations between rates of unemployment and rates of hospital emergency and clinic utilization, a fundamentally different question. The measures of change for unemployment rates between two time periods included the absolute difference and the per cent change in rates. The indices of change for emergency and clinic visits between two time periods were the absolute difference between visits per capita and the per cent change in visits. Kendall's tau was employed as the primary measure of association between the indices of change.*** Multiple regression analysis was also performed to study how indices of utilization related to changes in the following independent variables: unemployment rates, rates of hospital-based and office-based physicians per population, and per capita income.
Findings Analyses of these data suggest that increases in unemployment do not cause increases in the volume, or changes in the characteristics of hospital-based ambulatory care utilization. In fact, in the major labor areas, the rate of increase in emergency and clinic visits from 1974 to 1975
**Unemployment can be measured in many ways. The two primary measures of unemployment used in this study are the unemployment rate and a classification based on the degree of unemployment. A complete discussion of why these measures were chosen is available in the full study report.3 ***Tfhis correlation coefficient was chosen because the distribution of variables used in the study was, in general, highly non-normal and did not seem to fit any other useful standard distribution. 1219
PUBLIC HEALTH BRIEFS 31.
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trol, and size of city in which the hospital is located. Nor did a comparison of 1974 unemployment data with 1975 visit data show any strong consistent relationships between an early rise in unemployment and volume of visits, even when major labor areas and hospitals were stratified as described above. The only significant regression coefficient (r = .61) produced by multiple regression analysis showed a relationship between the number of hospital-based physicians per capita and rates of emergency plus clinic visits. While this implies that demand and supply for hospital-based ambulatory care tend to move together, it does not establish causality. Any changes in utilization related to changes in unemployment are masked by other factors at work during the same period.ttt
-23
-29. O.
1.
2.
3.
4.
5.
S.
7.
6.
9.
10.
Discussion
March 1975 minus March 1974 Unemployment Rates Correlation I -0.03758 STD ERR OF EST - 8.62297 R Squared 0.00141
Intercept (A) - 5.01473 Significance - 032680 Slope (B)
-
4.17250
* Emergeny ndodinic visits graphed individually show similar paterns. *^Two lbor ar are not shown.
FIGURE 1-Per Cent Change in Emergency Plus Clinic Visits* by Absolute Difference in Unemployment, 1974 to 1975, in 145** Major Labor Areas
was only 2 per cent, compared with an average of 7 per cent annually for the period 1969-1974. This reduced rate of growth bore no systematic relationship to unemployment rates or changes in these rates. The unemployment rates and the visits to community hospitals in the country as a whole from 1973 to 1975t were: 1973 1974 1975
Per Cent Unemployment Rate Emergency Room and Clinic visits (millions) Per Cent Change in Visits overPrevious Yearstl
5.2
6.1
8.5
115.6
121.7
119.7
6.2
5.3
-1.7
For the 147 major labor areas combined, there was no discernible relationship between indices of visits and indices of unemployment (Figure 1). Even when labor areas were stratified by rate of unemployment, type of unemployment, rate of hospital-based physicians, region, or per capita income, correlations remained too small to be of any predictive value. Comparison of indices of visits with indices of unemployment revealed no significant relationships when the following hospital characteristics were controlled for: teaching status, bed size, number of ambulatory visits, con-
ner.
tData from earlier years were not collated in a comparable man-
ttIn the major labor areas, the comparable per cent increases were 8.2, 6.1, and 2.2. 1 220
The data presented here have shown that sudden and large increases in unemployment do not appear to affect the level or character of utilization in hospital clinics or emergency services. People do not seem to have reacted to economic stringency by switching from private physicians to hospital emergency rooms where they might feel less inhibited about not paying a bill or postponing payment, and where sliding fee scales are often available. This may be due to the fact that two-thirds of the unemployed had at least one other relative who was employed, whose income and/or insurance coverage might have had a cushioning effect.4 "Spending down" to hospital-based care might take more than the one year of continued unemployment examined in this study. Many hospital-based ambulatory care facilities, especially clinics, are used by stable, predominantly poor populations, who do not have alternative providers of care. This hospital-based clinic system is relatively saturated. Emergency rooms, where use would appear to be less discretionary, are also saturated.* The fact that the only relatively large correlations found were between utilization rates and the ratio of hospital-based physicians to population suggests the possibility that ambulatory care utilization, like inpatient utilization, may be largely supply-determined. Other explanations, which our study could not test, are that unemployed persons may have a different number of illness episodes, may delay seeking care, or may seek care less frequently. A complete explanation of the findings reported here would require far more detailed information about what happens to the health care behavior of individuals affected by unemployment, a crucial question outside the scope of this study.
tttThese aggregate data findings were confirmed in a series of 19 site visits throughout the nation. For a full description of site visit phase of the study see the complete project report.3 *The conclusions are drawn from data collected by site visits. A fuller discussion of the special problem of inner-city public hospitals appears in the full project report.3 AJPH December 1978, Vol. 68, No. 12
PUBLIC HEALTH BRIEFS
REFERENCES 1. U.S. Department of Labor Employment and Training Administration, Area Trends in Employment and Unemployment Bulletins, Washington, D.C. 1973-1975. 2. American Medical Association Center for Health Services Research and Development, Physician Distribution and Medical Licensure in the U.S., 1974. Chicago, 1975. 3. Ginsberg A, Cohen S, and Vladeck B: Study on Impact of National Economic Conditions of Health Care of the Poor (Utilization). Contract HRA 230-75-0124 NCHSR; NTIS, Springfield, VA 22161, No. PB263, 1977.
4. Hayghe H: Research Summaries, Monthly Labor Review, pp. 46- 49, December, 1976.
ACKNOWLEDGMENTS This research was supported by Contract #HRA-230-75-0124, National Center for Health Services Research (NCHSR) DHEW. Limited copies of the final report, "Study on Impact of National Economic Conditions on Health Care of the Poor (Utilization)" are available from NTIS, Springfield, VA 22161, No. PB263.
Certification of Safety and Health Managers The International Hazard Control Manager Certification Board has announced new requirements,. effective April 15, 1978, stressing college education and safety/health program experience for candidates who wish to apply for Certified Hazard Control Manager. The Board strongly believes that education is the key to upgrading the safety and health profession. Requirements as outlined below reflect this philosophy:
Summary of Qualification Requirements for Certification No Examination Required Education (with major in Administrative Safety/Health or Management) Experience* Baccalaureate Degree 6 years Master's Degree - and 5 years Doctor's Degree 4 years Examination Required
Education Baccalaureate Degree (in any field) Associate Degree (major in Safety/Health)
Administrative Experience *
-and-
4 years 6 years
*Achievement (contributions to the field) may be substituted for up to one year of experience.
AJPH December 1978, Vol. 68, No. 12
1221
This study was conducted to determine whether the depressed economic conditions of the mid-1970s, particularly the 3 per cent rise in unemployment, led to larger increases in hospital emergency room and clinic visits than would otherwise be expected, and whether such conditions caused shifts in the characteristics of hospital-based ambulatory care visits.
Methods Data about hospital ambulatory care utilization, unemployment, medical manpower, and population characteristics in the 147 major labor areas* of the United States were obtained from three sources: the tapes of the American Hospital Association's (AHA) Annual Survey from 1969 through 1975, the United States Department of Labor,' and the American Medical Association.2 The AHA tapes were "cleaned" by linear interpolation of missing data, and by editing for inconsistencies in the classification of total outpatient visits into emergency, clinic, and referred categories. The 147 major labor areas contained 2,440 community hospitals that reported emergency and/or clinic visits in one or more years from 1969 through 1974. Fifty-five per cent of the population of the United States, 85 per cent of all physicians in hospital-based practice, and 71 per cent of the physicians in officebased practice are located in these labor areas. Although hospitals in the major labor areas are, in general, representative of the 5,800 community hospitals nationwide, they are, on the whole, somewhat larger: while they comprise 42 per cent of the nation's community hospitals, they account for 62 per cent of the beds, 63 per cent of the emergency visits, and 79 per cent of the clinic visits. There are proportionately fewer state and local government hospitals *Major labor areas are defined by the U.S. Department of Labor as economically integrated geographical units within which workers may change jobs without changing their place of residence. Generally there is at least one central city with a minimum population of 50,000. From the Center for Community Health Systems, Columbia University. Address reprint requests to Dr. Allen S. Ginsberg, Deputy Director, Center for Community Health Systems, and Associate Professor of Public Health, Columbia University, 21 Audubon Avenue, New York, NY 10032. This paper, submitted to the Journal July 1, 1977, was revised and accepted for publication May 10, 1978. AJPH December 1978, Vol. 68, No. 12
in the major labor areas than in the entire country, 14 per cent versus 30 per cent. The data were examined to determine whether changes in outpatient utilization paralleled changes in unemployment rates when controlling for labor area characteristics such as rate of unemployment, degree of unemployment, and regional location, and by hospitals with different characteristics such as size, control, teaching status, and location. Utilization data were also lagged by one year to determine whether any relationships between indices of unemployment and visits might appear after this lapse of time. The relationship of changes in outpatient visits to changes in unemployment rates was emphasized,** rather than static correlations between rates of unemployment and rates of hospital emergency and clinic utilization, a fundamentally different question. The measures of change for unemployment rates between two time periods included the absolute difference and the per cent change in rates. The indices of change for emergency and clinic visits between two time periods were the absolute difference between visits per capita and the per cent change in visits. Kendall's tau was employed as the primary measure of association between the indices of change.*** Multiple regression analysis was also performed to study how indices of utilization related to changes in the following independent variables: unemployment rates, rates of hospital-based and office-based physicians per population, and per capita income.
Findings Analyses of these data suggest that increases in unemployment do not cause increases in the volume, or changes in the characteristics of hospital-based ambulatory care utilization. In fact, in the major labor areas, the rate of increase in emergency and clinic visits from 1974 to 1975
**Unemployment can be measured in many ways. The two primary measures of unemployment used in this study are the unemployment rate and a classification based on the degree of unemployment. A complete discussion of why these measures were chosen is available in the full study report.3 ***Tfhis correlation coefficient was chosen because the distribution of variables used in the study was, in general, highly non-normal and did not seem to fit any other useful standard distribution. 1219
PUBLIC HEALTH BRIEFS 31.
25. 0
0
0 19.
0 0
0 00
O
" 13.
0
° 0
._
e
00 0
00
0 0
000
7.
0 00
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0
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trol, and size of city in which the hospital is located. Nor did a comparison of 1974 unemployment data with 1975 visit data show any strong consistent relationships between an early rise in unemployment and volume of visits, even when major labor areas and hospitals were stratified as described above. The only significant regression coefficient (r = .61) produced by multiple regression analysis showed a relationship between the number of hospital-based physicians per capita and rates of emergency plus clinic visits. While this implies that demand and supply for hospital-based ambulatory care tend to move together, it does not establish causality. Any changes in utilization related to changes in unemployment are masked by other factors at work during the same period.ttt
-23
-29. O.
1.
2.
3.
4.
5.
S.
7.
6.
9.
10.
Discussion
March 1975 minus March 1974 Unemployment Rates Correlation I -0.03758 STD ERR OF EST - 8.62297 R Squared 0.00141
Intercept (A) - 5.01473 Significance - 032680 Slope (B)
-
4.17250
* Emergeny ndodinic visits graphed individually show similar paterns. *^Two lbor ar are not shown.
FIGURE 1-Per Cent Change in Emergency Plus Clinic Visits* by Absolute Difference in Unemployment, 1974 to 1975, in 145** Major Labor Areas
was only 2 per cent, compared with an average of 7 per cent annually for the period 1969-1974. This reduced rate of growth bore no systematic relationship to unemployment rates or changes in these rates. The unemployment rates and the visits to community hospitals in the country as a whole from 1973 to 1975t were: 1973 1974 1975
Per Cent Unemployment Rate Emergency Room and Clinic visits (millions) Per Cent Change in Visits overPrevious Yearstl
5.2
6.1
8.5
115.6
121.7
119.7
6.2
5.3
-1.7
For the 147 major labor areas combined, there was no discernible relationship between indices of visits and indices of unemployment (Figure 1). Even when labor areas were stratified by rate of unemployment, type of unemployment, rate of hospital-based physicians, region, or per capita income, correlations remained too small to be of any predictive value. Comparison of indices of visits with indices of unemployment revealed no significant relationships when the following hospital characteristics were controlled for: teaching status, bed size, number of ambulatory visits, con-
ner.
tData from earlier years were not collated in a comparable man-
ttIn the major labor areas, the comparable per cent increases were 8.2, 6.1, and 2.2. 1 220
The data presented here have shown that sudden and large increases in unemployment do not appear to affect the level or character of utilization in hospital clinics or emergency services. People do not seem to have reacted to economic stringency by switching from private physicians to hospital emergency rooms where they might feel less inhibited about not paying a bill or postponing payment, and where sliding fee scales are often available. This may be due to the fact that two-thirds of the unemployed had at least one other relative who was employed, whose income and/or insurance coverage might have had a cushioning effect.4 "Spending down" to hospital-based care might take more than the one year of continued unemployment examined in this study. Many hospital-based ambulatory care facilities, especially clinics, are used by stable, predominantly poor populations, who do not have alternative providers of care. This hospital-based clinic system is relatively saturated. Emergency rooms, where use would appear to be less discretionary, are also saturated.* The fact that the only relatively large correlations found were between utilization rates and the ratio of hospital-based physicians to population suggests the possibility that ambulatory care utilization, like inpatient utilization, may be largely supply-determined. Other explanations, which our study could not test, are that unemployed persons may have a different number of illness episodes, may delay seeking care, or may seek care less frequently. A complete explanation of the findings reported here would require far more detailed information about what happens to the health care behavior of individuals affected by unemployment, a crucial question outside the scope of this study.
tttThese aggregate data findings were confirmed in a series of 19 site visits throughout the nation. For a full description of site visit phase of the study see the complete project report.3 *The conclusions are drawn from data collected by site visits. A fuller discussion of the special problem of inner-city public hospitals appears in the full project report.3 AJPH December 1978, Vol. 68, No. 12
PUBLIC HEALTH BRIEFS
REFERENCES 1. U.S. Department of Labor Employment and Training Administration, Area Trends in Employment and Unemployment Bulletins, Washington, D.C. 1973-1975. 2. American Medical Association Center for Health Services Research and Development, Physician Distribution and Medical Licensure in the U.S., 1974. Chicago, 1975. 3. Ginsberg A, Cohen S, and Vladeck B: Study on Impact of National Economic Conditions of Health Care of the Poor (Utilization). Contract HRA 230-75-0124 NCHSR; NTIS, Springfield, VA 22161, No. PB263, 1977.
4. Hayghe H: Research Summaries, Monthly Labor Review, pp. 46- 49, December, 1976.
ACKNOWLEDGMENTS This research was supported by Contract #HRA-230-75-0124, National Center for Health Services Research (NCHSR) DHEW. Limited copies of the final report, "Study on Impact of National Economic Conditions on Health Care of the Poor (Utilization)" are available from NTIS, Springfield, VA 22161, No. PB263.
Certification of Safety and Health Managers The International Hazard Control Manager Certification Board has announced new requirements,. effective April 15, 1978, stressing college education and safety/health program experience for candidates who wish to apply for Certified Hazard Control Manager. The Board strongly believes that education is the key to upgrading the safety and health profession. Requirements as outlined below reflect this philosophy:
Summary of Qualification Requirements for Certification No Examination Required Education (with major in Administrative Safety/Health or Management) Experience* Baccalaureate Degree 6 years Master's Degree - and 5 years Doctor's Degree 4 years Examination Required
Education Baccalaureate Degree (in any field) Associate Degree (major in Safety/Health)
Administrative Experience *
-and-
4 years 6 years
*Achievement (contributions to the field) may be substituted for up to one year of experience.
AJPH December 1978, Vol. 68, No. 12
1221
