In network
Party Politics, Governors, and Healthcare Expenditures
Nayan Krishna Joshi
Economics & Politics, forthcoming
Abstract:
This study examines the impact of gubernatorial partisanship on the growth of healthcare expenditures (HCE) for a panel dataset of 50 U.S. states over the 1991–2009 period. Using the parametric regression discontinuity design, I find no partisan effect on the growth of state's per capita real total personal HCE. However, an analysis of the growth rates of the components of HCE suggests that there is a causal effect of party affiliation on the “prescription drugs” component. These findings are robust to the inclusion of additional covariates in the parametric approach as well to the use of the non-parametric regression discontinuity approach. The results further suggest that the impact of gubernatorial partisanship does not depend on the length of the governor's term in office.
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Professional Societies, Political Action Committees, and Party Preferences
Steven Bernstein, Carol Barsky & Eleanor Powell
American Journal of Public Health, January 2015, Pages e11-e14
Abstract:
Societies representing physician specialties and other health care personnel commonly have political action committees (PACs). These PACs seek to advance their members’ interests through advocacy and campaign contributions. We examined contribution data for health care workers’ PACs from the 2010 to 2012 election cycles and found that higher annual income was strongly associated with greater giving to Republican candidates. Patterns of giving may offer insights into various medical workers’ party preferences, political leanings, and views of health care reform.
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Arnold Epstein et al.
Health Affairs, November 2014, Pages 2041-2047
Abstract:
Expansion of Medicaid under the Affordable Care Act to millions of low-income adults has been controversial, yet little is known about what these Americans themselves think about Medicaid. We conducted a telephone survey in late 2013 of nearly 3,000 low-income adults in three Southern states — Arkansas, Kentucky, and Texas — that have adopted different approaches to the options for expansion. Nearly 80 percent of our sample in all three states favored Medicaid expansion, and approximately two-thirds of uninsured respondents said that they planned to apply for either Medicaid or subsidized private coverage in 2014. Yet awareness of their state’s actual expansion plans was low. Most viewed having Medicaid as better than being uninsured and at least as good as private insurance in overall quality and affordability. While the debate over Medicaid expansion continues, support for expansion is strong among low-income adults, and the perceived quality of Medicaid coverage is high.
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People respond better to robots than computer tablets delivering healthcare instructions
Jordan Mann et al.
Computers in Human Behavior, February 2015, Pages 112–117
Abstract:
The population of the world is ageing, particularly in developed countries. As the population’s age increases, the healthcare workforce is becoming progressively unable to meet the high healthcare demands of the elderly population. Increasingly, technology is being used to solve this dilemma. Using a sample from the general population (n = 65), this study examined how people interacted with either a robot or a tablet computer delivering healthcare instructions. During this interaction, the robot/tablet asked them several health-related questions, and to perform limited physical tests and a relaxation exercise. Results showed participants had more positive interactions with the robot compared to the computer tablet, including increased speech and positive emotion (smiling), and participation in the relaxation exercise. Further results showed the robot was rated higher on scales of trust, enjoyment, and desire for future interaction. This suggests that robots may offer benefits over and above computer tablets in delivering healthcare. These results further demonstrate that the physical nature of technology is important in determining responses to healthcare interactions.
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The Relationship between Commercial Health Care Prices and Medicare Spending and Utilization
John Romley et al.
Health Services Research, forthcoming
Objective: To explore the relationship between commercial health care prices and Medicare spending/utilization across U.S. regions.
Data Sources: Claims from large employers and Medicare Parts A/B/D over 2007–2009.
Study Design: We compared prices paid by commercial health plans to Medicare spending and utilization, adjusted for beneficiary health and the cost of care, across 301 hospital referral regions.
Principal Findings: A 10 percent lower commercial price (around the average level) is associated with 3.0 percent higher Medicare spending per member per year, and 4.3 percent more specialist visits (p < .01).
Conclusions: Commercial health care prices are negatively associated with Medicare spending across regions. Providers may respond to low commercial prices by shifting service volume into Medicare. Further investigation is needed to establish causality.
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Quality and Equity of Care in U.S. Hospitals
Amal Trivedi et al.
New England Journal of Medicine, 11 December 2014, Pages 2298-2308
Background: Nearly every U.S. hospital publicly reports its performance on quality measures for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia. Because performance rates are not reported according to race or ethnic group, it is unclear whether improvements in equity of care have accompanied aggregate improvements in health care quality over time.
Methods: We assessed performance rates for quality measures covering three conditions (six measures for acute myocardial infarction, four for heart failure, and seven for pneumonia). These rates, adjusted for patient- and hospital-level covariates, were compared among non-Hispanic white, non-Hispanic black, and Hispanic patients who received care between 2005 and 2010 in acute care hospitals throughout the United States.
Results: Adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points between 2005 and 2010 for white, black, and Hispanic adults (P<0.001 for all comparisons). In 2005, as compared with adjusted performance rates for white patients, adjusted performance rates were more than 5 percentage points lower for black patients on 3 measures (range of differences, 12.3 to 14.2) and for Hispanic patients on 6 measures (5.6 to 14.5). Gaps decreased significantly on all 9 of these measures between 2005 and 2010, with adjusted changes for differences between white patients and black patients ranging from −8.5 to −11.8 percentage points and from −6.2 to −15.1 percentage points for differences between white patients and Hispanic patients. Decreasing differences according to race or ethnic group were attributable to more equitable care for white patients and minority patients treated in the same hospital, as well as to greater performance improvements among hospitals that disproportionately serve minority patients.
Conclusions: Improved performance on quality measures for white, black, and Hispanic adults hospitalized for acute myocardial infarction, heart failure, or pneumonia was accompanied by increased racial and ethnic equity in performance rates both within and among U.S. hospitals.
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Physician payments under health care reform
Abe Dunn & Adam Hale Shapiro
Journal of Health Economics, January 2015, Pages 89–105
Abstract:
This study examines the impact of major health insurance reform on payments made in the health care sector. We study the prices of services paid to physicians in the privately insured market during the Massachusetts health care reform. The reform increased the number of insured individuals as well as introduced an online marketplace where insurers compete. We estimate that, over the reform period, physician payments increased at least 11 percentage points relative to control areas. Payment increases began around the time legislation passed the House and Senate — the period in which their was a high probability of the bill eventually becoming law. This result is consistent with fixed-duration payment contracts being negotiated in anticipation of future demand and competition.
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Kurt Angstman et al.
Medical Care, January 2015, Pages 32-37
Background/Objectives: Racial and ethnic disparities in depression incidence, prevalence, treatment, and outcomes still persist. The hypothesis of this study was that use of collaborative care management (CCM) in treating depressed primary care patients would decrease racial disparities in 6-month clinical outcomes compared with those patients treated with usual primary care (UC).
Research Design/Subjects: In a retrospective chart review analysis, 3588 (51.2%) patients received UC and 3422 (48.8%) patients were enrolled in CCM. Logistic regression analyses were used to examine disparities in 6-month outcomes.
Results: Minority patients enrolled in CCM were more likely to be participating in depression care at 6 months than minority patients in UC (61.8% vs. 14.4%; P≤0.001). After adjustment for demographic and clinical covariates, this difference remained statistically significant (odds ratio=9.929; 95% CI, 6.539–15.077, P≤0.001). The 568 minority UC patients with 6-month follow-up PHQ-9 data demonstrated a much lower odds ratio of a PHQ-9 score of <5 (0.220; 95% CI, 0.085–0.570; P=0.002) and a much higher odds ratio of PHQ-9 score of ≥10 (3.068; 95% CI, 1.622–5.804; P<0.001) when compared with the white, non-Hispanic patients. In contrast, the 2329 patients treated with CCM, the odds ratio for a PHQ-9 score of <5 or ≥10 after 6 months, demonstrated no significance of minority status.
Conclusions: Utilization of CCM for depression was associated with a significant reduction of the disparities for outcomes of compliance, remission, or persistence of depressive symptoms for minority patients with depression versus those treated with UC.
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Candice Chen et al.
Journal of the American Medical Association, 10 December 2014, Pages 2385-2393
Importance: Graduate medical education training may imprint young physicians with skills and experiences, but few studies have evaluated imprinting on physician spending patterns.
Design, Setting, and Participants: Secondary multilevel multivariable analysis of 2011 Medicare claims data (Part A hospital and Part B physician) for a random, nationally representative sample of family medicine and internal medicine physicians completing residency between 1992 and 2010 with Medicare patient panels of 40 or more patients (2851 physicians providing care to 491 948 Medicare beneficiaries).
Exposures: Locations of practice and residency training were matched with Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups, with approximately equal distribution of beneficiary numbers. There were 674 physicians in low-spending training and low-spending practice HRRs, 180 in average-spending training/low-spending practice, 178 in high-spending training/low-spending practice, 253 in low-spending training/average-spending practice, 417 in average-spending training/average-spending practice, 210 in high-spending training/average-spending practice, 97 in low-spending training/high-spending practice, 275 in average-spending training/high-spending practice, and 567 in high-spending training/high-spending practice.
Results: For physicians practicing in high-spending regions, those trained in high-spending regions had a mean spending per beneficiary per year $1926 higher (95% CI, $889-$2963) than those trained in low-spending regions. For practice in average-spending HRRs, mean spending was $897 higher (95% CI, $71-$1723) for physicians trained in high- vs low-spending regions. For practice in low-spending HRRs, the difference across training HRR levels was not significant ($533; 95% CI, –$46 to $1112). After controlling for patient, community, and physician characteristics, there was a 7% difference (95% CI, 2%-12%) in patient expenditures between low- and high-spending training HRRs. Across all practice HRRs, this corresponded to an estimated $522 difference (95% CI, $146-$919) between low- and high-spending training regions. For physicians 1 to 7 years in practice, there was a 29% difference ($2434; 95% CI, $1004-$4111) in spending between those trained in low- and high-spending regions; however, after 16 to 19 years, there was no significant difference.
Conclusions and Relevance: Among general internists and family physicians who completed residency training between 1992 and 2010, the spending patterns in the HRR in which their residency program was located were associated with expenditures for subsequent care they provided as practicing physicians for Medicare beneficiaries. Interventions during residency training may have the potential to help control future health care spending.
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Dan Shane & Padmaja Ayyagari
Health Services Research, forthcoming
Objectives: To assess whether the Affordable Care Act's (ACA) dependent coverage health insurance mandate had a spillover impact on young adult dental insurance coverage and whether any observed effects varied by household income.
Data: Medical Expenditure Panel Surveys from 2006 through 2011.
Study Design: We employed a difference-in-difference regression approach comparing changes in insurance rates for young adults ages 19–25 years to changes in insurance rates for adults ages 27–30 years. Separate regressions were estimated by categories of household income as a percentage of the Federal Poverty Level (FPL) to understand whether the mandate had heterogeneous spillover effects.
Results: Private dental insurance increased by 6.7 percentage points among young adults compared to a control group of 27–30-year olds. Increases were concentrated at middle-income levels (125–400 percent FPL).
Conclusions: The dependent coverage mandate provision of the Affordable Care Act has not only increased health insurance rates among young adults but also dental insurance coverage rates.
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Evaluation of the Effectiveness of a Surgical Checklist in Medicare Patients
Bradley Reames et al.
Medical Care, January 2015, Pages 87-94
Background: Surgical checklists are increasingly used to improve compliance with evidence-based processes in the perioperative period. Although enthusiasm exists for using checklists to improve outcomes, recent studies have questioned their effectiveness in large populations.
Objective: We sought to examine the association of Keystone Surgery, a statewide implementation of an evidence-based checklist and Comprehensive Unit–based Safety Program, on surgical outcomes and health care costs.
Methods: We performed a study using national Medicare claims data for patients undergoing general and vascular surgery (n=1,002,241) from 2006 to 2011. A difference-in-differences approach was used to evaluate whether implementation was associated with improved surgical outcomes and decreased costs when compared with a national cohort of nonparticipating hospitals. Propensity score matching was used to select 10 control hospitals for each participating hospital. Costs were assessed using price-standardized 30-day Medicare payments for acute hospitalizations, readmissions, and high-cost outliers.
Results: Keystone Surgery implementation in participating centers (N=95 hospitals) was not associated with improved outcomes. Difference-in-differences analysis accounting for trends in nonparticipating hospitals (N=950 hospitals) revealed no differences in adjusted rates of 30-day mortality [relative risk (RR)=1.03; 95% confidence intervals (CI), 0.97–1.10], any complication (RR=1.03; 95% CI, 0.99–1.07), reoperations (RR=0.89; 95% CI, 0.56–1.22), or readmissions (RR=1.01; 95% CI, 0.97–1.05). Medicare payments for the index admission increased following implementation ($516 average increase in payments; 95% CI, $210–$823 increase), as did readmission payments ($564 increase; 95% CI, $89–$1040 increase). High-outlier payments ($965 increase; 95% CI, $974decrease to $2904 increase) did not change.
Conclusions: Implementation of Keystone Surgery in Michigan was not associated with improved outcomes or decreased costs in Medicare patients.
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Jack Resneck et al.
JAMA Dermatology, December 2014, Pages 1290-1297
Objective: To determine the accuracy of MA plan directories of participating dermatologists, and the appointment availability of listed physicians.
Design, Setting, and Participants: Scripted telephone calls were placed to every dermatologist listed in directories for the largest MA plans in 12 US metropolitan areas. The caller sought an appointment on behalf of his fictitious father who had severe itch for several months, asked whether the dermatologist accepted the relevant plan, and asked for the next available appointment date.
Results: Among 4754 total physician listings, 45.5% represented duplicates in the same plan directory. Among the remaining unique listings, 48.9% of physicians were reachable, accepted the listed plan, and offered an appointment for our fictitious patient. Many of the dermatologists listed had incorrect contact information, were deceased, retired, or had moved, were not accepting new patients, did not accept the insurance plan, or were subspecialized. The mean (range) wait time for appointments among the remaining listings was 45.5 (1-414) days. Both the accuracy of network directories and the appointment wait times varied substantially by health plan and metropolitan area. For 1 plan, our caller was unable to obtain an appointment with any listed dermatologist.
Conclusions and Relevance: Medicare Advantage physician directories for dermatology in many areas substantially overestimate the number of in-network physicians available to treat patients with medical skin conditions. These inaccuracies occurred in areas with long appointment wait times and where plans are terminating selected physician contracts. This suggests a lack of capacity that would be exacerbated by further network narrowing. Accurate physician directories are essential for proper oversight of network adequacy, and for patients who rely on these listings to evaluate health plan options during open enrollment.
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Seth Seabury, Eric Helland & Anupam Jena
Health Affairs, November 2014, Pages 2048-2056
Abstract:
The impact of medical malpractice reforms on the average size of malpractice payments in specific physician specialties is unknown and subject to debate. We analyzed a national sample of malpractice claims for the period 1985–2010, merged with information on state liability reforms, to estimate the impact of state noneconomic damages caps on average malpractice payment size for physicians overall and for ten different specialty categories. We then compared how the effects differed according to the restrictiveness of the cap ($250,000 versus $500,000). We found that, overall, noneconomic damages caps reduced average payments by $42,980 (15 percent), compared to having no cap at all. A more restrictive $250,000 cap reduced average payments by $59,331 (20 percent), and a less restrictive $500,000 cap had no significant effect, compared to no cap at all. The effect of the caps overall varied according to specialty, with the largest impact being on claims involving pediatricians and the smallest on claims involving surgical subspecialties and ophthalmologists.
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Jennifer Lee et al.
Medical Care, January 2015, Pages 38-44
Objectives: This study aimed to estimate the change in emergency department (ED) utilization per individual among a cohort who qualified for subsidized health insurance following the Massachusetts health care reform.
Research Design: We obtained Massachusetts public health insurance enrollment data for the fiscal years 2004–2008 and identified 353,515 adults who enrolled in Commonwealth Care, a program that subsidizes insurance for low-income adults. We merged the enrollment data with statewide ED visit claims and created a longitudinal file that indicated each enrollee’s ED visits and insurance status each month during the preenrollment and postenrollment periods.
Results: Among the 112,146 CommCare enrollees who made at least 1 ED visit during the study period, an individual’s odds of an ED visit decreased 4% [odds ratio (OR)=0.96; 95% confidence interval (CI), 0.94, 0.98] postenrollment. However, it varied significantly depending on preenrollment insurance status. A person’s odds of an ED visit was 12% higher in the postperiod among enrollees not publicly insured prior (OR=1.12; 95% CI, 1.10, 1.25), but was 18% lower among enrollees who transitioned from the Health Safety Net, a program that pays for limited services for low-income individuals (OR=0.82; 95% CI, 0.78, 0.85).
Conclusions: Expanding subsidized health insurance did not uniformly change ED utilization for all newly insured low-income adults in Massachusetts.
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Public Health Insurance Expansions and Hospital Technology Adoption
Seth Freedman, Haizhen Lin & Kosali Simon
Journal of Public Economics, forthcoming
Abstract:
This paper explores the effects of public health insurance expansions on hospitals’ decisions to adopt medical technology. Specifically, we test whether the expansion of Medicaid eligibility for pregnant women during the 1980s and 1990s affects hospitals’ decisions to adopt neonatal intensive care units (NICUs). While Medicaid expansion provided new insurance to a substantial number of pregnant women, prior literature also finds that some newly insured women would otherwise have been covered by more generously reimbursed private sources. Such crowd-out, combined with Medicaid’s low reimbursement rats, leads to a theoretically ambiguous net effect of Medicaid expansion on a hospital’s incentive to invest in technology. Using American Hospital Association data, we find that on average, Medicaid expansion has no statistically significant effect on NICU adoption. However, we also find that in geographic areas where more of the newly Medicaid-insured may have come from the privately insured population, Medicaid expansion slows NICU adoption. This holds true particularly when Medicaid payment rates are very low relative to private payment rates. Our findings are consistent with prior evidence on reduced NICU adoption from increased managed-care penetration. We conclude by discussing the policy implications of our work for insurance expansions associated with the Affordable Care Act.
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The effect of state dependent mandate laws on the labor supply decisions of young adults
Briggs Depew
Journal of Health Economics, January 2015, Pages 123–134
Abstract:
Prior to the Affordable Care Act, the majority of states in the U.S. had already implemented state laws that extended the age that young adults could enroll as dependents on their parent's employer-based health insurance plans. Because of the fundamental link between health insurance and employment in the U.S., such policies may affect the labor supply decisions of young adults. Although the interaction between labor supply and health insurance has been extensively studied for other subpopulations, little is known about the role of health insurance in the labor supply decisions of young adults. I use the variation from the implementation and changes in state policies that expanded dependent health insurance coverage to examine how young adults adjusted their labor supply when they were able to be covered as a dependent on their parent's plan. I find that these state mandates led to a decrease in labor supply on the intensive margin.
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What Is the Cost of Quality for Diabetes Care?
Jean Abraham et al.
Medical Care Research and Review, December 2014, Pages 580-598
Abstract:
Increasing the quality of care and reducing cost growth are core objectives of numerous private- and public-sector performance improvement initiatives. Using a unique panel data set for a commercially insured population and multivariate regression analysis, this study examines the relationship between medical care spending and diabetes-related quality measures, including provider-initiated processes of care and patient-dependent quality activities. Empirical evidence generated from this analysis of the relationship between a comprehensive set of diabetes quality measures and diabetes-related spending does not lend support for the assumption that high-quality preventive and primary care combined with effective patient self-management can lead to lower costs in the near term. Finally, we find no relationship between adjusted spending and intermediate clinical outcomes (e.g., HbA1c level) measured at the clinic level.
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Martha Bailey & Andrew Goodman-Bacon
NBER Working Paper, October 2014
Abstract:
This paper uses the rollout of the first Community Health Centers (CHCs) to study the longer-term health effects of increasing access to primary care. Within ten years, CHCs are associated with a reduction in age-adjusted mortality rates of 2 percent among those 50 and older. The implied 7 to 13 percent decrease in one-year mortality risk among beneficiaries amounts to 20 to 40 percent of the 1966 poor/non-poor mortality gap for this age group. Large effects for those 65 and older suggest that increased access to primary care has longer-term benefits, even for populations with near universal health insurance.
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Hennepin Health: A Safety-Net Accountable Care Organization For The Expanded Medicaid Population
Shana Sandberg et al.
Health Affairs, November 2014, Pages 1975-1984
Abstract:
Health care payment and delivery models that challenge providers to be accountable for outcomes have fueled interest in community-level partnerships that address the behavioral, social, and economic determinants of health. We describe how Hennepin Health — a county-based safety-net accountable care organization in Minnesota — has forged such a partnership to redesign the health care workforce and improve the coordination of the physical, behavioral, social, and economic dimensions of care for an expanded community of Medicaid beneficiaries. Early outcomes suggest that the program has had an impact in shifting care from hospitals to outpatient settings. For example, emergency department visits decreased 9.1 percent between 2012 and 2013, while outpatient visits increased 3.3 percent. An increasing percentage of patients have received diabetes, vascular, and asthma care at optimal levels. At the same time, Hennepin Health has realized savings and reinvested them in future improvements. Hennepin Health offers lessons for counties, states, and public hospitals grappling with the problem of how to make the best use of public funds in serving expanded Medicaid populations and other communities with high needs.
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Public insurance expansions and the health of immigrant and native children
Erin Todd Bronchetti
Journal of Public Economics, December 2014, Pages 205–219
Abstract:
The costs of public insurance expansions are ordinarily justified by the claim that increased eligibility causes gains in insurance coverage, which translate into improved health care and health. This paper studies dramatic changes in public health insurance eligibility for immigrant and native children from 1998 to 2009 and finds that children's nativity status is crucial to understanding the impacts of recent eligibility expansions. I document a significantly higher degree of take-up (and less crowding out of private insurance) among first- and second-generation immigrant children than among children of U.S. natives. Eligibility expansions increased immigrant children's use of preventive and ambulatory care and decreased emergency care in hospitals, while estimated effects for children of natives are negligible. My results also suggest improvements in some health measures that would be expected to respond to preventive and ambulatory care.
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Brandyn Lau et al.
Medical Care, January 2015, Pages 18-24
Background: All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen.
Subjects: The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients.
Results: Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort.
Conclusions: Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.
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State tax subsidies to bolster the long-term care insurance market
David Nixon
Journal of Public Policy, December 2014, Pages 415-436
Abstract:
This paper examines long-term care insurance sales to assess whether state income tax subsidies are effective in encouraging the private purchase of long-term care insurance. Drawing from the most comprehensive available sales data on long-term care insurance policies, cross-state and over-time variation in sales data during the late 1990s and early 2000s are analysed. This analysis uses a panel model with fixed effects controls for potential endogeneity between state provision of tax subsidies and actual sales of long-term care insurance policies. Income, health and family support factors are significant determinants in the sale of long-term care insurance, but the tax incentives provided by many state governments do not induce any more sales of long-term care insurance than could be expected without such incentives. These costly subsidies have not been prudent uses of public dollars, and have not helped states cope with the challenge of long-term care costs.
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Early Elective Deliveries Accounted For Nearly 9 Percent Of Births Paid For By Medicaid
Tara Trudnak Fowler et al.
Health Affairs, December 2014, Pages 2170-2178
Abstract:
Reducing early elective deliveries has become a priority for Medicaid medical directors and their state partners. Such deliveries lead to poor health outcomes for newborns and their mothers and generate additional costs for patients, providers, and Medicaid, which pays for up to 48 percent of all births in the United States each year. Early elective deliveries are non–medically indicated labor inductions or cesarean deliveries of infants with a confirmed gestational age of less than thirty-nine weeks. This retrospective descriptive study reports the results of a perinatal project, led by the state Medicaid medical directors, that sought to coordinate quality improvement efforts related to early elective deliveries for the Medicaid population. Twenty-two states participated in the project and provided data on elective deliveries in the period 2010–12. We found that 75,131 (8.9 percent) of 839,688 Medicaid singleton births were early elective deliveries. Thus, we estimate that there are 160,000 early elective Medicaid deliveries nationwide each year. In twelve states, early-term elective deliveries declined 32 percent between 2007 and 2011. Our study offers additional evidence and new tools for policy makers pursuing strategies to further reduce the number of such deliveries.
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Bradley Gray et al.
Journal of the American Medical Association, 10 December 2014, Pages 2348-2357
Importance: In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes.
Design, Setting, and Participants: Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control.
Main Outcomes and Measures: Quality measures were ambulatory care–sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars).
Results: Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, −1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of −$167 (95% CI, −$270.5 to −$63.5; P = .002; 2.5% of overall mean cost).
Conclusion and Relevance: Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.
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John Hayes et al.
Journal of the American Medical Association, 10 December 2014, Pages 2358-2363
Importance: American Board of Internal Medicine (ABIM) initiatives encourage internists with time-unlimited certificates to recertify. However, there are limited data evaluating differences in performance between internists with time-limited or time-unlimited board certification.
Design, Setting, and Participants: Retrospective analysis of performance data from 1 year (2012-2013) at 4 Veterans Affairs (VA) medical centers. Participants were internists with time-limited (n = 71) or time-unlimited (n = 34) ABIM certification providing primary care to 68 213 patients. Median physician panel size was 610 patients (range, 19-1316), with no differences between groups (P = .90).
Main Outcomes and Measures: Ten primary care performance measures: colorectal screening rates; diabetes with glycated hemoglobin (HbA1c level) less than 9.0%; diabetes with blood pressure less than 140/90 mm Hg; diabetes with low-density lipoprotein cholesterol (LDL-C) level less than 100 mg/dL; hypertension with blood pressure less than 140/90 mm Hg; thiazide diuretics used in multidrug hypertensive regimen; atherosclerotic coronary artery disease and LDL-C level less than 100 mg/dL; post–myocardial infarction use of aspirin; post–myocardial infarction use of β-blockers; congestive heart failure (CHF) with use of angiotensin-converting enzyme (ACE) inhibitor.
Results: After adjustment for practice site, panel size, years since certification, and clustering by physician, there were no differences in outcomes for patients cared for by internists with time-limited or time-unlimited certification for any performance measure: colorectal screening (odds ratio [OR], 0.95 [95% CI, 0.89-1.01]); diabetes with HbA1c level less than 9.0% (OR, 0.96 [95% CI, 0.74-1.2]); blood pressure control (OR, 0.99 [95% CI, 0.69-1.4]); LDL-C level less than 100 mg/dL (OR, 1.1 [95% CI, 0.79-1.5]); hypertension with blood pressure less than 140/90 mm Hg (OR, 1.0 [95% CI, 0.92-1.2]); thiazide use (OR, 1.0 [95% CI, 0.8-1.3]); atherosclerotic coronary artery disease with LDL-C level less than 100 mg/dL (OR, 1.1 [95% CI, 0.75-1.7]); post–myocardial infarction use of aspirin (OR, 0.98 [95% CI, 0.58-1.68]) or β-blockers (OR, 1.0 [95% CI, 0.57-1.9]); CHF with use of ACE inhibitor (OR, 0.98 [95% CI, 0.61-1.6]).
Conclusions and Relevance: Among internists providing primary care at 4 VA medical centers, there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures. Additional research to examine the difference in patient outcomes among holders of time-limited and time-unlimited certificates in non-VA and nonacademic settings and the association with other ABIM goals may help clarify the potential benefit of Maintenance of Certification participation.
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Yaa Akosa Antwi, Asako Moriya & Kosali Simon
Journal of Health Economics, forthcoming
Abstract:
The Affordable Care Act of 2010 expanded coverage to young adults by allowing them to remain on their parent's private health insurance until they turn 26 years old. While there is evidence on insurance effects, we know very little about use of general or specific forms of medical care. We study the implications of the expansion for the use of inpatient hospitalizations. Given the prevalence of mental health needs for young adults, we also specifically study mental health related inpatient care. We find evidence that compared to those aged 27–29 years, treated young adults aged 19–25 years increased their inpatient visits by 3.5 percent while mental illness visits increased 9.0 percent. The prevalence of uninsurance among hospitalized young adults decreased by 12.5 percent; however, it does not appear that the intensity of inpatient treatment changed despite the change in reimbursement composition of patients.
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Tianyan Hu, Sandra Decker & Shin-Yi Chou
NBER Working Paper, November 2014
Abstract:
We test the effect of the introduction of Medicare Part D on physician prescribing behavior by using data on physician visits from the National Ambulatory Medical Care Survey (NAMCS) 2002-2004 and 2006-2009 for patients aged 60-69. We use a combined DD-RD specification that is an improvement over either the difference-in-difference (DD) or regression discontinuity (RD) designs. Comparing the discrete jump in outcomes at age 65 before and after 2006, we find a 35% increase in the number of prescription drugs prescribed or continued per visit and a 55% increase in the number of generic drugs prescribed or continued, providing evidence of physician response to changes in patient out-of-pocket costs.
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Does health reform affect self-employment? Evidence from Massachusetts
Bradley Heim & Ithai Lurie
Small Business Economics, December 2014, Pages 917-930
Abstract:
This paper evaluates whether the implementation of the 2006 Massachusetts health reform law affected the decision of taxpayers to be self-employed, using both difference-in-differences and synthetic control methods on a panel of tax returns that spans 1999–2010. Though tenuous, our results suggest that the reform led to a decline in the rate of taxpayers earning a majority of income from self-employment. In addition, it appears to have had a positive impact on earning some self-employment income among joint filers and earning the majority of income from self-employment among older taxpayers, but these were offset by negative impacts on single filers and taxpayers age 35–49.
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Organization of Hospital Nursing and 30-Day Readmissions in Medicare Patients Undergoing Surgery
Chenjuan Ma, Matthew McHugh & Linda Aiken
Medical Care, January 2015, Pages 65-70
Objectives: To determine the relationships between hospital nursing factors — nurse work environment, nurse staffing, and nurse education — and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery.
Method and Design: We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-adjusted robust logistic regressions were used for analyses.
Results: The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03; 95% CI, 1.00–1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97; 95% CI, 0.95–0.99). Administrative support to nursing practice (OR=0.96; 95% CI, 0.94–0.99) and nurse-physician relations (OR=0.97; 95% CI, 0.95–0.99) were 2 main attributes of the work environment that were associated with readmissions.
Conclusions: Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.