Exchange rates
Adverse Selection and an Individual Mandate: When Theory Meets Practice
Martin Hackmann, Jonathan Kolstad & Amanda Kowalski
NBER Working Paper, June 2013
Abstract:
We develop a model of selection that incorporates a key element of recent health reforms: an individual mandate. We identify a set of key parameters for welfare analysis, allowing us to model the welfare impact of the actual policy as well as to estimate the socially optimal penalty level. Using data from Massachusetts, we estimate the key parameters of the model. We compare health insurance coverage, premiums, and insurer average health claim expenditures between Massachusetts and other states in the periods before and after the passage of Massachusetts health reform. In the individual market for health insurance, we find that premiums and average costs decreased significantly in response to the individual mandate; consistent with an initially adversely selected insurance market. We are also able to recover an estimated willingness-to-pay for health insurance. Combining demand and cost estimates as sufficient statistics for welfare analysis, we find an annual welfare gain of $335 dollars per person or $71 million annually in Massachusetts as a result of the reduction in adverse selection. We also find evidence for smaller post-reform markups in the individual market, which increased welfare by another $107 dollars per person per year and about $23 million per year overall. To put this in perspective, the total welfare gains were 8.4% of medical expenditures paid by insurers. Our model and empirical estimates suggest an optimal mandate penalty of $2,190. A penalty of this magnitude would increase health insurance to near universal levels. Our estimated optimal penalty is higher than the individual mandate penalty adopted in Massachusetts but close to the penalty implemented under the ACA.
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Public Health Insurance, Labor Supply, and Employment Lock
Craig Garthwaite, Tal Gross & Matthew Notowidigdo
NBER Working Paper, July 2013
Abstract:
We study the effect of public health insurance eligibility on labor supply by exploiting the largest public health insurance disenrollment in the history of the United States. In 2005, approximately 170,000 Tennessee residents abruptly lost public health insurance coverage. Using both across- and within-state variation in exposure to the disenrollment, we estimate large increases in labor supply, primarily along the extensive margin. The increased employment is concentrated among individuals working at least 20 hours per week and receiving private, employer-provided health insurance. We explore the dynamic effects of the disenrollment and find an immediate increase in job search behavior and a steady rise in both employment and health insurance coverage following the disenrollment. Our results suggest a significant degree of "employment lock" - workers employed primarily in order to secure private health insurance coverage. The results also suggest that the Affordable Care Act - which similarly affects adults not traditionally eligible for public health insurance - may cause large reductions in the labor supply of low-income adults.
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John Ayanian et al.
Health Affairs, July 2013, Pages 1228-1235
Abstract:
With quality-of-care bonus payments now available for Medicare Advantage health maintenance organizations (HMOs) and for accountable care organizations in traditional Medicare, the need to understand the relative quality of care delivered to Medicare enrollees has increased. We compared the quality of ambulatory care from 2003 through 2009 between beneficiaries enrolled in Medicare Advantage HMOs and those enrolled in traditional Medicare, and we assessed how the performance of various types of Medicare HMOs differed from that of traditional Medicare for these same measures. We found that beneficiaries in Medicare HMOs were consistently more likely than those in traditional Medicare to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease. We also found that Medicare HMO physicians were rated less favorably by their patients than were physicians in traditional Medicare in 2003; however, by 2009 the opposite was true. Not-for-profit, larger, and older Medicare HMOs performed consistently more favorably on clinical measures and ratings of care than for-profit, smaller, and newer HMOs. Our results suggest that the positive effects of more-integrated delivery systems on the quality of ambulatory care in Medicare HMOs may outweigh the potential incentives to restrict care under capitated payments.
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Happy Doctor Makes Happy Baby? Incentivizing Physicians Improves Quality of Prenatal Care
Vibeke Myrup Jensen
Review of Economics and Statistics, forthcoming
Abstract:
Physician-induced demand, whereby physicians alter their patient treatment for personal gain, lies at the heart of concerns about publicly-provided health care. However, little is known about how payment systems affect the ultimate outcome - patient health. Exploiting a unique policy-induced variation in Denmark, I investigate the impact of physician payment contracts on infant health. In a difference-in-differences framework, I find that firstborn infants exposed in the womb to the care of general practitioners with capitation contracts have poorer infant health outcomes than infants exposed to fee-for-service contracts. The firstborn children of younger women primarily drive the effects.
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The Poverty-Reducing Effect Of Medicaid
Benjamin Sommers & Donald Oellerich
Journal of Health Economics, September 2013, Pages 816-832
Abstract:
Medicaid provides health insurance for 54 million Americans. Using the Census Bureau's supplemental poverty measure (which subtracts out-of-pocket medical expenses from family resources), we estimated the impact of eliminating Medicaid. In our counterfactual, Medicaid beneficiaries would become uninsured or gain other insurance. Counterfactual medical expenditures were drawn stochastically from propensity-score-matched individuals without Medicaid. While this method captures the importance of risk protection, it likely underestimates Medicaid's impact due to unobserved differences between Medicaid and non-Medicaid individuals. Nonetheless, we find that Medicaid reduces out-of-pocket medical spending from $871 to $376 per beneficiary, and decreases poverty rates by 1.0% among children, 2.2% among disabled adults, and 0.7% among elderly individuals. When factoring in institutionalized populations, an additional 500,000 people were kept out of poverty. Overall, Medicaid kept at least 2.6 million - and as many as 3.4 million - out of poverty in 2010, making it the U.S.'s third largest anti-poverty program.
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Mariacristina De Nardi, Eric French & John Bailey Jones
NBER Working Paper, June 2013
Abstract:
The old age provisions of the Medicaid program were designed to insure poor retirees against medical expenses. However, it is the rich who are most likely to live long and face expensive medical conditions when very old. We estimate a rich structural model of savings and endogenous medical spending with heterogeneous agents, and use it to compute the distribution of lifetime Medicaid transfers and Medicaid valuations across single retirees. We find that retirees with high lifetime incomes can end up on Medicaid, and often value Medicaid's insurance features the most, as they face a larger risk of catastrophic medical needs at old ages, and face the greatest consumption risk. Finally, our compensating differential calculations indicate that retirees value Medicaid insurance at more than its actuarial cost, but that most would value expansions of the current Medicaid program at less than cost.
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Sandra Decker et al.
Journal of the American Medical Association, 26 June 2013, Pages 2579-2586
Objective: To document the health care needs and health risks of uninsured adults who could gain Medicaid coverage under the ACA. These data will help physicians, other clinicians, and state Medicaid programs prepare for the possible expansions.
Design, Setting, and Patients: Data from the National Health and Nutrition Examination Survey 2007-2010 were used to analyze health conditions among a nationally representative sample of 1042 uninsured adults aged 19 through 64 years with income no more than 138% of the federal poverty level, compared with 471 low-income adults currently enrolled in Medicaid.
Main Outcomes and Measures: Prevalence and control of diabetes, hypertension, and hypercholesterolemia based on examinations and laboratory tests, measures of self-reported health status including medical conditions, and risk factors such as measured obesity status.
Results: Compared with those already enrolled in Medicaid, uninsured adults were less likely to be obese and sedentary and less likely to report a physical, mental, or emotional limitation. They also were less likely to have several chronic conditions. For example, 30.1% (95% CI, 26.8%-33.4%) of uninsured adults had hypertension, hypercholesterolemia, or diabetes compared with 38.6% (95% CI, 32.0%-45.3%) of those enrolled in Medicaid (P = .02). However, if they had these conditions, uninsured adults were less likely to be aware of them and less likely to have them controlled. For example, 80.1% (95% CI, 75.2%-85.1%) of the uninsured adults with at least 1 of these 3 conditions had at least 1 uncontrolled condition, compared with 63.4% (95% CI, 53.7%-73.1%) of adults enrolled in Medicaid.
Conclusion and Relevance: Compared with adults currently enrolled in Medicaid, uninsured low-income adults potentially eligible to enroll in Medicaid under the ACA had a lower prevalence of many chronic conditions. A substantial proportion of currently uninsured adults with chronic conditions did not have good disease control; projections based on sample weighting suggest this may represent 3.5 million persons (95% CI, 2.9 million-4.2 million). These adults may need initial intensive medical care following Medicaid enrollment.
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Sandra Decker
Health Affairs, July 2013, Pages 1183-1187
Abstract:
As part of the Affordable Care Act, primary care physicians providing services to patients insured through Medicaid in some states will receive higher payments in 2013 and 2014 than in the past. Payments for some services will increase to match Medicare rates. This change may lead to wider acceptance of new Medicaid patients among primary care providers. Using data from the 2011-12 National Ambulatory Medical Care Survey Electronic Medical Records Supplement, I summarize baseline rates of acceptance of new Medicaid patients among office-based physicians by specialty and practice type. I also report state-level acceptance rates for both primary care and other physicians. About 33 percent of primary care physicians (those in general and family medicine, internal medicine, or pediatrics) did not accept new Medicaid patients in 2011-12, ranging from a low of 8.9 percent in Minnesota to a high of 54.0 percent in New Jersey. Primary care physicians in New Jersey, California, Alabama, and Missouri were less likely than the national average to accept new Medicaid patients in 2011-12. The data presented here provide a baseline for comparison of new Medicaid acceptance rates in 2013-14.
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Consumers' Misunderstanding of Health Insurance
George Loewenstein et al.
Journal of Health Economics, September 2013, Pages 850-862
Abstract:
We report results from two surveys of representative samples of Americans with private health insurance. The first examines how well Americans understand, and believe they understand, traditional health insurance coverage. The second examines whether those insured under a simplified all-copay insurance plan will be more likely to engage in cost-reducing behaviors relative to those insured under a traditional plan with deductibles and coinsurance, and measures consumer preferences between the two plans. The surveys provide strong evidence that consumers do not understand traditional plans and would better understand a simplified plan, but weaker evidence that a simplified plan would have strong appeal to consumers or change their healthcare choices.
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Katy Kozhimannil et al.
Medical Care, August 2013, Pages 639-645
Background: Prior studies show that men are more likely than women to defer essential care. Enrollment in high-deductible health plans (HDHPs) could exacerbate this tendency, but sex-specific responses to HDHPs have not been assessed. We measured the impact of an HDHP separately for men and women.
Methods: Controlled longitudinal difference-in-differences analysis of low, intermediate, and high severity emergency department (ED) visits and hospitalizations among 6007 men and 6530 women for 1 year before and up to 2 years after their employers mandated a switch from a traditional health maintenance organization plan to an HDHP, compared with contemporaneous controls (18,433 men and 19,178 women) who remained in an health maintenance organization plan.
Results: In the year following transition to an HDHP, men substantially reduced ED visits at all severity levels relative to controls (changes in low, intermediate, and high severity visits of -21.5% [-37.9 to -5.2], -21.6% [-37.4 to -5.7], and -34.4% [-62.1 to -6.7], respectively). Female HDHP members selectively reduced low severity emergency visits (-26.9% [-40.8 to -13.0]) while preserving intermediate and high severity visits. Male HDHP members also experienced a 24.2% [-45.3 to -3.1] relative decline in hospitalizations in year 1, followed by a 30.1% [2.1 to 58.1] relative increase in hospitalizations between years 1 and 2.
Conclusions: Initial across-the-board reductions in ED and hospital care followed by increased hospitalizations imply that men may have foregone needed care following an HDHP transition. Clinicians caring for patients with HDHPs should be aware of sex differences in response to benefit design.
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Physicians Treating Physicians: Information and Incentives in Childbirth
Erin Johnson & Marit Rehavi
NBER Working Paper, July 2013
Abstract:
This paper provides new evidence on the interaction between patient information and financial incentives in physician induced demand (PID). Using rich microdata on childbirth, we compare the treatment of physicians when they are patients with that of comparable non-physicians. We exploit a unique institutional feature of California to determine how inducement varies with obstetricians' financial incentives. Consistent with PID, physicians are almost 10 percent less likely to receive a C-section, with only a quarter of this effect attributable to differential sorting of patients to hospitals or obstetricians. Financial incentives have a large effect on C-section probabilities for non-physicians, but physician-patients are relatively unaffected. Physicians also have better health outcomes, suggesting overuse of C-sections adversely impacts patient health.
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Behavioral Economics Holds Potential To Deliver Better Results For Patients, Insurers, And Employers
George Loewenstein, David Asch & Kevin Volpp
Health Affairs, July 2013, Pages 1244-1250
Abstract:
Many programs being implemented by US employers, insurers, and health care providers use incentives to encourage patients to take better care of themselves. We critically review a range of these efforts and show that many programs, although well-meaning, are unlikely to have much impact because they require information, expertise, and self-control that few patients possess. As a result, benefits are likely to accrue disproportionately to patients who already are taking adequate care of their health. We show how these programs could be made more effective through the use of insights from behavioral economics. For example, incentive programs that offer patients small and frequent payments for behavior that would benefit the patients, such as medication adherence, can be more effective than programs with incentives that are far less visible because they are folded into a paycheck or used to reduce a monthly premium. Deploying more-nuanced insights from behavioral economics can lead to policies with the potential to increase patient engagement and deliver dividends for patients and favorable cost-effectiveness ratios for insurers, employers, and other relevant commercial entities.
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Lauren Hersch Nicholas
Forum for Health Economics and Policy, forthcoming
Abstract:
Do differences in rates of use among managed care and Fee-for-Service Medicare beneficiaries reflect selection bias or successful care management by insurers? I demonstrate a new method to estimate the treatment effect of insurance status on health care utilization. Using clinical information and risk-adjustment techniques on data on acute admission that are unrelated to recent medical care, I create a proxy measure of unobserved health status. I find that positive selection accounts for between one-quarter and one-third of the risk-adjusted differences in rates of hospitalization for ambulatory care sensitive conditions and elective procedures among Medicare managed care and Fee-for-Service enrollees in 7 years of Healthcare Cost and Utilization Project State Inpatient Databases from Arizona, Florida, New Jersey and New York matched to Medicare enrollment data. Beyond selection effects, I find that managed care plans reduce rates of potentially preventable hospitalizations by 12.5 per 1000 enrollees (compared to mean of 46 per 1000) and reduce annual rates of elective admissions by 4 per 1000 enrollees (mean 18.6 per 1000).
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Adverse Selection and Inertia in Health Insurance Markets: When Nudging Hurts
Benjamin Handel
American Economic Review, forthcoming
Abstract:
This paper investigates consumer inertia in health insurance markets, where adverse selection is a potential concern. We leverage a major change to insurance provision that occurred at a large firm to identify substantial inertia, and develop and estimate a choice model that also quantifies risk preferences and ex ante health risk. We use these estimates to study the impact of policies that nudge consumers toward better decisions by reducing inertia. When aggregated, these improved individual-level choices substantially exacerbate adverse selection in our setting, leading to an overall reduction in welfare that doubles the existing welfare loss from adverse selection.
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Evolving Choice Inconsistencies in Choice of Prescription Drug Insurance
Jason Abaluck & Jonathan Gruber
NBER Working Paper, June 2013
Abstract:
We explore choice inconsistency over time within the Medicare Part D Prescription Drug Program. Using the full universe of Part D claims data, we revisit our earlier work on partial data to replicate our results showing large "foregone savings" among Part D enrollees. We also document that this foregone savings increases over time during the first four years of the Part D program. We then develop a rich dynamic structural framework that allows us to mathematically decompose the "foregone welfare" from inconsistent plan choices into components due to demand side factors, supply side factors, and changes in preferences over time. We find that the welfare cost of choice inconsistencies increases over time. Most importantly, we find that there is little improvement in the ability of consumers to choose plans over time; we identify and estimate little learning at either the individual or cohort level over the years of our analysis. Inertia does reduce welfare, but even in a world with no inertia we estimate that substantial welfare losses would remain. We conclude that the increased choice inconsistencies over time are driven by changes on the supply side that are not offset both because of inertia and because non-inertial consumers still make inconsistent choices.
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Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care
Shreya Kangovi et al.
Health Affairs, July 2013, Pages 1196-1203
Abstract:
Patients with low socioeconomic status (SES) use more acute hospital care and less primary care than patients with high socioeconomic status. This low-value pattern of care use is harmful to these patients' health and costly to the health care system. Many current policy initiatives, such as the creation of accountable care organizations, aim to improve both health outcomes and the cost-effectiveness of health services. Achieving those goals requires understanding what drives low-value health care use. We conducted qualitative interviews with forty urban low-SES patients to explore why they prefer to use hospital care. They perceive it as less expensive, more accessible, and of higher quality than ambulatory care. Efforts that focus solely on improving the quality of hospital care to reduce readmissions could, paradoxically, increase hospital use. Two different profile types emerged from our research. Patients in Profile A (five or more acute care episodes in six months) reported social dysfunction and disability. Those in Profile B (fewer than five acute care episodes in six months) reported social stability but found accessing ambulatory care to be difficult. Interventions to improve outcomes and values need to take these differences into account.
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Hospital readmission rates: Signal of failure or success?
Mauro Laudicella, Paolo Li Donni & Peter Smith
Journal of Health Economics, forthcoming
Abstract:
Hospital readmission rates are increasingly used as signals of hospital performance and a basis for hospital reimbursement. However, their interpretation may be complicated by differential patient survival rates. If patient characteristics are not perfectly observable and hospitals differ in their mortality rates, then hospitals with low mortality rates are likely to have a larger share of un-observably sicker patients at risk of a readmission. Their performance on readmissions will then be underestimated. We examine hospitals' performance relaxing the assumption of independence between mortality and readmissions implicitly adopted in many empirical applications. We use data from the Hospital Episode Statistics on emergency admissions for fractured hip in 290,000 patients aged 65 and over from 2003-2008 in England. We find evidence of sample selection bias that affects inference from traditional models. We use a bivariate sample selection model to allow for the selection process and the dichotomous nature of the outcome variables.
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Does Higher Malpractice Pressure Deter Medical Errors?
Toshiaki Iizuka
Journal of Law and Economics, February 2013, Pages 161-188
Abstract:
An important objective of medical liability law is to deter medical errors by punishing negligent mistakes. However, relatively little evidence exists on the deterrence effect. Using newly constructed measures of preventable medical complications and state tort reforms in the United States between 1994 and 2007, I find evidence that higher liability pressure deters preventable medical complications associated with four specific obstetric and gynecologic procedures. The results also show that the effects of tort reforms vary according to the specific reform in question. While joint and several liability reform (which increases doctor accountability) appears to decrease preventable medical complications, collateral source rule reform and caps on punitive damages appear to increase these complications. Opponents of tort reform often argue that tort reforms may adversely affect patient safety, and the results of this paper suggest that such a concern is legitimate.
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Medicaid ‘Welcome-Mat' Effect Of Affordable Care Act Implementation Could Be Substantial
Julie Sonier, Michel Boudreaux & Lynn Blewett
Health Affairs, July 2013, Pages 1319-1325
Abstract:
The Affordable Care Act will have important impacts on state Medicaid programs, likely increasing participation among populations that are currently eligible but not enrolled. The size of this "welcome-mat" effect is of concern for two reasons. First, the eligible but uninsured constitute a substantial share of the uninsured population in some states. Second, the newly eligible population will affect states' Medicaid caseloads and budgets. Using the Massachusetts 2006 health reforms as a case study and controlling for other factors, we found that among low-income parents who were previously eligible for Medicaid in Massachusetts, Medicaid enrollment increased by 16.3 percentage points, and Medicaid participation by those without private coverage increased by 19.4 percentage points, in comparison to a group of control states. In many states the potential size of the welcome-mat effect could be even larger than what we observed in Massachusetts. Our analysis has potentially important implications for other states attempting to predict the impact of this effect on their budgets.
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Heterogeneity in Cost-Sharing and Cost-Sensitivity, and the Role of the Prescribing Physician
Mariana Carrera, Dana Goldman & Geoffrey Joyce
NBER Working Paper, June 2013
Abstract:
In this paper, we use individual level data on purchases of one of the most prescribed categories of drugs (cholesterol-lowering statins) to study the responses of physicians and patients to variation in the cost of drugs. In a sample of first-time statin prescriptions to employees from a group of Fortune 500 firms, we find that copay variation across plans has a relatively small effect on the choice of drug, and this effect does not vary with patient income. After the highly-publicized expiration of the patent for Zocor (simvastatin), however, prescriptions for this drug increased substantially, especially for lower-income patients. Our analysis suggests that physicians can perceive the adherence elasticity of their patients and adjust their initial prescriptions accordingly, but only in response to a large and universal price change. Using prescriber identifiers, we present suggestive evidence that physicians learn about a patient's price sensitivity through their own experience of prescribing to that patient.
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Julia Adler-Milstein et al.
Annals of Internal Medicine, 16 July 2013, Pages 97-104
Objective: To assess short-term cost savings from community-wide adoption of ambulatory EHRs.
Setting: Natural experiment in which 806 ambulatory clinicians across 3 Massachusetts communities adopted subsidized EHRs. Six matched control communities applied but were not selected to participate.
Measurements: Monthly standardized health care costs from commercial claims data from January 2005 to June 2009, including total cost, inpatient cost, and ambulatory cost and its subtypes (pharmacy, laboratory, and radiology). Projected savings per member per month (PMPM), excluding EHR adoption costs.
Results: Ambulatory EHR adoption did not impact total cost (pre- to postimplementation difference in monthly trend change, -0.30 percentage point; P = 0.135), but the results favored savings (95% CI, $21.95 PMPM in savings to $1.53 PMPM in higher costs). It slowed ambulatory cost growth (difference in monthly trend change, -0.35 percentage point; P = 0.012); projected ambulatory savings were $4.69 PMPM (CI, $8.45 to $1.09 PMPM) (3.10% of total PMPM cost). Ambulatory radiology costs decreased (difference in monthly trend change, -1.61 percentage points; P < 0.001), with projected savings of $1.61 PMPM (1.07% of total PMPM cost).
Conclusion: Using commercially available EHRs in community practices seems to modestly slow ambulatory cost growth. Broader changes in the organization and payment of care may prompt clinicians to use EHRs in ways that result in more substantial savings.
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Trends in cost sharing among selected high income countries - 2000-2010
Zare Hossein & Anderson Gerard
Health Policy, forthcoming
Abstract:
Many high income countries increased their level of patient cost sharing between 2000 and 2010 as one component of their policy agenda to reduce the level of health care spending. We use data from the OECD, European Observatory, and country-specific resources to analyze trends in the UK, Germany, Japan, France, and the United States. Some forms of cost sharing - deductibles, co-insurance, or co-payments - increased in all these countries, with the highest rates of increase occurring in the pharmaceutical sector. In spite of higher levels of cost-sharing, out-of-pocket spending as a percentage of total spending remained unchanged in most of these countries because they instituted programs to protect certain categories of individuals by creating out-of-pocket limits, exempting people with certain chronic diseases, or eliminating cost sharing for certain demographic groups and low-income people.
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Neeraj Sood et al.
Journal of Health Economics, forthcoming
Abstract:
We examine provider responses to the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS), which simultaneously reduced marginal reimbursement and increased average reimbursement. IRFs could respond to the PPS by changing the number of patients admitted, admitting different types of patients, or changing the intensity of care. We use Medicare claims data to separately estimate each type of provider response. We also examine changes in patient outcomes and spillover effects on other post-acute care providers. We find that costs of care initially fell following the PPS, which we attribute to changes in treatment decisions rather than the characteristics of patients admitted to IRFs within the diagnostic categories we examine. However, the probability of admission to IRFs increased after the PPS due to the expanded admission policies of providers. We find modest spillover effects in other post-acute settings and negative health impacts for only one of three diagnostic groups studied.
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James Reschovsky et al.
Health Services Research, forthcoming
Objectives: To measure geographic variations in treatment costs for specific conditions, explore the consistency of these patterns across conditions, and examine how service mix and population health factors are associated with condition-specific and total area costs.
Data Sources: Medicare claims for 1.5 million elderly beneficiaries from 60 community tracking study (CTS) sites who received services from 5,500 CTS Physician Survey respondents during 2004-2006.
Study Design: Episodes of care for 10 costly and common conditions were formed using Episode Treatment Group grouper software. Episode and total annual costs were calculated, adjusted for price, patient demographics, and comorbidities. We correlated episode costs across sites and examined whether episode service mix and patient health were associated with condition-specific and total per-beneficiary costs.
Principal Findings: Adjusted episode costs varied from 34 to 68 percent between the most and least expensive site quintiles. Area mean costs were only weakly correlated across conditions. Hospitalization rates, surgery rates, and specialist involvement were associated with site episode costs, but local population health indicators were most related to site total per-beneficiary costs.
Conclusions: Population health appears to drive local per-beneficiary Medicare costs, whereas local practice patterns likely influence condition-specific episode costs. Reforms should be flexible to address local conditions and practice patterns.
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Potentially Preventable Use of Emergency Services: The Role of Low Health Literacy
Jessica Schumacher et al.
Medical Care, August 2013, Pages 654-658
Background: Limited health literacy is a barrier for understanding health information and has been identified as a risk factor for overuse of the emergency department (ED). The association of health literacy with access to primary care services in patients presenting to the ED has not been fully explored.
Objective: To examine the relationship between health literacy, access to primary care, and reasons for ED use among adults presenting for emergency care.
Methods: Structured interviews that included health literacy assessment were performed involving 492 ED patients at one Southern academic medical center. Unadjusted and multivariable logistic regression models assessed the relationship between health literacy and (1) access to a personal physician; (2) doctor office visits; (3) ED visits; (4) hospitalizations; and (5) potentially preventable hospital admissions.
Results: After adjusting for sociodemographic and health status, those with limited health literacy reported fewer doctor office visits [odds ratio (OR)=0.6; 95% confidence interval (CI), 0.4-1.0], greater ED use, (OR=1.6; 95% CI, 1.0-2.4), and had more potentially preventable hospital admissions (OR=1.7; 95% CI, 1.0-2.7) than those with adequate health literacy. After further controlling for insurance and employment status, fewer doctor office visits remained significantly associated with patient health literacy (OR=0.5; 95% CI, 0.3-0.9). Patients with limited health literacy reported a preference for emergency care, as the services were perceived as better.
Conclusions: Among ED patients, limited health literacy was independently associated with fewer doctor office visits and a preference for emergency care. Policies to reduce ED use should consider steps to limit barriers and improve attitudes toward primary care services.
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Kevin Stange
NBER Working Paper, June 2013
Abstract:
Nurse practitioners (NPs) and physician assistants (PAs) now outnumber family practice doctors in the United States and are the principal providers of primary care to many communities. Recent growth of these professions has occurred amidst considerable cross-state variation in their regulation, with some states permitting autonomous practice and others mandating extensive physician oversight. I find that expanded NP and PA supply has had minimal impact on the office-based healthcare market overall, but utilization has been modestly more responsive to supply increases in states permitting greater autonomy. Results suggest the importance of laws impacting the division of labor, not just its quantity.
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Trends in PCI Volume after Negative Results from the COURAGE Trial
David Howard & Yu-Chu Shen
Health Services Research, forthcoming
Objective: To describe trends in the use of percutaneous coronary intervention (PCI) following the COURAGE trial, which found that medical therapy is as effective as PCI for patients with stable angina.
Data Sources: We used the National Hospital Discharge Survey; inpatient and outpatient discharge data from Florida, Maryland, and New Jersey; and the English Hospital Episode Statistics database.
Study Design: We report trends in PCI volume by diagnosis (stable angina vs. unstable angina or AMI) before and after publication of the COURAGE trial.
Principal Findings: The number of PCIs in patients without a diagnosis of AMI or unstable angina in Florida, Maryland, and New Jersey declined from 48,000 in 2006 to 40,000 in 2008 (-17 percent). There was no change in the number of PCIs in patients with a diagnosis of AMI. We observed similar patterns in U.S. community hospitals. PCI volume did not decline in England.
Conclusions: PCI volume declined after publication of the COURAGE trial. The experience of the COURAGE trial suggests that comparative effectiveness research can lead to cost-saving changes in medical practice patterns. However, there are many patients with stable coronary disease who continue to receive PCI post-COURAGE.