The mental health of migrants living in limbo: A mixed-methods systematic review with meta-analysis

The number of forcibly displaced people has more than doubled over the past decade. Many people fleeing are left in limbo without a secure pathway to citizenship or residency. This mixed-methods systematic review reports the prevalence of mental disorders in migrants living in limbo, the association between limbo and mental illness, and the experiences of these migrants in high income countries. We searched electronic databases for quantitative and qualitative studies published after January 1, 2010, on mental illness in precarious migrants living in HICs and performed a meta-analysis of prevalence rates. Fifty-eight articles met inclusion criteria. The meta-analysis yielded prevalence rates of 43.0 % for anxiety disorders (95 % CI 29.0-57.0), 49.5 % for depression (40.9-58.0) and 40.8 % for posttraumatic stress disorder (30.7-50.9). Having an insecure status was associated with higher rates of mental illness in most studies comparing migrants in limbo to those with secure status. Six themes emerged from the qualitative synthesis: the threat of deportation, uncertainty, social exclusion, stigmatization, social connection and religion. Clinicians should take an ecosocial approach to care that attends to stressors and symptoms. Furthermore, policymakers can mitigate the development of mental disorders among migrants by adopting policies that ensure rapid pathways to protected status.

Moving Forward in Mental Health Care for Refugee, Asylum-Seeking, and Undocumented Children: Social Determinants, Phased Approach to Care, and Advocacy

Given the current political and climate crisis, the number of forcedly displaced individuals continues to rise, posing new challenges to host societies aiming to support and respond to the needs of those fleeing war or persecution. In this article, we turn our attention to current and historical sociopolitical contexts influencing the mental health of forcedly displaced children (ie, refugee, asylum-seeking, and undocumented) during their resettlement in high-income countries, proposing timely ways to respond to evolving needs and recommendations to redress ubiquitous structural inequities that act as barriers to education and care for the children, youth, and families seeking sanctuary.

The Relationship between Wellbeing, Self-Determination, and Resettlement Stress for Asylum-Seeking Mothers Attending an Ecosocial Community-Based Intervention: A Mixed-Methods Study

Psychosocial support programs have been increasingly implemented to protect asylum seekers' wellbeing, though how and why these interventions work is not yet fully understood. This study first uses questionnaires to examine how self-efficacy, satisfaction of basic psychological needs, and adaptive stress may influence wellbeing for a group of asylum-seeking mothers attending a community-based psychosocial program called Welcome Haven. Second, we explore mothers' experiences attending the Welcome Haven program through qualitative interviews. Analysis reveals the importance of relatedness as a predictor of wellbeing as well as the mediating role of adaptive stress between need satisfaction and wellbeing. Further, attending Welcome Haven is associated with reduced adaptive stress and increased wellbeing, which correspond with the thematic analysis showing that attendance at the workshops fostered a sense of belonging through connection with other asylum seekers and service providers as well as empowerment through access to information and self-expression. The results point to the importance of community-based support that addresses adaptive stress and the promotion of social connection as key determinants of wellbeing. Nonetheless, the centrality of pervasive structural stressors asylum seekers experience during resettlement also cautions that relief offered by interventions may be insufficient in the face of ongoing systemic inequality and marginalization.

Adaptation under strain: an ethnographic process evaluation of community-based psychosocial support services for refugee claimants during the height of the COVID-19 pandemic in Montreal, Canada

During the first 2 years of the COVID-19 pandemic in Canada, tens of thousands of refugee claimants faced worsened resettlement stress with limited access to services. Community-based programs that address social determinants of health faced significant disruptions and barriers to providing care as a result of public health restrictions. Little is known about how and if these programs managed to function under these circumstances. This qualitative study aims to understand how community-based organizations based in Montreal, Canada, responded to public health directives and the challenges and opportunities that arose as they attempted to deliver services to asylum seekers during the COVID-19 pandemic. We used an ethnographic ecosocial framework generating data through in-depth semi-structured interviews with nine service providers from seven different community organizations and 13 refugee claimants who were purposively sampled, as well as participant observation during program activities. Results show that organizations struggled to serve families due to public health regulations that limited in-person services and elicited anxiety about putting families at risk. First, we found a central trend in service delivery that was the transition from in-person services to online, which presented specific challenges including (a) technological and material barriers, (b) threats to claimants' sense of privacy and security, (c) meeting linguistic diversity needs, and (d) disengagement from online activities. At the same time, opportunities of online service delivery were identified. Second, we learned that organizations adapted to public health regulations by pivoting and expanding their services as well as fostering and navigating new partnerships and collaborations. These innovations not only demonstrated the resilience of community-organizations, but also revealed tensions and areas of vulnerability. This study contributes to a better understanding of the limits of online service delivery for this population and also captures the agility and limits of community-based programs in the COVID-19 context. Its results can inform decision-makers, community groups and care providers to develop improved policies and program models that preserve what are clearly essential services for refugee claimants.

Refugee mental health and human rights: A challenge for global mental health

This article introduces a thematic issue of Transcultural Psychiatry that presents recent work that deepens our understanding of the refugee experience-from the forces of displacement, through the trajectory of migration, to the challenges of resettlement. Mental health research on refugees and asylum seekers has burgeoned over the past two decades with epidemiological studies, accounts of the lived experience, new conceptual frameworks, and advances in understanding of effective treatment and intervention. However, there are substantial gaps in available research, and important ethical and methodological challenges. These include: the need to adopt decolonizing, participatory methods that amplify refugee voices; the further development of frameworks for studying the broad impacts of forced migration that go beyond posttraumatic stress disorder; and more translational research informed by longitudinal studies of the course of refugee adaptation. Keeping a human rights advocacy perspective front and center will allow researchers to work in collaborative ways with both refugee communities and receiving societies to develop innovative mental health policy and practice to meet the urgent need for a global response to the challenge of forced migration, which is likely to grow dramatically in the coming years as a result of the impacts of climate change.

“Do you want to help or go to war?”: Ethical challenges of critical research in immigration detention in Canada

In a time of mass displacement, countries across the globe are seeking to protect borders through coercive methods of deterrence such as immigration detention. In Canada, migrants—including children—may be detained in penal facilities having neither been charged nor convicted of crimes. In this paper we examine how we dealt with the series of ethical dilemmas that emerged while doing research in immigration detention centres in Canada. Using a critical ethnographic approach, we examine the process of our research in the field, seeking to understand what our emotional responses and those of the staff could tell us about detention itself, but also about what is at stake when researchers are faced with the suffering of participants in these spaces of confinement. The findings suggest that field work in immigration detention centres is an emotionally demanding process and that there were several pivotal moments in which our sense of moral and clinical obligations toward distressed detainees, especially children, were in conflict with our role as researchers. We also grapple with how the disciplinary gaze of the detention centre affects researchers entering the space. Given these tensions, we argue, spaces of critical reflection that can consider and contain the strongly evoked emotions are crucial, both for researchers, and perhaps more challengingly, for detention centre employees and gatekeepers as well.

Mental Health of Refugees and Asylum Seekers: Assessment and Intervention

With unprecedented numbers of displaced persons worldwide, mental health clinicians in high-income countries will increasingly encounter refugee and asylum-seeking patients, many of whom have experienced significant adversity before and after their migration. This paper presents a summary of the recent evidence on the assessment and treatment of refugees across the lifespan to inform clinicians' approaches to care of refugee patients in mental health care settings. Assessment and interventions for refugees are grounded in an ecosystemic approach which considers not only pre-migratory trauma, but social, familial, and cultural determinants of mental health in the host country. Evidence for psychotherapy and pharmacological treatments are reviewed, highlighting promising interventions while acknowledging that further research is needed. Ultimately, serving refugees necessitates a biopsychosocial approach that engages clinicians as medical experts, therapists, and advocates.

Refugee children's sandplay narratives in immigration detention in Canada

Asylum seeking children arriving in Canada regularly face incarceration in medium-security-style immigration detention centres. Research demonstrates the human cost of detaining migrant children and families and the psychiatric burden linked with such imprisonment. This study aims to understand the lived experiences of children aged 3-13 held in detention. Informed by a qualitative methodology of narrative inquiry, child participants created worlds in the sand and generated stories to express their subjective experience. Results suggest that children's sandplay confirms the traumatic nature of immigration detention while also revealing children's sometimes conflicting understanding of the meaning of detention and their own migration. The results are contextualized by a description of detention conditions and the psychiatric symptoms associated with immigration incarceration. The study highlights the need for more research examining the impact of immigration detention on children's mental health, while also underlining how refugee children's voices provide important direction for policy change.

Asylum-seeking children's experiences of detention in Canada: A qualitative study

Children and parents seeking asylum are regularly detained in Canada, however little is known about the experiences of detained families. International literature suggests that the detention of children is associated with significant morbidity. Our study aims to understand the experiences of detained children and families who have sought asylum in Canada by using a qualitative methodology that includes semistructured interviews and ethnographic participant observation. Detention appears to be a frightening experience of deprivation that leaves children feeling criminalized and helpless. Family separation further shatters children's sense of well-being. Children's emotional and behavioral responses to separation and to detention suggest that the experience is acutely stressful and, in some cases, traumatic--even when detention is brief. Distress and impairment may persist months after release. Given the burden of psychological suffering and the harmful consequences of separating families, children should not be detained for immigration reasons and parents should not be detained without children.

Prevalence, expenditures, utilization, and payment for persons with MS in insured populations

OBJECTIVE

To determine the prevalence, expenditures, and utilization of enrollees with MS relative to all enrollees in privately insured, Medicare, and Medicaid populations.

METHODS

The authors used insurer administrative billing data to identify persons with MS, their insured medical expenditures and utilization, and benchmark general insured population expenditures and utilization. Three samples of insurer billing data were analyzed: nationally representative samples for the privately insured (1994 through 1995) and Medicare (1996 though 1997) populations, and Medicaid data for disabled (1991 through 1996) populations from six states.

RESULTS

Using 2 years of diagnoses on claims, the prevalence of MS in the privately insured population was 24 per 10,000, 36 per 10,000 in the Medicare population, and 71 per 10,000 in the Medicaid disabled population. Annual insured expenditures were $7,677 per privately insured enrollee with MS vs $2,394 for all privately insured enrollees, $13,048 per Medicare beneficiary with MS compared with $6,006 for all Medicare beneficiaries, and $7,352 per Medicaid disabled recipient with MS vs $4,088 per disabled recipient without MS. Home health expenditures were very high for Medicare beneficiaries with MS and nursing facility expenditures were very high for Medicaid disabled recipients with MS. A small proportion of enrollees with MS accounted for most expenditures.

CONCLUSIONS

Insured enrollees with MS are two to three times more expensive than average insured enrollees. If the premiums that employers or governments pay health insurers and the capitation amounts that insurers pay health care providers do not account for these higher costs, a disincentive is created for the enrollment and care of persons with MS.

The Medicaid Rx model: pharmacy-based risk adjustment for public programs

BACKGROUND

Risk adjustment models typically use diagnoses from claims or encounter records to assess illness severity. However, concerns about the availability and reliability of diagnostic data raise the potential for alternative methods of risk adjustment. Here, we explore the use of pharmacy data as an alternative or complement to diagnostic data in risk adjustment.

OBJECTIVES

To develop and test a pharmacy-based risk adjustment model for SSI and TANF Medicaid populations.

RESEARCH DESIGN

Pharmacological review combined with empirical evaluation. We developed the Medicaid Rx model, a system that classifies a subset of the National Drug Codes into categories that can be used for risk-assessment and risk-adjusted payment.

SUBJECTS

Subjects consisted of 362,370 persons with disability and 1.5 million AFDC and TANF beneficiaries in California, Colorado, Georgia, and Tennessee during 1990-1999.

MEASURES

We compare pharmacy and diagnostic classification for three chronic diseases. We also compare R2 statistics and use simulated health plans to evaluate the performance of alternative models.

RESULTS

Pharmacy and diagnostic classification vary in their ability to identify specific chronic disease. Using simulated plans, diagnostic models are better at predicting expenditures than are pharmacy-based models for disabled Medicaid beneficiaries, although the models perform similarly for TANF Medicaid beneficiaries. Models that combine diagnostic and pharmacy data have superior overall performance.

CONCLUSIONS

The performance of risk adjustment models using a combination of pharmacy and diagnostic data are superior to that of models using either data source alone, particularly among TANF beneficiaries. Concerns regarding variations in prescribing patterns and the incentives that may follow from linking payment to pharmacy use warrant further research.

Valuing charity

Arrow asserted that a variety of institutional arrangements and observable mores of the medical profession were functional responses to the failure of the market to insure against uncertainties. But one of these norms--the ethic to provide treatment without regard to ability to pay--was also a response to the failure of the political system to assure the elderly and poor would not suffer more than others when they got sick. This ethic is strikingly different from the norm in most other areas of the economy. Automobile dealers and department stores are not expected to give away their products to the poor; neither are grocery stores or farmers. Public education is a closer analogy, reflecting the norm that all children deserve a good education. In education, however, unlike in medicine, we collectively support this norm by providing public funds to accomplish this goal rather than by relying on the private market. In 1963, physicians argued that a combination of the market and private philanthropy (including the obligations of physicians) would be sufficient to guarantee high-quality care for the elderly and the poor. Government financing, they argued, would lead to socialized medicine, impairing relationships between physicians and patients and between physicians and society. Based on his article, Arrow would not have agreed. Neither, apparently, did the public. The enactment of Medicare indicated, in part, that many people understood, even in 1965, the extent to which treatment choices and outcomes were affected by ability to pay. Events since 1965 suggest that there is some tension between insurance and ethical responses to uncertainty despite Arrow's endorsement of both. I have argued here that Medicare and Medicaid further eroded the ethic that treatment should be available without regard to ability to pay by reducing physician willingness to provide charity care and by reducing the resources available to public hospitals and the interest of private teaching hospitals in providing care to the uninsured poor. Largely independent of Medicare and Medicaid, the increasing importance of pharmaceuticals and other services delivered outside of the hospital further strengthened the connection between treatment choices and ability to pay, and the growth of capitated payment systems made this connection salient to many insured patients and their physicians. In part, then, the AMA was correct: Medicare and Medicaid have contributed to the erosion of trust in physicians as incorruptible agents for patients. Some of this trust undoubtedly was misplaced, even in 1965, and trust alone was not sufficient to guarantee widespread access to medical care or to assure that treatment provided would take true social benefits and costs into account. Medicare and Medicaid, as well as the growth of prepayment insurance plans, represent institutional responses to the failure of the 1963 norms to accomplish societal goals. Still, as we have seen, these responses create their own challenges, and we continue to search for institutions that will allow widespread insurance to coexist with the physician-patient trust that Arrow correctly identified as an important response to uncertainties and information asymmetries in the medical care market.

Improving health-based payment for Medicaid beneficiaries: CDPS

This article describes the Chronic Illness and Disability Payment System (CDPS), a diagnostic classification system that Medicaid programs can use to make health-based capitated payments for TANF and disabled Medicaid beneficiaries. The authors describe the diversity of diagnoses and different burdens of illness among disabled and AFDC Medicaid beneficiaries. Claims from seven States are analyzed, and payment weights are provided that States can use when adjusting HMO payments. The authors also compare the taxonomy and statistical performance of CDPS to other leading diagnostic classification systems and find that the new model performs better in a number of respects.

Waiting for Godot: wishes and worries in managed care

Managed care has done a better job at reducing expenditure growth than it has in improving quality. Although reduced expenditure growth is not appreciated by many, it has real benefits. For the majority of Americans who are privately insured, it results in greater disposable income for goods and services other than health care (although the illusion of employer-paid health insurance obscures this reality for many). For Medicaid programs, slower growth of expenditures facilitates efforts at expanding coverage. For low-income workers, slower expenditure growth results in larger numbers of people retaining insurance coverage than would have been the case if premiums rose more quickly. While there are some victories to which managed care organizations can point, we cannot credibly argue that overall levels of quality and health outcomes are improving as the health care system is massively disrupted by changes in health care finance and delivery. The disruptions create real hardships for some physicians and other health care workers, and worries for many consumers. These worries fuel the managed care backlash. The danger is that politicians will respond to these worries with policies that inhibit the development of high-quality delivery systems. The opportunity is for relatively modest public policy changes--external review organizations, better public-sector purchasing capabilities, public investment in producing and publicizing information on health plan and medical group performance, and establishment of a public ombudsperson--to respond to consumer worries and lead to improvements in health care quality and outcomes. Finally, I would be remiss without a reminder that the single most effective action politicians could take to improve health care quality and outcomes would be to change the rules of health care financing to assure that all Americans are covered by managed care. Even with all of its inadequacies, managed care is much superior to the patchwork care available to the 43 million Americans who are uninsured. The managed care backlash is concerned with protecting patients who are insured (and their providers). Far more valuable would be to protect those without insurance. Sadly, no politician has yet figured out how to do this. Still waiting.

Explaining the decline in health insurance coverage, 1979-1995

The decline in health insurance coverage among workers from 1979 to 1995 can be accounted for almost entirely by the fact that per capita health care spending rose much more rapidly than personal income during this time period. We simulate health insurance coverage levels for 1996-2005 under alternative assumptions concerning the rate of growth of spending. We conclude that reduction in spending growth creates measurable increases in health insurance coverage for low-income workers and that the rapid increase in health care spending over the past fifteen years has created a large pool of low-income workers for whom health insurance is unaffordable.

The Community Medical Alliance: an integrated system of care in Greater Boston for people with severe disability and AIDS

The Community Medical Alliance in Boston has adapted principles of prepaid managed care to redesign service delivery for people with severe physical disability and with late-stage AIDS. Experience to date suggests that the flexibility of capitation can be used to substantially shift care from its usual hospital focus to clinicians in home and community settings, especially nurse practitioners, with a high degree of patient satisfaction and without apparent compromise in quality. Instead of limiting access, managed care can use prepayment to support early interventions, coordination, and the development of services specifically designed to meet the needs of the target population.

Diagnostic risk adjustment for Medicaid: the disability payment system

This article describes a system of diagnostic categories that Medicaid programs can use for adjusting capitation payments to health plans that enroll people with disability. Medicaid claims from Colorado, Michigan, Missouri, New York, and Ohio are analyzed to demonstrate that the greater predictability of costs among people with disabilities makes risk adjustment more feasible than for a general population and more critical to creating health systems for people with disability. The application of our diagnostic categories to State claims data is described, including estimated effects on subsequent-year costs of various diagnoses. The challenges of implementing adjustment by diagnosis are explored.

The marketplace in health care reform. The demographic limitations of managed competition

BACKGROUND

The theory of managed competition holds that the quality and economy of health care delivery will improve if independent provider groups compete for consumers. In sparsely populated areas where relatively few providers are required, however, it is not feasible to divide the provider community into competing groups. We examined the demographic features of health markets in the United States to see what proportion of the population lives in areas that might successfully support managed competition.

METHODS

The ratios of physicians to enrollees in large staff-model health maintenance organizations were determined as an indicator of the staffing needs of an efficient health plan. These ratios were used to estimate the populations necessary to support health organizations with various ranges of specialty services. Metropolitan areas with populations large enough to support managed competition were identified.

RESULTS

We estimated that a health care services market with a population of 1.2 million could support three fully independent plans. A population of 360,000 could support three plans that independently provided most acute care hospital services, but the plans would need to share hospital facilities and contract for tertiary services. A population of 180,000 could support three plans that provided primary care and many basic specialty services but that shared inpatient cardiology and urology services. Health markets with populations greater than 180,000 would include 71 percent of the U.S. population; those with populations greater than 360,000, 63 percent; and those with populations greater than 1.2 million, 42 percent.

CONCLUSIONS

Reform of the U.S. health care system through expansion of managed competition is feasible in medium-sized or large metropolitan areas. Smaller metropolitan areas and rural areas would require alternative forms of organization and regulation of health care providers in order to improve quality and economy.

Effects of offering advance directives on medical treatments and costs

OBJECTIVE

To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing.

DESIGN

Randomized, controlled trial.

SETTING

University and Veterans Affairs medical center.

PATIENTS

Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study.

INTERVENTION

Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization.

MEASUREMENTS

Cognitive function, patient satisfaction, psychological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges.

RESULTS

No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19,502 (95% CI, $13,030 to $25,974) for medical treatments in the last month of life compared with $19,700 (95% CI, $13,704 to $25,696) for controls.

CONCLUSIONS

Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patient's medical record had no significant positive or negative effect on a patient's well-being, health status, medical treatments, or medical treatment charges.

Universal health insurance through incentives reform

Roughly 35 million Americans have no health care coverage. Health care expenditures are out of control. The problems of access and cost are inextricably related. Important correctable causes include cost-unconscious demand, a system not organized for quality and economy, market failure, and public funds not distributed equitably or effectively to motivate widespread coverage. We propose Public Sponsor agencies to offer subsidized coverage to those otherwise uninsured, mandated employer-provided health insurance, premium contributions from all employers and employees, a limit on tax-free employer contributions to employee health insurance, and "managed competition". Our proposed new government revenues equal proposed new outlays. We believe our proposal will work because efficient managed care does exist and can provide satisfactory care for a cost far below that of the traditional fee-for-service third-party payment system. Presented with an opportunity to make an economically responsible choice, people choose value for money; the dynamic created by these individual choices will give providers strong incentives to render high-quality, economical care. We believe that providers will respond to these incentives.

A consumer-choice health plan for the 1990s. Universal health insurance in a system designed to promote quality and economy (2)

We describe the characteristics necessary for a plan for universal health insurance to find broad acceptance. Such a plan must represent incremental, not radical, change; must respect the preferences of voters, patients, and providers; must avoid major disruption in satisfactory existing arrangements; must avoid creating major windfall gains or losses; must avoid large-scale income redistribution; and must not be inflationary. Our proposal would create a framework that would encourage the efficient organization of care. Successful organizations would probably be those that attracted the loyalty and commitment of physicians, integrated insurance and the provision of care, and aligned the interests of doctors and patients toward high-quality, cost-effective care. The proposal's chief potential disadvantage would be its effect on the employment opportunities of low-wage workers, but this effect could be minimized. In addition, we discuss a proposal to mandate coverage by employers of full-time employees, legislation enacted recently in Massachusetts, high-risk pools, and the system followed in Canada, comparing each of these alternatives with our proposal.

A consumer-choice health plan for the 1990s. Universal health insurance in a system designed to promote quality and economy (1)

America's health care economy is a paradox of excess and deprivation. We spend more than 11 percent of the gross national product on health care, yet roughly 35 million Americans have no financial protection from medical expenses. To an increasing degree, the present financing system is inflationary, unfair, and wasteful. In its place we need a strategy that addresses the whole system, offers financial protection from health care expenses to all, and promotes the development of economical financing and delivery arrangements. Such a strategy must be designed to be broadly acceptable in our society. To remedy the deprivation, we propose that everyone not covered by Medicare, Medicaid, or some other public program be enabled to buy affordable coverage, either through their employers or through a "public sponsor." To attack the excess, we propose a strategy of managed competition in which collective agents, called sponsors, such as the Health Care Financing Administration and large employers, contract with competing health plans and manage a process of informed cost-conscious consumer choice that rewards providers who deliver high-quality care economically.

The cyclical behavior of hospital utilization and staffing

Aggregate monthly data on hospital utilization and staffing are examined to assess the hospital industry's ability to adjust staffing levels to regular monthly cycles in demand. Graphical analysis and linear regression are used to assess the relationship between monthly trends in utilization and full-time-equivalent hospital personnel. We show that although regular seasonal patterns exist in both utilization and staffing levels, these series are largely independent of each other. The staffing level response to cycles in admissions and patient-days is, in fact, small relative to those observed for other industries that face predictable and regular fluctuations in product demand. Staffing levels appear to be more closely related to bed levels than to actual utilization levels. For a typical hospital which does not face effective incentives to control costs, smoother patterns of seasonal utilization probably will not result in lower staffing levels and reduced costs unless accompanied by a slowdown in the rate of increase in hospital bed size.