Medical Bills
Daniel Carpenter
Annual Review of Political Science, 2012, Pages 287-311
Abstract:
The aging of the global population, combined with changes in technology and cultural understandings of disease and the body, have thrust discussion and contestation over health into the center of local, national, and global politics. Is the politics of health different from the politics of other policy domains? On a number of dimensions, I conclude that it is. Voters and politicians in the developed world appear more likely to accept redistributive claims with respect to health than they are in other policy areas. Nations vary less widely in spending on health than on other functions of government and policy. Moral claims made about health are more likely to attach to its politics than are moral claims about the environment, labor, finance, and energy. More than these other realms, health politics encompasses issues regarding identity, the human body, and other personal matters that endow the health arena with greater significance. Bureaucratic agencies of state are more involved in the provision and regulation of health politics than in other areas, and the science-related nature of state expertise allows medical science itself to be sculpted in deeply political and administrative ways. The article concludes with reasons why political scientists should approach cross-policy generalizations cautiously, and with a call for greater engagement with health politics - to do for political science what health economics, the history of medicine, and medical sociology have done for other social science disciplines.
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Naoki Ikegami & Gerard Anderson
Health Affairs, May 2012, Pages 1049-1056
Abstract:
In Japan's health insurance system, the prices paid by multiple payers for nearly all health care goods and services are codified into a single fee schedule and are individually revised within the global rate set by the government. This single payment system has allowed total health care spending to be controlled despite a fee-for-service system with its incentives for increased volume of services; Japan's growing elderly population; and the regular introduction of new technologies and therapies. This article describes aspects of Japan's approach, as well as how that nation has expanded payment for inpatient hospital care based on case-mix. The result of the payment system is that Japan's rate of health spending growth has been well below that of other industrial nations. The percentage of gross domestic product spent on health increased from 7.7 percent in 2000 to 8.5 percent in 2008, compared to an increase from 13.7 percent to 16.4 percent in the United States. Japan's approach confirms that enlightened government regulation can maintain access to care, avoid rationing, make use of the latest technology, and allow for multiple insurance plans and an aging population-all while restraining the growth of health care spending.
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Will Tort Reform Bend the Cost Curve? Evidence from Texas
Myungho Paik et al.
Journal of Empirical Legal Studies, June 2012, Pages 173-216
Abstract:
Will tort reform "bend the cost curve?" Health-care providers and tort reform advocates insist the answer is "yes." They claim that defensive medicine is responsible for hundreds of billions of dollars in health-care spending every year. If providers and reform advocates are right, once damages are capped and lawsuits are otherwise restricted, defensive medicine, and thus overall health-care spending, will fall substantially. We study how Medicare spending changed after Texas adopted comprehensive tort reform in 2003, including a strict damages cap. We compare Medicare spending in Texas counties with high claim rates (high risk) to spending in Texas counties with low claim rates (low risk), since tort reform should have a greater impact on physician incentives in high-risk counties. Pre-reform, Medicare spending levels and trends were similar in high- and low-risk counties. Post-reform, we find no evidence that spending levels or trends in high-risk counties declined relative to low-risk counties and some evidence of increased physician spending in high-risk counties. We also compare spending trends in Texas to national trends, and find no evidence of reduced spending in Texas post-reform, and some evidence that physician spending rose in Texas relative to control states. In sum, we find no evidence that Texas's tort reforms bent the cost curve downward.
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How Did Health Care Reform in Massachusetts Impact Insurance Premiums?
John Graves & Jonathan Gruber
American Economic Review, May 2012, Pages 508-513
Abstract:
It is widely recognized that the 2006 Massachusetts health reforms served as a blueprint for national reform under the 2010 Affordable Care Act (ACA). As such, there is interest in using the Massachusetts experience to understand how insurance premiums might change under the ACA. In this paper, we analyze changes in private insurance premiums in Massachusetts between 2002 and 2010. In contrast to earlier estimates from Massachusetts (Cogan, Hubbard and Kessler 2010), we find no statistical evidence of changes in group premiums. By contrast, we find large reductions in non-group premiums in Massachusetts relative to the rest of the U.S.
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Bankruptcy as Implicit Health Insurance
Neale Mahoney
NBER Working Paper, May 2012
Abstract:
This paper examines the implicit health insurance households receive from the ability to declare bankruptcy. Exploiting cross-state and within-state variation in asset exemption law, I show that uninsured households with greater seizable assets make higher out-of-pocket medical payments, conditional on the amount of care received. In turn, I find that households with greater wealth-at-risk are more likely to hold health insurance. The implicit insurance from bankruptcy distorts the insurance coverage decision. Using a microsimulation model, I calculate that the optimal Pigovian penalties are similar on average to the penalties under the Affordable Care Act (ACA).
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Arthur Garson et al.
Health Affairs, May 2012, Pages 1016-1021
Abstract:
Because the Affordable Care Act will expand health insurance to cover an estimated thirty-two million additional people, new approaches are needed to expand the primary care workforce. One possible solution is Grand-Aides®, who are health care professionals operating under the direct supervision of nurses, and who are trained and equipped to conduct telephone consultations or make primary care home visits to patients who might otherwise be seen in emergency departments and clinics. We conducted pilot tests with Grand-Aides in two pediatric Medicaid settings: an urban federally qualified health center in Houston, Texas, and a semi-rural emergency department in Harrisonburg, Virginia. We estimated that Grand-Aides and their supervisors averted 62 percent of drop-in visits at the Houston clinic and would have eliminated 74 percent of emergency department visits at the Virginia test site. We calculated the cost of the Grand-Aides program to be $16.88 per encounter. That compares with current Medicaid payments of $200 per clinic visit in Houston and $175 per emergency department visit in Harrisonburg. In addition to reducing health care costs, Grand-Aides have the potential to make a substantial impact in reducing congestion in primary care practices and emergency departments.
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Tony Yang et al.
Journal of Empirical Legal Studies, June 2012, Pages 217-245
Abstract:
Previous research has identified an association between malpractice liability risk levels in a state and greater use of cesarean sections in obstetrical care. However, it is unclear whether such practice changes are associated with better birth outcomes. Using a mixed-effects model, we investigate the impact of malpractice risk, as measured by malpractice insurance premiums and various state tort reforms, on four adverse birth outcomes. We use a longitudinal research design to examine millions of individual births from 51 jurisdictions over 12 years (1991-2002). We find that the odds of adverse birth outcomes are not associated with premium levels or tort reforms. Our results suggest that rather than having a socially desirable deterrent effect on substandard care, liability pressure may produce a level of precaution taking in obstetrics that is higher than socially optimal. By the same token, the results also suggest that the adoption of liability-limiting reforms is unlikely to have an adverse impact on outcomes.
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Do Health Plans Risk-Select? An Audit Study on Germany's Social Health Insurance
Sebastian Bauhoff
Journal of Public Economics, forthcoming
Abstract:
This paper evaluates whether health plans in Germany's Social Health Insurance select on an easily observable predictor of risk: geography. To identify plan behavior separately from concurrent demand-side adverse selection, I implement a double-blind audit study in which plans are contacted by fictitious applicants from different locations. I find that plans are less likely to respond and follow-up with applicants from higher-cost regions, such as West Germany. The results suggest that supply-side selection may emerge even in heavily regulated insurance markets. The prospect of risk selection by firms has implications for studies of demand-side selection and regulatory policy in these settings.
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Jon Gabel et al.
Health Affairs, June 2012, Pages 1339-1348
Abstract:
The Affordable Care Act creates state-based health exchanges that will begin acting as a market place for health insurance plans and consumers in 2014. This paper compares the financial protection offered by today's group and individual plans with the standards that will apply to insurance sold in state-based exchanges. Some states may apply these standards to all health insurance sold within the state. More than half of Americans who had individual insurance in 2010 were enrolled in plans that would not qualify as providing essential coverage under the rules of the exchanges in 2014. These people were enrolled in plans with an actuarial value below 60 percent, which means that the plans covered less than that proportion of the enrollees' health expenses. Many of today's individual health plans are below the "bronze" level, the lowest level of plan that can be sold through exchanges. In contrast, most group plans in 2010 had an actuarial benefit of 80-89 percent and would qualify as highly rated "gold" plans in the exchanges. To sell to ten million new buyers on the exchanges, insurers will need to redesign benefit packages. Combined with a ban on medical underwriting, the individual insurance market in a post-health reform world will sharply contrast with the market of past decades.
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George Chressanthis et al.
Journal of Clinical Hypertension, forthcoming
Abstract:
The authors explored to what extent important medical decisions by practitioners can be influenced by pharmaceutical representatives and, in particular, whether restricting such access could delay appropriate changes in clinical practice. Medical practices were divided into four categories based on the degree of sales representative access to clinicians: very low, low, medium, and high from a database compiled by ZS Associates called AccessMonitor (Evanston, IL) used extensively by many pharmaceutical companies. Clinical decisions of 58,647 to 72,114 physicians were statistically analyzed using prescription data from IMS Health (Danbury, CT) in three critical areas: an innovative drug for type 2 diabetes (sitagliptin), an older diabetes drug with a new Food and Drug Administration-required black box warning for cardiovascular safety (rosiglitazone), and a combination lipid therapy that had reported negative outcomes in a clinical trial (simvastatin+ezetimbe). For the uptake of the new diabetes agent, the authors found that physicians with very low access to representatives had the lowest adoption of this new therapy and took 1.4 and 4.6 times longer to adopt than physicians in the low- and medium-access restriction categories, respectively. In responding to the black box warning for rosiglitazone, the authors found that physicians with very low access were 4.0 times slower to reduce their use of this treatment than those with low access. Likewise, there was significantly less response in terms of changing prescribing to the negative news with the lipid therapy for physicians in more access-restricted offices. Overall, cardiologists were the most responsive to information changes relative to primary care physicians. These findings emphasize that limiting access to pharmaceutical representatives can have the unintended effect of reducing appropriate responses to negative information about drugs just as much as responses to positive information about innovative drugs.
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Medicaid and the Housing and Asset Decisions of the Elderly: Evidence from Estate Recovery Programs
Nadia Greenhalgh-Stanley
Journal of Urban Economics, forthcoming
Abstract:
I examine the impact of Medicaid on elderly housing and portfolio decisions by using recent state-by-calendar-year level variation in the Medicaid treatment of owner-occupied housing assets from the adoption of Medicaid estate recovery programs. Prior to the adoption of these programs, the house, which represents the most important non-pension asset to the elderly, was exempt from determining Medicaid eligibility and served as both a place of residence and a store of wealth. Adoption of estate recovery programs changed the owner-occupied housing safety net by making the house eligible for recovery by the government, which increased the implicit tax of holding owner-occupied housing. Using data from 1993-2004 in the Health and Retirement Study on elderly individuals, I find that state adoption of estate recovery programs makes the elderly decrease homeownership by 4.6%, decreases home equity by 15%, and also decreases the housing share of the elderly wealth portfolio. State adoption of these programs results in elderly baseline homeowners being 33% less likely to own their homes at death and more likely to use a trust as a substitute to housing in order to preserve assets and carry out bequest motives at death.
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Esther Neuwirth et al.
Health Affairs, June 2012, Pages 1244-1250
Abstract:
Keeping patients and caregivers at the center of quality improvement is critical. Kaiser Permanente's Care Management Institute adapted video ethnography to achieve this aim, using video to capture interviews with - and observations of - patients and caregivers, identify patient-centered improvement opportunities, and communicate them effectively to clinical and administrative leaders and front-line staff. This method is particularly effective for helping understand the needs of frail elders, patients nearing the end of life, those with multiple chronic conditions, and other vulnerable people who are not well represented in focus groups and patient advisory councils. As part of an initiative to improve care transitions for elders with heart failure, video ethnography contributed to greatly reduced thirty-day hospital readmission rates, helping reduce readmissions at one medical center from 13.6 percent to 9 percent in six months. It also helped improve the reliability of the readmissions reduction program. When embedded within an established quality improvement framework, video ethnography can be an effective tool for innovating new solutions, improving existing processes, and spreading knowledge about how best to meet patient needs.
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Medical Expenditure Risk and Household Portfolio Choice
Dana Goldman & Nicole Maestas
Journal of Applied Econometrics, forthcoming
Abstract:
Medical expenses are an increasingly important contributor to household financial risk. We examine the effect of medical expenditure risk on the willingness of Medicare beneficiaries to hold risky assets. Using a discrete-factor maximum likelihood method to address the endogeneity of insurance choices, we find that having a moderately protective Medigap or employer supplemental policy increases risky asset holding by 7.1 percentage points relative to those without supplemental coverage, while participation in a highly protective Medicare health maintenance organization increases risky asset holding by 13.0 percentage points. Our results highlight an important link between the availability of health insurance and financial behavior.
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Cathy Bradley, David Neumark & Scott Barkowski
NBER Working Paper, May 2012
Abstract:
Employment-contingent health insurance creates incentives for ill workers to remain employed at a sufficient level (usually full-time) to maintain access to health insurance coverage. We study employed married women, newly diagnosed with breast cancer, comparing labor supply responses to breast cancer diagnoses between women dependent on their own employment for health insurance and women with access to health insurance through their spouse's employer. We find evidence that women more dependent on their own job for health insurance reduce their labor supply by less after a diagnosis of breast cancer - the estimate difference is about 5.5 to 7 percent. Women's subjective responses to questions about working more to maintain health insurance are consistent with the conclusions from observed behavior.
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Tetine Sentell
Health Affairs, May 2012, Pages 1039-1048
Abstract:
Despite high rates of low health literacy among uninsured American adults, empirical research until now has not quantified whether low health literacy is associated with lack of health insurance above and beyond other related factors, such as employment, the availability of employment-based insurance, race or ethnicity, and poverty. This study analyzed a large, representative sample of adults in California and found that even when these related factors were considered, people with low health literacy were more likely to be uninsured than those with adequate health literacy. This finding represents the first empirical evidence that low health literacy predicts the lack of health insurance in adults. The study also found that among people who were uninsured, those with low health literacy were sicker and less likely to have ever had health insurance. They were also more likely to be eligible for the expanded Medicaid program under the Affordable Care Act, compared to uninsured respondents with adequate health literacy. These findings suggest that it will be critical to keep health literacy in mind in implementing the law - for example, in the design of eligibility documents and required forms, insurance exchange interfaces, and educational and outreach campaigns related to the Medicaid expansion and the insurance exchanges.
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Amanda Kowalski
NBER Working Paper, May 2012
Abstract:
Insurance induces a well-known tradeoff between the welfare gains from risk protection and the welfare losses from moral hazard. Empirical work traditionally estimates each side of the tradeoff separately, potentially yielding mutually inconsistent results. I develop a nonlinear budget set model of health insurance that allows for the calculation of both sides of the tradeoff simultaneously, allowing for a relationship between moral hazard and risk protection. An important feature of this model is that it considers nonlinearities in the consumer budget set that arise from deductibles, coinsurance rates, and stoplosses that alter moral hazard as well as risk protection relative to no insurance. I illustrate the properties of my model by estimating it using data on employer sponsored health insurance from a large firm. Within my empirical context, the average deadweight losses from moral hazard substantially outweigh the average welfare gains from risk protection. However, the welfare impact of moral hazard and risk protection are both small relative to transfers from the government through the tax preference for employer sponsored health insurance and transfers from some agents to other agents through a common premium.
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Zhanlian Feng, Brad Wright & Vincent Mor
Health Affairs, June 2012, Pages 1251-1259
Abstract:
When it is not clear that an ill patient needs to be hospitalized, he or she may be placed "under observation" in a hospital for further evaluation and short-term treatment. These hospital observation services, often a kind of halfway point between emergency department treatment and full inpatient admission, have become a hotly debated policy issue and subject of lawsuits. Using Medicare enrollment and claims data nationwide, we documented a rising trend in the prevalence and duration of hospital observation services in the fee-for-service Medicare population during 2007-09, accompanied by a downward shift in inpatient admissions. As a result, the ratio of observation stays to inpatient admissions increased 34 percent, from an average of 86.9 observation stay events per 1,000 inpatient admissions per month in 2007 to 116.6 in 2009. Medicare beneficiaries were increasingly subjected to hospital observation care and treated as outpatients instead of inpatients, which can expose them to greater out-of-pocket expenses if they are eventually admitted to skilled nursing facilities. Additionally, the nearly one million beneficiaries receiving observation services each year were, on average, being held in observation for a longer period of time per episode - some for longer than seventy-two hours. The prevalence of observation services varied greatly across geographic regions and hospitals. This may be an unintended consequence of Medicare payment policies designed to constrain hospital admissions. Additional research is needed to pinpoint the drivers and consequences of this phenomenon, as is more clarity in clinical practice and Medicare policy guidelines regarding observation care.
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The performance of the leveraged buyout of the Hospital Corporation of America, Inc
Tae Hyun Kim & Michael McCue
Health Care Management Review, July/September 2012, Pages 214-222
Background: A leveraged buyout (LBO) is a type of corporate reorganization and acquisition practice whereby private investors borrow a substantial amount of debt to acquire a firm by buying back its publicly held stock to go private. The Hospital Corporation of America, Inc. (HCA), went through its second LBO in July of 2006. A prior study on the performance changes of the first LBO found no significant changes in revenues, expenses, or profitability.
Purposes: In this study, we evaluated the changes in performance measures for HCA hospitals during the second LBO period. We looked at the effect of the LBO on financial and operational performance indicators, controlling for market and hospital characteristics.
Methodology: We identified 121 urban HCA hospitals that consistently reported data over a 4-year window from 1 year pre-LBO to 3 years post-LBO and evaluated their study performance changes during the period. Primary data for operational and financial measures are derived from Health Care Cost Report Information System data sets.
Findings: On the basis of this study, the LBO led to significant increases in cash flow margin, net patient revenues, and total asset turnover ratio. It also increased operating expenses significantly. However, it was not associated with changes in labor costs, staffing, and capital investment.
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Differences between non-profit and for-profit hospices: Patient selection and quality
Sabina Ohri Gandhi
International Journal Of Health Care Finance And Economics, June 2012, Pages 107-127
Abstract:
This research compares the behavior of non-profit organizations and private for-profit firms in the hospice industry, where there are financial incentives created by the Medicare benefit. Medicare reimburses hospices on a fixed per diem basis, regardless of patient diagnosis. Because under this system patients with lower expected costs are more profitable, hospices can selectively enroll patients with longer lengths of stay. While it is illegal for hospices to reject potential patients explicitly, they can influence their patient mix through referral networks. A fixed per diem rate also creates an incentive shirk on quality and to substitute lower skilled for higher skilled labor, which has implications for quality of care. By using within-market variation in hospice characteristics, the empirical evidence suggests that for-profit hospices differentially take advantage of these incentives. The results show that for-profit hospices engage in patient selection through significantly different referral networks than non-profits. They receive more patients from long-term care facilities and fewer patients through more traditional paths, such as physician referrals. This mechanism of patient selection is supported by the result that for-profits have fewer cancer patients and more patients with longer lengths of stay. While non-profit and for-profit hospices report similar numbers of staff visits per patient, for-profit firms make significantly less use of skilled nursing providers. We also find some weak evidence of lower levels of quality in for-profit hospices.
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Quality Measures for the U.S. Hospice System
Kelly Noe & Pamela Smith
Ageing International, June 2012, Pages 165-180
Abstract:
Academic research analyzing hospice quality and performance is limited. The purpose of this exploratory study is to investigate potential measurements to address quality within the U.S. hospice system. We endeavor to use Medicare Hospice Cost Report data for 2000 through 2007 to operationalize three constructs of quality - operational, labor, and clinical. These constructs are an attempt to answer the call for quality measures that focus on the following areas: (1) how the organization is functioning, (2) how the workforce is improving, and (3) how to measure changes in the patient's condition. We examine these hospice quality measures in both nonprofit (NP) and for-profit (FP) hospice providers. Our sample includes 7,039 observations for the investigation period. Our results indicate that hospice quality significantly improves for our sample. These findings also hold when separately examining for-profit and nonprofit hospice providers. To our knowledge, research has not fully explored potential measures of hospice quality. Our exploratory study is an attempt to bridge dialogue between research and practice to further the discussion of quality in hospice care. Quality is a difficult concept to measure when referring to hospice care especially since the patients are terminally ill and are expected to die. Quality care consists of keeping the patient comfortable as he/she goes through the dying process. For this reason typically quality standards are not applicable, and our findings assist in the development of performance-related hospice quality measures.
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Jennifer Thompson, Melissa Carlson & Elizabeth Bradley
Health Affairs, June 2012, Pages 1286-1293
Abstract:
The US hospice industry, which provides palliative and supportive care to patients with terminal illness, has undergone substantial changes during the last decade. The magnitude of these changes has not been fully captured in previous studies or reports. In this longitudinal study of hospices active in Medicare during 1999-2009, we analyzed Provider of Services files to understand key shifts in the industry. We found evidence of substantial turbulence. One-fifth of Medicare-certified hospices active in 1999 had closed or withdrawn from the program by 2009, and more than 40 percent had experienced one or more changes in ownership. The most prominent trend was the shift in ownership type from nonprofit to for-profit ownership. Four out of five Medicare-certified hospices that entered the marketplace between 2000 and 2009 were for-profit. Hospices also became larger, as the proportion with 100 or more full-time employees doubled to 5 percent from 1999 to 2009. Although each of the Census regions had more hospices in 2009 than in 1999, the geographic distribution of hospices in the country changed, with proportionally more in the South and West. The impact of all of these changes on cost and quality of hospice care, as well as patient access, remains a critical area for future research.
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Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral Health Care
Jürgen Unützer et al.
American Journal of Public Health, June 2012, Pages e41-e45
Objectives: We evaluated a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics.
Methods: We used a quasi-experimental design with 1673 depressed adults before and 6304 adults after the implementation of the P4P program. Survival analyses examined the time to improvement in depression before and after implementation of the P4P program, with adjustments for patient characteristics and clustering by health care organization.
Results: Program participants had high levels of depression, other psychiatric and substance abuse problems, and social adversity. After implementation of the P4P incentive program, participants were more likely to experience timely follow-up, and the time to depression improvement was significantly reduced. The hazard ratio for achieving treatment response was 1.73 (95% confidence interval = 1.39, 2.14) after the P4P program implementation compared with pre-program implementation.
Conclusions: Although this quasi-experiment cannot prove that the P4P initiative directly caused improved patient outcomes, our analyses strongly suggest that when key quality indicators are tracked and a substantial portion of payment is tied to such quality indicators, the effectiveness of care for safety-net populations can be substantially improved.
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Assisted Living Expansion and the Market for Nursing Home Care
David Grabowski, David Stevenson & Portia Cornell
Health Services Research, forthcoming
Objective: To analyze the effect of market-level changes in assisted living supply on nursing home utilization and resident acuity.
Data Sources: Primary data on the supply of assisted living over time were collected from 13 states from 1993 through 2007 and merged with nursing home-level data from the Online Survey Certification and Reporting System and market-level information from the Area Resource File.
Study Design: Least squares regression specification incorporating market and time-fixed effects.
Principal Findings: A 10 percent increase in assisted living capacity led to a 1.4 percent decline in private-pay nursing home occupancy and a 0.2-0.6 percent increase in patient acuity.
Conclusions: Assisted living serves as a potential substitute for nursing home care for some healthier individuals with greater financial resources, suggesting implications for policy makers, providers, and consumers.
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How Often Do Catastrophic Injury Victims Become Medicaid Recipients?
Eduard Zaloshnja et al.
Medical Care, June 2012, Pages 513-519
Background: People without adequate insurance may separate financially from their families and move onto Medicaid after a catastrophic injury. Medicaid then covers all of their medical care costs. No estimates for Medicaid conversions due to injury exist in the literature.
Objectives: To estimate Medicaid conversions due to injury for people 21-64 years old.
Research Design: This study analyzes the 2003 Medicaid Analytic eXtract files (the most recently available in 2009) for 14 states. For each state, we assigned a conversion cutoff date by examining the pattern of admissions after enrollment. The last day before the injury hospital admission rate decreased to its background level was considered as a cutoff date for conversions.
Subjects: Medicaid enrollees aged 21 to 64 years who received coverage due to a catastrophic injury.
Measures: Acute Medicaid conversions per 100 acute injury hospital admissions, estimated conversions remaining at least 1 year on Medicaid, and life-time public medical cost of disabled Medicaid recipients.
Results: Around 2.55% of all hospitalized injury patients not previously covered by Medicaid enrolled to cover their hospital bills. The average disabled recipient on Medicaid (possibly combined with Medicare) for 30 years has public medical payments exceeding $345,000.
Conclusions: The Medicaid postinjury enrollment policy provides important financial support to safety-net hospitals, provides better access to long-term care for trauma patients who need it, and permits states to offload costs to the federal government.
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Alison Evans Cuellar & Jehanzeb Cheema
Health Affairs, May 2012, Pages 931-938
Abstract:
During 2009, 730,000 prisoners were released from federal and state prisons - a 21 percent increase from the number of prisoners released in 2000. Poor health and poor health coverage have been major challenges for former prisoners trying to reintegrate into the community and find work. We discuss these challenges and the likely effect of recent federal legislation, including the Second Chance Act, the Mental Health Parity and Addiction Equity Act, and the Affordable Care Act. We estimated that with the implementation of health reform, up to 33.6 percent of inmates released annually - more than 245,000 people in 2009 - could enroll in Medicaid. Similarly, we estimated that up to 23.5 percent of prisoners released annually - more than 172,000 people in 2009 - could be eligible for federal tax credits to defray the cost of purchasing insurance from state health exchanges. This health insurance, combined with new substance abuse services and patient-centered medical home models, could dramatically improve the health and success of former inmates as they return to the community. States should consider several policy changes to ease prisoners' transitions, including suspending rather than terminating Medicaid benefits for offenders; incorporating corrections information into eligibility determination systems; aiming Medicaid outreach and enrollment efforts at prison inmates; and designing comprehensive approaches to meeting former prisoners' health care needs.
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Cost-Effectiveness of an Electronic Medical Record Based Clinical Decision Support System
Todd Gilmer et al.
Health Services Research, forthcoming
Background and Objective: Medical groups have invested billions of dollars in electronic medical records (EMRs), but few studies have examined the cost-effectiveness of EMR-based clinical decision support (CDS). This study examined the cost-effectiveness of EMR-based CDS for adults with diabetes from the perspective of the health care system.
Data Sources/Setting: Clinical outcome and cost data from a randomized clinical trial of EMR-based CDS were used as inputs into a diabetes simulation model. The simulation cohort included 1,092 patients with diabetes with A1c above goal at baseline.
Study Design: The United Kingdom Prospective Diabetes Study Outcomes Model, a validated simulation model of diabetes, was used to evaluate remaining life years, quality-adjusted life years (QALYs), and health care costs over patient lifetimes (40-year time horizon) from the health system perspective.
Principal Findings: Patients in the intervention group had significantly lowered A1c (0.26 percent, p = .014) relative to patients in the control arm. Intervention costs were $120 (SE = 45) per patient in the first year and $76 (SE = 45) per patient in the following years. In the base case analysis, EMR-based CDS increased lifetime QALYs by 0.04 (SE = 0.01) and increased lifetime costs by $112 (SE = 660), resulting in an incremental cost-effectiveness ratio of $3,017 per QALY. The cost-effectiveness of EMR-based CDS persisted in one-way, two-way, and probabilistic sensitivity analyses.
Conclusions: Widespread adoption of sophisticated EMR-based CDS has the potential to modestly improve the quality of care for patients with chronic conditions without substantially increasing costs to the health care system.