Post-existing conditions
The Affordable Care Act's Dependent Care Coverage and Mortality
Chandler McClellan
Medical Care, May 2017, Pages 514–519
Research Design: Using the Multiple Cause Mortality public use database for 2008–2013, the impact of the ACA is examined with a difference-in-differences analysis of monthly mortality rates using individuals aged 26–30 as a natural control group for young adults aged 19–25.
Results: The average monthly disease-related mortality rate of the 19–25 years old group fell by between 3.1% and 6.1% in the wake of the dependent care coverage expansion. Reduction in mortality was primarily in disease-related causes which are amenable to general medical care such as cardiovascular disease, while mortality due to trauma-related causes, which must be treated regardless of insurance status under preexisting laws, was unaffected.
The impact of the Affordable Care Act on self-employment
Bradley Heim & Lang Kate Yang
Health Economics, forthcoming
Abstract:
This paper estimates the impact of the implementation of the Affordable Care Act (ACA) in 2014 on the decision to be self-employed. Using data from the Current Population Survey, we employ two identification strategies. Utilizing prereform variation in state nongroup health insurance market regulations, we find that the ACA did not increase self-employment overall in states that lacked similar provisions in their nongroup markets prior to 2014. In specifications that utilize variation across individuals in characteristics that could make it harder for them to purchase insurance if they left their current employer, we also do not find that the ACA differentially increased self-employment. However, in states that lacked the ACA nongroup market provisions, we do find a statistically significant increase in the second year of implementation (when individuals had more time to adjust behavior and the exchanges functioned properly) among individuals eligible for insurance subsidies, suggesting that a combination of time to adjust, low uncertainty and low insurance costs may be necessary for nongroup health insurance reforms to impact self-employment.
High-Price And Low-Price Physician Practices Do Not Differ Significantly On Care Quality Or Efficiency
Eric Roberts, Ateev Mehrotra & Michael McWilliams
Health Affairs, May 2017, Pages 855-864
Abstract:
Consolidation of physician practices has intensified concerns that providers with greater market power may be able to charge higher prices without having to deliver better care, compared to providers with less market power. Providers have argued that higher prices cover the costs of delivering higher-quality care. We examined the relationship between physician practice prices for outpatient services and practices’ quality and efficiency of care. Using commercial claims data, we classified practices as being high- or low-price. We used national data from the Consumer Assessment of Healthcare Providers and Systems survey and linked claims for Medicare beneficiaries to compare high- and low-price practices in the same geographic area in terms of care quality, utilization, and spending. Compared with low-price practices, high-price practices were much larger and received 36 percent higher prices. Patients of high-price practices reported significantly higher scores on some measures of care coordination and management but did not differ meaningfully in their overall care ratings, other domains of patient experiences (including physician ratings and access to care), receipt of preventive services, acute care use, or total Medicare spending. This suggests an overall weak relationship between practice prices and the quality and efficiency of care and calls into question claims that high-price providers deliver substantially higher-value care.
The Racial Divide in State Medicaid Expansions
Colleen Grogan & Sunggeun (Ethan) Park
Journal of Health Politics, Policy and Law, June 2017, Pages 539-572
Abstract:
This study considers five important questions related to the role of race in state‐level public support for the Medicaid expansion: (1) whether public support for the Medicaid expansion varies across the American states; (2) whether public support is positively related to state adoption; (3) whether this support is racialized; (4) whether, if racialized, there is evidence of more state responsiveness to white support than to nonwhite (black and/or Latino) support; and (5) does the size of the nonwhite population matter more when white support is relatively low? Our findings suggest that while public support for the Medicaid expansion is high at the state level, especially in comparison to public support for the ACA, there are important variations across the states. Although overall public support is positively related to state adoption, we find that public support for the Medicaid expansion is racialized in two ways. First, there are large differences in support levels by race; and second, state adoption decisions are positively related to white opinion and do not respond to nonwhite support levels. Most importantly, there is evidence that when the size of the black population increases and white support levels are relatively low, the state is significantly less likely to expand the Medicaid program. Our discussion highlights the democratic deficits and racial bias at the state level around this important coverage policy.
Expanding Medicaid, Expanding the Electorate: The Affordable Care Act's Short-Term Impact on Political Participation
Jake Haselswerdt
Journal of Health Politics, Policy and Law, forthcoming
Abstract:
The Affordable Care Act is a landmark piece of social legislation with the potential to reshape health care in the United States. Its potential to reshape politics is also considerable, but existing scholarship suggests conflicting expectations about the law's policy feedbacks, especially given uneven state-level implementation. In this article I focus on the policy feedbacks of the law's Medicaid expansion on political participation, using district-level elections data for 2012 and 2014 US House races and cross-sectional survey data from 2014. I find that the increases in Medicaid enrollment associated with the expansion are related to considerably higher voter turnout and that this effect was likely due to both an increase in turnout for new beneficiaries and a backlash effect among conservative voters opposed to the law and its implementation. These results have important implications for our understanding of the ACA and of the impact of welfare state expansions on political participation, particularly in federalized systems.
Cost of Service Regulation in U.S. Health Care: Minimum Medical Loss Ratios
Steve Cicala, Ethan Lieber & Victoria Marone
NBER Working Paper, April 2017
Abstract:
In health insurance markets, an insurer's Medical Loss Ratio (MLR) is the share of premiums spent on medical claims. As part of the goal of reducing the cost of health care coverage, the Affordable Care Act introduced minimum MLR provisions for all health insurance sold in fully-insured commercial markets as of 2011, thereby explicitly capping insurer profit margins, but not levels. This cap was binding for many insurers, with over $1 billion of rebates paid in the first year of implementation. We model this constraint imposed upon a monopolistic insurer, and derive distortions analogous to those created under cost of service regulation. We test the implications of the model empirically using administrative data from 2005–2013, with insurers persistently above the minimum MLR threshold serving as the control group in a difference-in-difference design. We find that rather than resulting in reduced premiums, claims costs increased nearly one-for-one with distance below the regulatory threshold, 7% in the individual market, and 2% in the group market.
The impact of provider consolidation on physician prices
Caroline Carlin, Roger Feldman & Bryan Dowd
Health Economics, forthcoming
Abstract:
When a clinic system is acquired by an integrated delivery system (IDS), the ownership change includes both vertical integration with the hospital(s), and horizontal integration with the IDS's previously owned or “legacy” clinics, causing increased market concentration in physician services. Although there is a robust literature on the impact of hospital market concentration, the literature on physician market concentration is sparse. The objective of this study is to determine the impact on physician prices when two IDSs acquired three multispecialty clinic systems in Minneapolis–St Paul, Minnesota at the end of 2007, using commercial claims data from a large health plan (2006–2011). Using a difference-in-differences model and nonacquired clinics as controls, we found that four years after the acquisitions (2011), average physician price indices in the acquired clinic systems were 32–47% higher than expected in absence of the acquisitions. Average physician prices in the IDS legacy clinics were 14–20% higher in 2011 than expected. Procedure-specific prices for common office visit and inpatient procedures also increased following the acquisitions.
Hospital and Health Insurance Markets Concentration and Inpatient Hospital Transaction Prices in the U.S. Health Care Market
Seidu Dauda
Health Services Research, forthcoming
Data Sources: Measures of hospital and insurer markets concentration derived from American Hospital Association and HealthLeaders-InterStudy data are linked to 2005–2008 inpatient administrative data from Truven Health MarketScan Databases.
Study Design: Uses a reduced-form price equation, controlling for cost and demand shifters and accounting for possible endogeneity of market concentration using instrumental variables (IV) technique.
Principal Findings: The findings suggest that greater hospital concentration raises prices, whereas greater insurer concentration depresses prices. A hypothetical merger between two of five equally sized hospitals is estimated to increase hospital prices by about 9 percent (p < .001). A similar merger of insurers would depress prices by about 15.3 percent (p < .001). Over the 2003–2008 periods, the estimates imply that hospital consolidation likely raised prices by about 2.6 percent, while insurer consolidation depressed prices by about 10.8 percent. Additional analysis using longer panel data and applying hospital fixed effects confirms the impact of hospital concentration on prices.
Macroeconomic Effects of Medicare
Juan Carlos Conesa et al.
NBER Working Paper, May 2017
Abstract:
This paper develops an overlapping generations model to study the macroeconomic effects of an unexpected elimination of Medicare. We find that a large share of the elderly respond by substituting Medicaid for Medicare. Consequently, the government saves only 46 cents for every dollar cut in Medicare spending. We argue that a comparison of steady states is insufficient to evaluate the welfare effects of the reform. In particular, we find lower ex-ante welfare gains from eliminating Medicare when we account for the costs of transition. Lastly, we find that a majority of the current population benefits from the reform but that aggregate welfare, measured as the dollar value of the sum of wealth equivalent variations, is higher with Medicare.
Changes in Emergency Department Utilization After Early Medicaid Expansion in California
Lindsay Sabik et al.
Medical Care, June 2017, Pages 576–582
Background: Medicaid expansions aim to improve access to primary care, which could reduce nonemergent (NE) use of the emergency department (ED). In contrast, Medicaid enrollees use the ED more than other groups, including the uninsured. Thus, the expected impact of Medicaid expansion on ED use is unclear.
Methods: We used a quasi-experimental approach to examine changes in ED utilization, comparing California expansion counties to comparison counties from California and 2 other states in the same region that did not implement Medicaid expansion during the study period.
Results: Regression estimates show no significant change in total number of ED visits following expansion. Medicaid visits increased by 145 visits per hospital-quarter in the first year following expansion and 242 visits subsequent to the first year, whereas visits among uninsured patients decreased by 129 visits per hospital-quarter in the first year and 175 visits in subsequent years, driven by changes at safety net hospitals. We also observe an increase in NE visits per hospital-quarter paid for by Medicaid, and a significant decrease in uninsured NE visits.
Medicaid Expansion Increased Coverage, Improved Affordability, And Reduced Psychological Distress For Low-Income Parents
Stacey McMorrow et al.
Health Affairs, May 2017, Pages 808-818
Abstract:
Despite receiving less attention than their childless counterparts, low-income parents also experienced significant expansions of Medicaid eligibility under the Affordable Care Act (ACA). We used data for the period 2010–15 from the National Health Interview Survey to examine the impacts of the ACA’s Medicaid expansion on coverage, access and use, affordability, and health status for low-income parents. We found that eligibility expansions increased coverage, reduced problems paying medical bills, and reduced severe psychological distress. We found only limited evidence of increased use of care among parents in states with the smallest expansions, and no significant effects of the expansions on general health status or problems affording prescription drugs or mental health care. Together, our results suggest that the improvements in mental health status may be driven by reduced stress associated with improved financial security from insurance coverage. We also found large missed opportunities for low-income parents in states that did not expand Medicaid: If these states had expanded Medicaid, uninsurance rates for low-income parents would have fallen by an additional 28 percent.
Superbugs versus Outsourced Cleaners: Employment Arrangements and the Spread of Health Care–Associated Infections
Adam Seth Litwin, Ariel Avgar & Edmund Becker
ILR Review, May 2017, Pages 610-641
Abstract:
On any given day, about one in 25 hospital patients in the United States has a health care–associated infection (HAI) that the patient contracts as a direct result of his or her treatment. Fortunately, the spread of most HAIs can be halted through proper disinfection of surfaces and equipment. Consequently, cleaners — “environmental services” (EVS) in hospital parlance — must take on the important task of defending hospital patients (as well as staff and the broader community) from the spread of HAIs. Despite the importance of this task, hospitals frequently outsource this function, increasing the likelihood that these workers are under-rewarded, undertrained, and detached from the organization and the rest of the care team. As a result, the outsourcing of EVS workers could have the unintended consequence of increasing the incidence of HAIs. The authors demonstrate this relationship empirically, finding support for their theory by using a self-constructed data set that marries infection data to structural, organizational, and workforce features of California’s general acute care hospitals. The study thus advances the literature on nonstandard work arrangements — outsourcing in particular — while sounding a cautionary note to hospital administrators and health care policymakers.
Disparities in Potentially Preventable Hospitalizations: Near-National Estimates for Hispanics
Chen Feng et al.
Health Services Research, forthcoming
Objective: To obtain near-national rates of potentially preventable hospitalization (PPH) — a marker of barriers to outpatient care access — for Hispanics; to examine their differences from other race-ethnic groups and by Hispanic national origin; and to identify key mediating factors.
Data Sources/Study Setting: Data from all-payer inpatient discharge databases for 15 states accounting for 85 percent of Hispanics nationally.
Principal Findings: Age-sex-adjusted PPH rates were 13 percent higher among Hispanics (1,375 per 100,000 adults) and 111 percent higher among blacks (2,578) compared to whites (1,221). Among Hispanics, these rates were relatively higher in areas with predominantly Puerto Rican and Cuban Americans than in areas with Hispanics of other nationalities. Small area variation in chronic condition prevalence and SES fully accounted for the higher rates among Hispanics, but only partially among blacks.
Conclusions: Hispanics and blacks face higher barriers to outpatient care access; the higher barriers among Hispanics (but not blacks) seem mediated by SES, lack of insurance, cost barriers, and limited provider availability.
Chronic Health Outcomes and Prescription Drug Copayments in Medicaid
Deliana Kostova & Jared Fox
Medical Care, May 2017, Pages 520–527
Subjects: Select adults aged 20–64 from NHANES 1999–2012 in 18 states.
Research Design: A differencing regression model was used to evaluate health outcomes among Medicaid beneficiaries in 4 states that introduced copayments during the study period, relative to 2 comparison groups — Medicaid beneficiaries in 14 states unaffected by shifts in copayment policy, and a within-state counterfactual group of low-income adults not on Medicaid, while controlling for individual demographic factors and unobserved state-level characteristics.
Results: Although uncontrolled hypertension and hypercholesterolemia declined among all low-income persons during the study period, the trend was less pronounced in Medicaid beneficiaries affected by copayments. After netting out concurrent trends in health outcomes of low-income persons unaffected by Medicaid copayment changes, we estimated that introduction of drug copayments in Medicaid was associated with an average rise in uncontrolled hypertension and uncontrolled hypercholesterolemia of 7.7 and 13.2 percentage points, respectively, and with reduced drug utilization for hypercholesterolemia.
The Effect of Medicaid Physician Fee Increases on Health Care Access, Utilization, and Expenditures
Kevin Callison & Binh Nguyen
Health Services Research, forthcoming
Data Source: We use the 2008 and 2012 waves of the Medical Expenditure Panel Survey linked to state-level Medicaid-to-Medicare primary care reimbursement ratios obtained through surveys conducted by the Urban Institute. We also incorporate data from the Current Population Survey and the Area Resource Files.
Study Design: Using a control group made up of the low-income privately insured, we conduct a difference-in-differences analysis to assess the relationship between Medicaid fee changes and access to care, utilization of health care services, and out-of-pocket medical expenditures for Medicaid enrollees.
Principal Findings: We find that an increase in the Medicaid-to-Medicare payment ratio for primary care services results in an increase in outpatient physician visits, emergency department utilization, and prescription fills, but only minor improvements in access to care. In addition, we report an increase in total annual out-of-pocket expenditures and spending on prescription medications.
Conclusions: Compared to the low-income privately insured, increased primary care reimbursement for Medicaid beneficiaries leads to higher utilization and out-of-pocket spending for Medicaid enrollees.
'Let the Sun Shine in': The Impact of Industry Payment Disclosure on Physician Prescription Behavior
Tong Guo, S. Sriram & Puneet Manchanda
University of Michigan Working Paper, April 2017
Abstract:
U.S. pharmaceutical companies frequently pay doctors to promote their medicine. This creates conflict of interest issues that policy-makers often address by introducing payment disclosure laws. However, it is unclear if such disclosure has an effect on physician prescription behavior. We use individual-level claims data from a major provider of health insurance in the U.S. and employ a diff-in-diff research design to study the effect of the payment disclosure law introduced in Massachusetts in June 2009. The research design exploits the fact that while physicians operating in Massachusetts were impacted by the legislation, their counterparts in the neighboring states of Connecticut and New York were not. In order to keep the groups of physicians comparable, we restrict our analysis to the physicians in the counties that are on the border of these states. We find that the Massachusetts disclosure law resulted in a decline in prescriptions in all three drug classes studied: statins, antidepressants, and antipsychotics. Our findings are robust under alternative controls, time periods, and variable transformations. We show that the effect is highly heterogeneous across brands and physician groups, and that the decrease in prescription is likely a consequence of increased self-monitoring among physicians to curb over-diagnosis.
Postmarket Safety Events Among Novel Therapeutics Approved by the US Food and Drug Administration Between 2001 and 2010
Nicholas Downing et al.
Journal of the American Medical Association, 9 May 2017, Pages 1854-1863
Design and Setting: Cohort study of all novel therapeutics approved by the FDA between January 1, 2001, and December 31, 2010, followed up through February 28, 2017.
Results: From 2001 through 2010, the FDA approved 222 novel therapeutics (183 pharmaceuticals and 39 biologics). There were 123 new postmarket safety events (3 withdrawals, 61 boxed warnings, and 59 safety communications) during a median follow-up period of 11.7 years (interquartile range [IQR], 8.7-13.8 years), affecting 71 (32.0%) of the novel therapeutics. The median time from approval to first postmarket safety event was 4.2 years (IQR, 2.5-6.0 years), and the proportion of novel therapeutics affected by a postmarket safety event at 10 years was 30.8% (95% CI, 25.1%-37.5%). In multivariable analysis, postmarket safety events were statistically significantly more frequent among biologics (incidence rate ratio [IRR] = 1.93; 95% CI, 1.06-3.52; P = .03), therapeutics indicated for the treatment of psychiatric disease (IRR = 3.78; 95% CI, 1.77-8.06; P < .001), those receiving accelerated approval (IRR = 2.20; 95% CI, 1.15-4.21; P = .02), and those with near–regulatory deadline approval (IRR = 1.90; 95% CI, 1.19-3.05; P = .008); events were statistically significantly less frequent among those with regulatory review times less than 200 days (IRR = 0.46; 95% CI, 0.24-0.87; P = .02).
Conclusions and Relevance: Among 222 novel therapeutics approved by the FDA from 2001 through 2010, 32% were affected by a postmarket safety event. Biologics, psychiatric therapeutics, and accelerated and near–regulatory deadline approval were statistically significantly associated with higher rates of events, highlighting the need for continuous monitoring of the safety of novel therapeutics throughout their life cycle.
The Demand for Healthcare Regulation: The Effect of Political Spending on Occupational Licensing Laws
Benjamin McMichael
Southern Economic Journal, forthcoming
Abstract:
Using data on political spending in state elections, this study considers the role of political contributions by healthcare professional interest groups in states' decisions to enact occupational licensing laws. These laws govern how different professions may operate in healthcare markets, and while they ostensibly exist to protect consumers, licensing laws can also insulate professionals from competition in healthcare markets. Higher political spending by physician interest groups increases the probability that a state maintains licensing laws restricting the practices of nurse practitioners (NPs) and physician assistants (PAs). Conversely, increased spending by hospital interest groups increases the probability that a state allows NPs and PAs to practice with more autonomy. Nurse groups, which include groups affiliated with NPs, have a smaller effect on licensing laws. And nonphysician groups, which include groups affiliated with PAs, have almost no effect on licensing laws. These results are consistent with the investment theory of political spending.
Physician age and outcomes in elderly patients in hospital in the US: Observational study
Yusuke Tsugawa et al.
British Medical Journal, May 2017
Participants: 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists.
Results: 736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients’ characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients’ adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses.
Outpatient Office Wait Times And Quality Of Care For Medicaid Patients
Tamar Oostrom, Liran Einav & Amy Finkelstein
Health Affairs, May 2017, Pages 826-832
Abstract:
The time patients spend in a doctor’s waiting room prior to a scheduled appointment is an important component of the quality of the overall health care experience. We analyzed data on twenty-one million outpatient visits obtained from electronic health record systems, which allowed us to measure time spent in the waiting room beyond the scheduled appointment time. Median wait time was a little more than four minutes. Almost one-fifth of visits had waits longer than twenty minutes, and 10 percent were more than thirty minutes. Waits were shorter for early-morning appointments, for younger patients, and at larger practices. Median wait time was 4.1 minutes for privately insured patients and 4.6 minutes for Medicaid patients. After adjustment for patient and appointment characteristics, Medicaid patients were 20 percent more likely than the privately insured patients to wait longer than twenty minutes, with most of this disparity explained by differences in practices and providers they saw. Wait times for Medicaid patients relative to privately insured patients were longer in states with relatively lower Medicaid reimbursement rates. The study complements other work that suggests that Medicaid patients face some additional barriers in the receipt of care.
Growing Insurance Coverage Did Not Reduce Access To Care For The Continuously Insured
Salam Abdus & Steven Hill
Health Affairs, May 2017, Pages 791-798
Abstract:
Recent expansions in health insurance coverage have raised concerns about health care providers’ capacity to supply additional services and how that may have affected access to care for people who were already insured. When we examined data for the period 2008–14 from the Medical Expenditure Panel Survey, we found no consistent evidence that increases in the proportions of adults with insurance at the local-area level affected access to care for adults residing in the same areas who already had, and continued to have, insurance. This lack of an apparent relationship held true across eight measures of access, which included receipt of preventive care. It also held true among two adult subpopulations that may have been at greater risk for compromised access: people residing in health care professional shortage areas and Medicaid beneficiaries.
Enrollment In A Health Plan With A Tiered Provider Network Decreased Medical Spending By 5 Percent
Anna Sinaiko, Mary Beth Landrum & Michael Chernew
Health Affairs, May 2017, Pages 870-875
Abstract:
Employers and health plans are increasingly using tiered provider networks in their benefit designs to steer patients to higher quality and more efficient providers in an effort to increase value in the health care system. We evaluated the impact of a tiered-network health plan on total health care spending and on inpatient, outpatient, and outpatient radiology spending for nonelderly enrollees in a commercial health plan in 2008–12. The tiered network was associated with $43.36 lower total adjusted medical spending per member per quarter ($830.07 versus $873.43), which represented about a 5 percent decrease in spending, relative to enrollees in similar plans without a tiered network. Similar levels of spending reductions were found for outpatient (4.6 percent) and outpatient radiology spending (6.5 percent). These findings suggest that health plans with tiered provider networks have the potential to reduce aggregate health care spending.
Malpractice Laws and Incentives to Shield Assets: Evidence from Nursing Homes
James Brickley, Susan Lu & Gerard Wedig
Journal of Empirical Legal Studies, June 2017, Pages 301–332
Abstract:
Empirical research on medical malpractice liability has largely ignored incentives to restructure to protect assets. This study provides evidence on asset shielding in the nursing home industry. There was a rapid increase in lawsuits alleging patient neglect or abuse in states with plaintiff-friendly tort environments beginning in the second half of the 1990s. We document two apparent asset-shielding trends in these states during the 1998–2004 period: (1) sales of homes by large chains to smaller, more judgment-proof owners; and (2) a reduced propensity to “brand” chain-owned units with names that linked them directly to the central corporation or sister units. Twelve states enacted tort reforms during the 2003–2006 period that placed caps on noneconomic damages. Using a difference-in-differences (DD) methodology, we find that the trends in asset-shielding behavior abated or reversed in the states that enacted tort reforms. These findings suggest that tort law affects ownership and other organizational choices in this industry.
Do State Continuing Medical Education Requirements for Physicians Improve Clinical Knowledge?
Jonathan Vandergrift, Bradley Gray & Weifeng Weng
Health Services Research, forthcoming
Data Sources: Secondary data for 19,563 general internists who took the Internal Medicine Maintenance of Certification (MOC) examination between 2006 and 2013.
Study Design: We took advantage of a natural experiment resulting from variations in CME requirements across states over time and applied a difference-in-differences methodology to measure associations between changes in CME requirements and physician clinical knowledge. We measured changes in clinical knowledge by comparing initial and MOC examination performance 10 years apart. We constructed difference-in-differences estimates by regressing examination performance changes against physician demographics, county and year fixed effects, trend–state indicators, and state CME change indicators.
Principal Findings: More rigorous CME credit-hour requirements (mostly implementing a new requirement) were associated with an increase in examination performance equivalent to a shift in examination score from the 50th to 54th percentile.
E-Prescribing and Adverse Drug Events: An Observational Study of the Medicare Part D Population With Diabetes
Meghan Hufstader Gabriel et al.
Medical Care, May 2017, Pages 456–462
Objective: To examine the impact of e-prescribing on emergency visits or hospitalizations for diabetes-related adverse drug events (ADEs) including hypoglycemia.
Design: This is a prospective, observational cohort study with patient fixed effects.
Setting: 2011–2013 fee for service Medicare.
Patients: In total, 3.1 million Medicare fee for service, Part D enrolled beneficiaries over age 66 with diabetes mellitus and at least 90 days of antidiabetic medications.
Measurements: E-prescribing was measured as the percentage of all prescriptions a person received transmitted to the pharmacy electronically. The outcome measure was the occurrence of an emergency department (ED) visit or hospitalization for hypoglycemia or diabetes-related ADE.
Results: Unadjusted results show that there were 21 ADEs per 1000 beneficiaries that had ≥75% of their medications e-prescribed. Beneficiaries with lower e-prescribing levels had significantly higher numbers of ADEs. We found a robust association between the greater use of electronic prescriptions in the outpatient setting and the lower risk of an inpatient or ED visit for an ADE event among Medicare beneficiaries with diabetes in our adjusted analysis. At the e-prescribing threshold of 75% and above, significant reductions in ADE risk can be seen.
Conclusions: Use of e-prescribing is associated with lower risk of an ED visit or hospitalization for diabetes-related ADE.