Prescription
Joshua Fenton et al.
Archives of Internal Medicine, forthcoming
Background: Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.
Methods: We conducted a prospective cohort study of adult respondents (N = 51 946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36 428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years.
Results: Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53).
Conclusion: In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.
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Thomas Buchmueller & Christopher Carpenter
Journal of Policy Analysis and Management, forthcoming
Abstract:
Health disparities related to sexual orientation are well documented and may be due to unequal access to a partner's employer-sponsored insurance (ESI). We provide the literature's first evaluation of legislation enacted by California in 2005 that required private employers within the state to treat employees in committed same-sex relationships in the same way as employees in different-sex marriages with respect to ESI. Our analysis uses data on sexual orientation, partnership, and health insurance from the 2001 to 2007 California Health Interview Surveys (CHIS). Prior to the reform, partnered gay men and lesbians were significantly less likely to have ESI in someone else's name than partnered heterosexuals. Pooling data from 2001 to 2007, we find that the reform had no effects on differences in insurance outcomes between gay and straight men. We find some evidence that the reform increased partnership, reduced full-time employment, and increased health insurance coverage among lesbians relative to heterosexual women. The increases in insurance coverage for lesbians are consistent with a role for expanded dependent ESI, suggesting that such policies may reduce sexual orientation-based insurance disparities among women.
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Medicare managed care and primary care quality: Examining racial/ethnic effects across states
Jayasree Basu
Health Care Management Science, March 2012, Pages 15-28
Abstract:
The study assesses the role of Medicare Advantage (MA) plans in providing quality primary care in comparison to FFS Medicare in three states, New York, California, Florida, across three racial ethnic groups. The performance is measured in terms of providing better quality primary care, as defined by lowering the risks of preventable hospital admissions. Using 2004 hospital discharge data (HCUP-SID) of Agency for Healthcare Research and Quality for three states, a multivariate cross sectional design is used with individual admission as the unit of analysis. The study found that MA plans were associated with lower preventable hospitalizations relative to marker admissions. The benefit also spilled over to different racial and ethnic subgroups and in some states, e.g. CA and FL, MA enrollment was associated with significantly lower odds of minority admissions than of white admissions. These results may indicate a potentially favorable role of MA plans in attenuating racial/ethnic inequalities in primary care in some states.
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Survey Shows That At Least Some Physicians Are Not Always Open Or Honest With Patients
Lisa Iezzoni et al.
Health Affairs, February 2012, Pages 383-391
Abstract:
The Charter on Medical Professionalism, endorsed by more than 100 professional groups worldwide and the US Accreditation Council for Graduate Medical Education, requires openness and honesty in physicians' communication with patients. We present data from a 2009 survey of 1,891 practicing physicians nationwide assessing how widely physicians endorse and follow these principles in communicating with patients. The vast majority of physicians completely agreed that physicians should fully inform patients about the risks and benefits of interventions and should never disclose confidential information to unauthorized persons. Overall, approximately one-third of physicians did not completely agree with disclosing serious medical errors to patients, almost one-fifth did not completely agree that physicians should never tell a patient something untrue, and nearly two-fifths did not completely agree that they should disclose their financial relationships with drug and device companies to patients. Just over one-tenth said they had told patients something untrue in the previous year. Our findings raise concerns that some patients might not receive complete and accurate information from their physicians, and doubts about whether patient-centered care is broadly possible without more widespread physician endorsement of the core communication principles of openness and honesty with patients.
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The Impact of Noneconomic Damages Cap on Health Care Delivery in Hospitals
Anca Cotet
American Law and Economics Review, forthcoming
Abstract:
Previous literature focused on narrowly defined treatments reached conflicting conclusions about the association between tort reforms and treatment intensity. Using county-level panel data, I evaluate the impact of noneconomic damages caps on broadly defined measures of health care delivery in hospitals. Caps adoption leads to a 3.5% decrease in surgeries, a 2.5% decrease in admissions, a 4.5% decrease in outpatient visits but has no significant effect on emergency care. These results are not driven by spillovers across state borders or by improvements in health and are accompanied by an increase in mortality from complications of medical and surgical care.
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Further Marginalization: The Link Between Incarceration Rates and State Medicaid Enrollments
Aaron Kupchik & Brian Gifford
Criminal Justice Review, March 2012, Pages 70-88
Abstract:
Although the penal system and public assistance programs play significant roles in the lives of disadvantaged populations in the United States, the relationship between the two institutions is not well understood. This is particularly true of publicly financed health care coverage. In this article, the authors study how state-level incarceration rates shape the provision of publicly financed health care and health insurance (Medicaid), using two theoretical frameworks as a guide: a collateral consequences model and a punitive regime model. The authors use state-level panel data to estimate how the size of the incarcerated population is related to Medicaid enrollments across states and within them over time. These analyses suggest that incarceration rates do have a substantial and positive effect on Medicaid rates within states over time. Across states, the relationship is less clear. On average, states with higher incarceration rates had somewhat fewer Medicaid enrollments until the early 1990s. After this point, Medicaid enrollments began to increase with the size of the incarcerated population. These findings suggest that though states' efforts to control crime and poverty may be linked, whereby states that use incarceration liberally are also stingy with Medicaid, the collateral consequences of mass incarceration undermine these efforts by producing greater demands for social welfare services.
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Salomeh Keyhani et al.
Medical Care, March 2012, Pages 257-261
Objective: To examine the relationship between overuse of healthcare services and geographic variations in medical care.
Design: Systematic Review.
Data Sources: Articles published in Medline between 1978, the year of publication of the first framework to measure quality, and January 1, 2009.
Study Selection: Four investigators screened 114,830 titles and 2 investigators screened all selected abstracts and articles for possible inclusion and extracted all data.
Data Extraction: We extracted data on rates of overuse in different geographic areas. We also extracted data on underuse, if available, for the same population in which overuse was measured.
Results: Five papers examined the relationship between geographic variations and overuse of healthcare services. One study in 2008 compared the appropriateness of coronary angiography (CA) for acute myocardial infarction in high-cost areas versus low cost areas in the Medicare population and found largely similar rates of inappropriateness (12.2% vs. 16.2%). A study in 2000 using national data concluded that overuse of CA explained little of the geographic variations in the use of this procedure in the Medicare program. An older study of Medicare patients found similar rates of inappropriate use of CA (15% to 17% vs. 18%), endoscopy (15% vs. 18% 19%), and carotid endarterectomy (29% vs. 30%) in low-use and high-use regions. A small area reanalysis of data from this study of 3 procedures found no evidence of a relationship between inappropriate use of procedures and volume in 23 adjacent counties of California. Another 2008 study found that inappropriate chemotherapy for stage I cancer was less common in low-cost areas compared with high-cost areas (3.1% vs. 6.3%).
Conclusions: The limited available evidence does not lend support to the hypothesis that inappropriate use of procedures is a major source of geographic variations in intensity and/or costs of care. More research is needed to improve our understanding of the relationship between geographic variations and the quality of care.
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Cathy Bradley et al.
Health Affairs, February 2012, Pages 350-359
Abstract:
The Affordable Care Act will expand health insurance coverage for an estimated thirty-two million uninsured Americans. Increased access to care is intended to reduce the unnecessary use of services such as emergency department visits and to achieve substantial cost savings. However, there is little evidence for such claims. To determine how the uninsured might respond once coverage becomes available, we studied uninsured low-income adults enrolled in a community-based primary care program at Virginia Commonwealth University Medical Center. For people continuously enrolled in the program, emergency department visits and inpatient admissions declined, while primary care visits increased during the study period. Inpatient costs fell each year for this group. Over three years of enrollment, average total costs per year per enrollee fell from $8,899 to $4,569 - a savings of almost 50 percent. We conclude that previously uninsured people may have fewer emergency department visits and lower costs after receiving coverage but that it may take several years of coverage for substantive health care savings to occur.
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The Value of Consumer Choice and the Decline in HMO Enrollments
Gerard Wedig
Economic Inquiry, forthcoming
Abstract:
Health insurance contracts may restrict consumers' choice of medical provider (e.g., hospital) in order to minimize moral hazard inefficiencies. In this article, I assess the economic value of this strategy by comparing the estimated "option value" that consumers assign to provider choice to the negotiated discounts that insurers can achieve by negotiating with a restricted set of providers (i.e., volume discounts). Using a panel of federal employees' health plan choices from 1999 to 2003, I show that the practice of selective contracting (SC) with a limited set of hospitals reduced health maintenance organization (HMO) plans' expected utility by $62-$118, on average, for a standard reduction in the provider choice set. I also conduct simulations which show that by 2003 health plans using SC were theoretically unable to achieve sufficiently large volume discounts from hospital providers to fully compensate for the associated utility losses. My results help to explain the flight from HMO enrollments that occurred in the early 2000s.
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The price sensitivity of Medicare beneficiaries: A regression discontinuity approach
Thomas Buchmueller et al.
Health Economics, forthcoming
Abstract:
We use 4 years of data from the retiree health benefits program of the University of Michigan to estimate the effect of price on the health plan choices of Medicare beneficiaries. During the period of our analysis, changes in the University's premium contribution rules led to substantial price changes. A key feature of this 'natural experiment' is that individuals who had retired before a certain date were exempted from having to pay any premium contributions. This 'grandfathering' creates quasi-experimental variation that is ideal for estimating the effect of price. Using regression discontinuity methods, we compare the plan choices of individuals who retired just after the grandfathering cutoff date and were therefore exposed to significant price changes to the choices of a 'control group' of individuals who retired just before that date and therefore did not experience the price changes. The results indicate a statistically significant effect of price, with a $10 increase in monthly premium contributions leading to a 2 to 3 percentage point decrease in a plan's market share.
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Jonathan Weiner et al.
Health Affairs, February 2012, Pages 306-315
Abstract:
The Affordable Care Act calls for the establishment of state-level health insurance exchanges. The viability and success of these exchanges will require effective risk-adjustment strategies to compensate for differences in enrollees' health status across health plans. This article describes why the Affordable Care Act could lead to favorable or adverse risk selection across plans. It reviews provisions in the act and recent proposed regulations intended to mitigate the problem of risk selection. We performed a simulation that showed that under the premium rating restrictions in the law, large incentives for insurers to attract healthier enrollees will be likely to persist - resulting in substantial overpayment to plans with very healthy enrollees and underpayment to plans with very sick members. We conclude that risk adjustment based on patients' diagnoses, such as will be in place from 2014 on, will yield payments to insurers that will be more accurate than what will come solely from the age-adjusted and other rating allowed by the act. We also describe additional challenges of implementing risk adjustment.
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Hospital Ownership Type and Treatment Choices
Esra Eren Bayindir
Journal of Health Economics, forthcoming
Abstract:
In the face of increasing health care costs, taxing not-for-profit hospitals may be seen as the right choice to increase government revenues if not-for-profit hospitals are not different from their for-profit counterparts. This study investigates how hospital ownership type affects treatment choices to show whether ownership type and teaching status are correlated with choosing a procedure as the treatment and how these choices relate to patient insurance type. Not-for-profit hospitals significantly differ from for-profits in terms of treatment choices of less profitable patients and all hospitals are more likely to accord the procedure when the patient is privately insured than uninsured though teaching government hospitals are the most likely to accord the procedures for all insurance types. Considering treatment choices, not-for-profit hospitals have different objectives than for-profit and government hospitals and in terms of profit-seeking behavior, not-for-profit hospitals seem to lie between for-profit and government hospitals.
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Aaron Sojourner et al.
NBER Working Paper, January 2012
Abstract:
This paper studies the effects of unions in private-sector nursing homes on a broad range of labor, firm, and consumer outcomes. We link national data on nursing home characteristics from the Centers for Medicare and Medicaid Services to records on establishment-level unionization from federal labor agencies, and employ a regression discontinuity design to identify union effects by contrasting outcomes in nursing homes where unions closely won representation elections to outcomes in facilities where unions closely lost such elections. After showing that these two sets of homes are similar leading up to the election, we estimate union effects on staffing levels, care quality, and other outcomes. We find negative effects of unions on staffing levels and no decline in care quality, suggesting positive productivity effects. Consistent with these results, supplementary analysis shows significant increases in wages for some classes of nursing labor. Some evidence suggests that nursing homes in local product markets that were less competitive and had lower union density at the time of election experienced stronger union employment effects. We find no impact of unionization on facility survival. By combining credible identification of union effects, a comprehensive set of outcomes over time with measures of market-level characteristics, this study generates some of the best evidence available on many controversial questions in the economics of unions. Furthermore, it generates evidence from the service sector, which has grown in importance and where evidence on these questions has been thin.
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How Choices In Exchange Design For States Could Affect Insurance Premiums And Levels Of Coverage
Fredric Blavin et al.
Health Affairs, February 2012, Pages 290-298
Abstract:
The Affordable Care Act gives states the option to create health insurance exchanges from which individuals and small employers can purchase health insurance. States have considerable flexibility in how they design and implement these exchanges. We analyze several key design options being considered, using the Urban Institute's Health Insurance Policy Simulation Model: creating separate versus merged small-group and nongroup markets, eliminating age rating in these markets, removing the small-employer credit, and setting the maximum number of employees for firms in the small-group market at 50 versus 100 workers. Among our findings are that merging the small-group and nongroup markets would result in 1.7 million more people nationwide participating in the exchanges and, because of greater affordability of nongroup coverage, approximately 1.0 million more people being insured than if the risk pools were not merged. The various options generate relatively small differences in overall coverage and cost, although some, such as reducing age rating bands, would result in higher costs for some people while lowering costs for others. These cost effects would be most apparent among people who purchase coverage without federal subsidies. On the whole, we conclude that states can make these design choices based on local support and preferences without dramatic repercussions for overall coverage and cost outcomes.
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U.S. hospital efficiency and adoption of health information technology
Natalia Zhivan & Mark Diana
Health Care Management Science, March 2012, Pages 37-47
Abstract:
This study empirically examines the association between hospital inefficiency and the decision to introduce electronic medical records (EMR) and computerized physician order entry (CPOE) in a national sample of U.S. general hospitals in urban areas in 2006. The main research question is whether the presence of hospital cost inefficiency or other factors driving inefficiency in the production process of a hospital explain low adoption rates of health information technology (HIT) in a hospital setting. We estimated a logistic regression of HIT adoption as a function of hospital cost inefficiency scores obtained using a stochastic frontier analysis. The results demonstrate that hospitals with a greater degree of cost inefficiency were more likely to introduce EMR, suggesting that the benefits of EMR implementation in terms of improved efficiency were likely to outweigh the costs of adoption compared to hospitals that are more efficient. The results showed no association between cost inefficiency and the CPOE adoption decision.
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Small Firms' Actions In Two Areas, And Exchange Premium And Enrollment Impact
Christine Eibner et al.
Health Affairs, February 2012, Pages 324-331
Abstract:
The Affordable Care Act changed the regulations governing small firms' health insurance premiums. However, small businesses can avoid many of the new regulations by self-insuring or maintaining grandfathered plans. If small firms with healthy and lower-cost enrollees avoid the regulations, premiums for coverage sold through insurance exchanges could be unaffordable. In this analysis we used the RAND Comprehensive Assessment of Reform Efforts microsimulation model to predict the effects of self-insurance and grandfathering exemptions on coverage and premiums available through the exchanges. We estimate that Affordable Care Act regulations restricting employers' ability to offer grandfathered plans will result in lower premiums on plans available through the exchanges and will have small negative effects on enrollment in the exchanges. Our results suggest that these regulations are essential to keeping premiums on the Small Business Health Options Program (SHOP) exchanges affordable. Our analysis also found that Affordable Care Act regulations limiting self-insurance will reduce enrollment in the exchanges somewhat, without substantially affecting exchange premiums.
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Robert Kaestner & Nasreen Khan
Journal of Policy Analysis and Management, forthcoming
Abstract:
We examine the effect of gaining prescription drug insurance, as a result of Medicare Part D, on use of prescription drugs and other medical services for a nationally representative sample of Medicare beneficiaries. Given the heightened importance of prescription drugs for those with chronic illness, we provide separate estimates for elderly in poorer health. We find that Medicare Part D significantly reduced socioeconomic and geographic disparities in prescription drug insurance among the elderly. Gaining prescription drug insurance through Medicare Part D was associated with a 30 percent increase in the number of annual prescriptions and a 40 percent increase in expenditures on prescription drugs for both the general population of the elderly and the elderly in poorer health. We find little evidence that prescription drug insurance was strongly associated with the use of outpatient and inpatient services, although our investigation of these associations was limited by a lack of statistical power.
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Melissa Ford Shah et al.
Journal of Disability Policy Studies, March 2012, Pages 220-229
Abstract:
This study examines the effectiveness of Washington State's Medicaid Buy-In (MBI) program - Healthcare for Workers With Disabilities (HWD) - which gives workers with disabilities who earn too much for conventional Medicaid the opportunity to purchase full Medicaid coverage by paying a monthly premium based on a sliding income scale. The authors compare HWD enrollees who recently had conventional Medicaid coverage to a statistically matched group of individuals who had conventional Medicaid coverage in recent history and at baseline. Their findings suggest that MBI in Washington State is encouraging work, increasing earnings, and decreasing reliance on food stamps while providing medical coverage to a vulnerable population for whom continuous health insurance is particularly important.