Trick or treat
Allocating Infection: The Political Economy of the Swine Flu (H1N1) Vaccine
Matt Ryan
Economic Inquiry, forthcoming
Abstract:
Previous research has isolated the effect of "congressional dominance" in explaining bureaucracy-related outcomes. This analysis extends the concept of congressional dominance to the allocation of H1N1, or swine flu, vaccine doses. States with Democratic United States Representatives on the relevant House oversight committee received roughly 60,000 additional doses per legislator during the initial allocation period, though this political advantage dissipated after the first 3 weeks of vaccine distribution. As a result political factors played a role in determining vaccine allocation only when the vaccine was in particularly short supply. At-risk groups identified by the Centers for Disease Control (CDC), such as younger age groups and first responders, do not receive more vaccine doses, and in fact receive slightly fewer units of vaccine.
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The Effect of Medicare Advantage on Hospital Admissions and Mortality
Christopher Afendulis, Michael Chernew & Daniel Kessler
NBER Working Paper, June 2013
Abstract:
Medicare currently allows beneficiaries to choose between a government-run health plan and a privately- administered program known as Medicare Advantage (MA). Because enrollment in MA is optional, conventional observational estimates of the program's impact are potentially subject to selection bias. To address this, we use a discontinuity in the rules governing MA payments to health plans that gives greater payments to plans operating in counties in Metropolitan Statistical Areas with populations of 250,000 or more. The sharp difference in payment rates at this population cutoff creates a greater incentive for plans to increase the generosity of benefits and therefore enroll more beneficiaries in MA in counties just above versus just below the cutoff. We find that the expansion of MA on this margin reduces beneficiaries' rates of hospitalization and mortality.
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Thomas DeLeire et al.
Health Affairs, June 2013, Pages 1037-1045
Abstract:
As states consider expanding Medicaid to low-income childless adults under the Affordable Care Act, their decisions will depend, in part, on how such coverage may affect the use of medical care. In 2009 Wisconsin created a new public insurance program for low-income uninsured childless adults. We analyzed administrative claims data spanning 2008 and 2009 using a case-crossover study design on a population of 9,619 Wisconsin residents with very low incomes who were automatically enrolled in this program in January 2009. In the twelve months following enrollment in public insurance, outpatient visits for the study population increased 29 percent, and emergency department visits increased 46 percent. Inpatient hospitalizations declined 59 percent, and preventable hospitalizations fell 48 percent. These results demonstrate that public insurance coverage expansions to childless adults have the potential to improve health and reduce costs by increasing access to outpatient care and reducing hospitalizations.
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Christopher Brunt & Gail Jensen
Health Economics, forthcoming
Abstract:
Medicare adjusts its payments to physicians for geographic differences in the cost of operating a medical practice, but the method it uses is imprecise. We measure the inaccuracy in its geographic adjustment factors and categorize beneficiaries by whether they live where Medicare's formula is favorable or unfavorable to physicians. Then, using the 2001-2003 Medicare Current Beneficiary Survey, we examine whether differences in physician payment generosity, that is, whether favorable or unfavorable, influence the satisfaction ratings Medicare seniors assign to their quality of care and access to services. We find strong evidence that they do. Many beneficiaries live in payment-unfavorable areas and receive a less satisfying quality of care and less satisfying access to services than beneficiaries who live where payments are favorable to physicians.
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James Reschovsky, Jack Hadley & Patrick Romano
Medical Care Research and Review, forthcoming
Abstract:
Control for area differences in population health (casemix adjustment) is necessary to measure geographic variations in medical spending. Studies use various casemix adjustment methods, resulting in very different geographic variation estimates. We study casemix adjustment methodological issues and evaluate alternative approaches using claims from 1.6 million Medicare beneficiaries in 60 representative communities. Two key casemix adjustment methods - controlling for patient conditions obtained from diagnoses on claims and expenditures of those at the end of life - were evaluated. We failed to find evidence of bias in the former approach attributable to area differences in physician diagnostic patterns, as others have found, and found that the assumption underpinning the latter approach - that persons close to death are equally sick across areas - cannot be supported. Diagnosis-based approaches are more appropriate when current rather than prior year diagnoses are used. Population health likely explains more than 75% to 85% of cost variations across fixed sets of areas.
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Paul Fronstin, Martín Sepúlveda & Christopher Roebuck
Health Affairs, June 2013, Pages 1126-1134
Abstract:
Consumer-directed health plans (CDHPs) are designed to make employees more cost- and health-conscious by exposing them more directly to the costs of their care, which should lower demand for care and, in turn, control premium growth. These features have made consumer-directed plans increasingly attractive to employers. We explored effects of consumer-directed health plans on health care and preventive care use, using data from two large employers - one that adopted a CDHP in 2007 and another with no CDHP. Our study had mixed results relative to expectations. After four years under the CDHP, there were 0.26 fewer physician office visits per enrollee per year and 0.85 fewer prescriptions filled, but there were 0.018 more emergency department visits. Also, the likelihood of receiving recommended cancer screenings was lower under the CDHP after one year and, even after recovering somewhat, still lower than baseline at the study's conclusion. If CDHPs succeed in getting people to make more cost-sensitive decisions, plan sponsors will have to design plans to incentivize primary care and prevention and educate members about what the plan covers.
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The Spillover Effects of Medicare Managed Care: Medicare Advantage and Hospital Utilization
Katherine Baicker, Michael Chernew & Jacob Robbins
NBER Working Paper, May 2013
Abstract:
More than a quarter of Medicare beneficiaries are enrolled in Medicare Advantage, which was created in large part to improve the efficiency of health care delivery by promoting competition among private managed care plans. This paper explores the spillover effects of the Medicare Advantage program on the traditional Medicare program and other patients, taking advantage of changes in Medicare Advantage payment policy to isolate exogenous increases in Medicare Advantage enrollment and trace out the effects of greater managed care penetration on hospital utilization and spending throughout the health care system. We find that when more seniors enroll in Medicare managed care, hospital costs decline for all seniors and for commercially insured younger populations. Greater managed care penetration is not associated with fewer hospitalizations, but is associated with lower costs and shorter stays per hospitalization. These spillovers are substantial - offsetting more than 10% of increased payments to Medicare Advantage plans.
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Does Expanding Public Insurance Prevent Material Hardship for Families With Children?
Brendan Saloner
Medical Care Research and Review, June 2013, Pages 267-286
Abstract:
The 1997 Children's Health Insurance Program (CHIP) provided states with funding to expand public insurance to children in low-income families. Recent studies suggest CHIP improved family finances, but it is unknown whether CHIP specifically affected the prevalence of material hardships such as food and housing insecurity. This study uses cross-sectional data on low-income children from the National Survey of American Families (1997-2002) to examine the impact of CHIP on material hardships. Using an instrumental variable that exploits variation in income eligibility cutoffs across states and years, I find that households gaining CHIP eligibility did not experience significant changes in material hardship. CHIP significantly reduced the prevalence of postponed care for the subgroup of households close to the poverty line. For low-income families with children, public health insurance may play a larger role in increasing access to care than in supplementing the budget for necessities.
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Bradley Heim & Ithai Lurie
Health Economics, forthcoming
Abstract:
This paper estimates whether state-level implementation of community rating and guaranteed issue regulations in the non-group health insurance market during the 1990s affected the decision of taxpayers to be self-employed. Using a panel of tax returns that span 1987-2000, we find no statistically significant effect of the reforms on the propensity to be self-employed overall, although we find evidence of an increase in self-employment among older taxpayers and weaker evidence of decreases among younger cohorts.
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Limits Of Readmission Rates In Measuring Hospital Quality Suggest The Need For Added Metrics
Matthew Press et al.
Health Affairs, June 2013, Pages 1083-1091
Abstract:
Recent national policies use risk-standardized readmission rates to measure hospital performance on the theory that readmissions reflect dimensions of the quality of patient care that are influenced by hospitals. In this article our objective was to assess readmission rates as a hospital quality measure. First we compared quartile rankings of hospitals based on readmission rates in 2009 and 2011 to see whether hospitals maintained their relative performance or whether shifts occurred that suggested either changes in quality or random variation. Next we examined the relationship between readmission rates and several commonly used hospital quality indicators, including risk-standardized mortality rates, volume, teaching status, and process-measure performance. We found that quartile rankings fluctuated and that readmission rates for lower-performing hospitals in 2009 tended to improve by 2011, while readmission rates for higher-performing hospitals tended to worsen. Regression to the mean (a form of statistical noise) accounted for a portion of the changes in hospital performance. We also found that readmission rates were higher in teaching hospitals and were weakly correlated with the other indicators of hospital quality. Policy makers should consider augmenting the use of readmission rates with other measures of hospital performance during care transitions and should build on current efforts that take a communitywide approach to the readmissions issue.
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Jean Abraham, Pinar Karaca-Mandic & Michel Boudreaux
Medical Care Research and Review, forthcoming
Abstract:
Provisions within the Affordable Care Act, including the introduction of subsidized, Exchange-based coverage for lower income Americans lacking access to employer coverage, are expected to greatly expand the size and importance of the individual market. Using multiple federal surveys and administrative data from the National Association of Insurance Commissioners, we generate national-, regional-, and state-level estimates of the individual market. In 2009, the number of nonelderly persons with individual coverage ranged from 9.55 million in the Medical Expenditure Panel Survey to 25.3 million in the American Community Survey. Notable differences also exist between survey estimates and National Association of Insurance Commissioners administrative counts, an outcome likely driven by variation in the type and measurement of individual coverage considered by surveys relative to administrative data. Future research evaluating the impact of the Affordable Care Act coverage provisions must be mindful of differences across surveys and administrative sources as it relates to the measurement of individual market coverage.
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Global Comparators Project: International Comparison of Hospital Outcomes Using Administrative Data
Alex Bottle et al.
Health Services Research, forthcoming
Objective: To produce comparable risk-adjusted outcome rates for an international sample of hospitals in a collaborative project to share outcomes and learning.
Data Sources: Administrative data varying in scope, format, and coding systems were pooled from each participating hospital for the years 2005-2010.
Study Design: Following reconciliation of the different coding systems in the various countries, in-hospital mortality, unplanned readmission within 30 days, and "prolonged" hospital stay (>75th percentile) were risk-adjusted via logistic regression. A web-based interface was created to facilitate outcomes analysis for individual medical centers and enable peer comparisons. Small groups of clinicians are now exploring the potential reasons for variations in outcomes in their specialty.
Principal Findings: There were 6,737,211 inpatient records, including 214,622 in-hospital deaths. Although diagnostic coding depth varied appreciably by country, comorbidity weights were broadly comparable. U.S. hospitals generally had the lowest mortality rates, shortest stays, and highest readmission rates.
Conclusions: Intercountry differences in outcomes may result from differences in the quality of care or in practice patterns driven by socio-economic factors. Carefully managed administrative data can be an effective resource for initiating dialog between hospitals within and across countries. Inclusion of important outcomes beyond hospital discharge would increase the value of these analyses.
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Mark Olfson & Steven Marcus
Health Affairs, June 2013, Pages 1116-1125
Abstract:
The Affordable Care Act offers strong support for comparative effectiveness research, which entails comparisons among active treatments, to provide the foundation for evidence-based practice. Traditionally, a key form of research into the effectiveness of therapeutic treatments has been placebo-controlled trials, in which a specified treatment is compared to placebo. These trials feature high-contrast comparisons between treatments. Historical trends in placebo-controlled trials have been evaluated to help guide the comparative effectiveness research agenda. We investigated placebo-controlled trials reported in four leading medical journals between 1966 and 2010. We found that there was a significant decline in average effect size or average difference in efficacy (the ability to produce a desired effect) between the active treatment and placebo. On average, recently studied treatments offered only small benefits in efficacy over placebo. A decline in effect sizes in conventional placebo-controlled trials supports an increased emphasis on other avenues of research, including comparative studies on the safety, tolerability, and cost of treatments with established efficacy.
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Co-payments and the Use of Emergency Department Services in the Children's Health Insurance Program
David Becker et al.
Medical Care Research and Review, forthcoming
Abstract:
Research suggests that more than half of all emergency department (ED) visits in the United States are for nonurgent conditions, leading to billions of dollars in potentially avoidable spending annually. In this study, we examine the effects of co-payment changes on ED utilization among children enrolled in ALL Kids, Alabama's Children's Health Insurance Program We separately model the effect of the 2003 co-payment increases on the monthly probability of any ED visit, and visits within three severity categories, using linear probability models that control for beneficiary characteristics and time trends that are allowed to vary in the pre- and postperiods. We observe a small decline in the probability of ED visits 1 year after the co-payment increase. However, low-severity visits, which we hypothesize to be more price sensitive, show no significant evidence of a decline. Our study suggests that the modest co-payment changes were not effective in improving the efficiency of ED utilization.
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Innovations At Miami Practice Show Promise For Treating High-Risk Medicare Patients
Craig Tanio & Christopher Chen
Health Affairs, June 2013, Pages 1078-1082
Abstract:
Patients with five or more chronic conditions drive most Medicare costs. Our organization, ChenMed, developed a scalable primary care-led delivery model that focuses on this population while getting reimbursed through full-risk capitation by Medicare Advantage plans. ChenMed is a primary care-led group practice based in Florida that serves low-to-moderate-income elderly patients, largely through the Medicare Advantage program. Our model includes a number of innovations: a one-stop-shop approach for delivering multispecialty services in the community, smaller physician panel sizes of 350-450 patients that allow for intensive health coaching and preventive care, on-site physician pharmacy dispensing, a collaborative physician culture with peer review, and customized information technology. These innovations have improved patient medication adherence, increased the time doctors and patients spend together, and led to high rates of patient satisfaction. Additionally, our Medicare patients have substantially lower rates of hospital use than their peers in the Miami Medicare market. Creating chronic disease centers focused on seniors with multiple chronic conditions is a promising delivery system innovation with major potential to improve the cost and quality of care.
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Employer-provided health insurance and hospital mergers
Christopher Garmon
Health Economics, Policy and Law, July 2013, Pages 365-384
Abstract:
This paper explores the impact of employer-provided health insurance on hospital competition and hospital mergers. Under employer-provided health insurance, employer executives act as agents for their employees in selecting health insurance options for their firm. The paper investigates whether a merger of hospitals favored by executives will result in a larger price increase than a merger of competing hospitals elsewhere. This is found to be the case even when the executive has the same opportunity cost of travel as her employees and even when the executive is the sole owner of the firm, retaining all profits. This is consistent with the Federal Trade Commission's findings in its challenge of Evanston Northwestern Healthcare's acquisition of Highland Park Hospital. Implications of the model are further tested with executive location data and hospital data from Florida and Texas.
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Malpractice Litigation and Nursing Home Quality of Care
Tamara Konetzka et al.
Health Services Research, forthcoming
Objective: To assess the potential deterrent effect of nursing home litigation threat on nursing home quality.
Data Sources/Study Setting: We use a panel dataset of litigation claims and Nursing Home Online Survey Certification and Reporting (OSCAR) data from 1995 to 2005 in six states: Florida, Illinois, Wisconsin, New Jersey, Missouri, and Delaware, for a total of 2,245 facilities. Claims data are from Westlaw's Adverse Filings database, a proprietary legal database, on all malpractice, negligence, and personal injury/wrongful death claims filed against nursing facilities.
Study Design: A lagged 2-year moving average of the county-level number of malpractice claims is used to represent the threat of litigation. We use facility fixed-effects models to examine the relationship between the threat of litigation and nursing home quality.
Principal Findings: We find significant increases in registered nurse-to-total staffing ratios in response to rising malpractice threat, and a reduction in pressure sores among highly staffed facilities. However, the magnitude of the deterrence effect is small.
Conclusions: Deterrence in response to the threat of malpractice litigation is unlikely to lead to widespread improvements in nursing home quality. This should be weighed against other benefits and costs of litigation to assess the net benefit of tort reform.
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Survey Shows Consumers Open To A Greater Role For Physician Assistants And Nurse Practitioners
Michael Dill et al.
Health Affairs, June 2013, Pages 1135-1142
Abstract:
Impending physician shortages in the United States will necessitate greater reliance on physician assistants and nurse practitioners, particularly in primary care. But how willing are Americans to accept that change? This study examines provider preferences from patients' perspective, using data from the Association of American Medical Colleges' Consumer Survey. We found that about half of the respondents preferred to have a physician as their primary care provider. However, when presented with scenarios wherein they could see a physician assistant or a nurse practitioner sooner than a physician, most elected to see one of the other health care professionals instead of waiting. Although our findings provide evidence that US consumers are open to the idea of receiving care from physician assistants and nurse practitioners, it is important to consider barriers to more widespread use, such as scope-of-practice regulations. Policy makers should incorporate such evidence into solutions for the physician shortage.
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Medicare Skilled Nursing Facility Reimbursement and Upcoding
John Bowblis & Christopher Brunt
Health Economics, forthcoming
Abstract:
Post-acute care provided by skilled nursing facilities (SNFs) is reimbursed by Medicare under a prospective payment system using resource utilization groups (RUGs) that adjust payment intensity on the basis of predefined ranges of weekly therapy minutes provided and the functionality of the patient. Individual RUGs account for differences in the intensity of care provided, but there exists significant regional variation in the payments SNFs receive from Medicare due to the use of geographic adjustment factors. This paper is the first to use this geographic variation in the generosity of Medicare reimbursement to empirically test if SNFs respond to payment differences between RUG categories. The results are highly suggestive that SNFs upcode patients by providing additional therapy minutes to increase revenue, whereas we find no evidence of upcoding related to patient functionality scores. Simulating how different payment differentials affect RUG selection, we predict that reducing the financial incentive to upcode could result in significant savings to Medicare.
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Debt and Foregone Medical Care
Lucie Kalousova & Sarah Burgard
Journal of Health and Social Behavior, June 2013, Pages 204-220
Abstract:
Most American households carry debt, yet we have little understanding of how debt influences health behavior, especially health care seeking. We examined associations between foregone medical care and debt using a population-based sample of 914 southeastern Michigan residents surveyed in the wake of the late-2000s recession. Overall debt and ratios of debt to income and debt to assets were positively associated with foregoing medical or dental care in the past 12 months, even after adjusting for the poorer socioeconomic and health characteristics of those foregoing care and for respondents' household incomes and net worth. These overall associations were driven largely by credit card and medical debt, while housing debt and automobile and student loans were not associated with foregoing care. These results suggest that debt is an understudied aspect of health stratification.
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Scott Ramsey et al.
Health Affairs, June 2013, Pages 1143-1152
Abstract:
Much has been written about the relationship between high medical expenses and the likelihood of filing for bankruptcy, but the relationship between receiving a cancer diagnosis and filing for bankruptcy is less well understood. We estimated the incidence and relative risk of bankruptcy for people age twenty-one or older diagnosed with cancer compared to people the same age without cancer by conducting a retrospective cohort analysis that used a variety of medical, personal, legal, and bankruptcy sources covering the Western District of Washington State in US Bankruptcy Court for the period 1995-2009. We found that cancer patients were 2.65 times more likely to go bankrupt than people without cancer. Younger cancer patients had 2-5 times higher rates of bankruptcy than cancer patients age sixty-five or older, which indicates that Medicare and Social Security may mitigate bankruptcy risk for the older group. The findings suggest that employers and governments may have a policy role to play in creating programs and incentives that could help people cover expenses in the first year following a cancer diagnosis.
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The 2010 U.S. health care reform: Approaching and avoiding how other countries finance health care
Joseph White
Health Economics, Policy and Law, July 2013, Pages 289-315
Abstract:
This article describes and analyzes the U.S. health care legislation of 2010 by asking how far it was designed to move the U.S. system in the direction of practices in all other rich democracies. The enacted U.S. reform could be described, extremely roughly, as Japanese pooling with Swiss and American problems at American prices. Its policies are distinctive, yet nevertheless somewhat similar to examples in other rich democracies, on two important dimensions: how risks are pooled and the amount of funds redistributed to subsidize care for people with lower incomes. Policies about compelling people to contribute to a finance system would be further from international norms, as would the degree to which coverage is set by clear and common substantive standards - that is, standardization of benefits. The reform would do least, however, to move the United States toward international practices for controlling spending. This in turn is a major reason why the results would include less standard benefits and incomplete coverage. In short, the United States would remain an outlier on coverage less because of a failure to make an effort to redistribute - a lack of solidarity - than due to a failure to control costs.
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Carter Price & Christine Eibner
Health Affairs, June 2013, Pages 1030-1036
Abstract:
The US Supreme Court's ruling on the Affordable Care Act in 2012 allowed states to opt out of the health reform law's Medicaid expansion. Since that ruling, fourteen governors have announced that their states will not expand their Medicaid programs. We used the RAND COMPARE microsimulation to analyze how opting out of Medicaid expansion would affect coverage and spending, and whether alternative policy options - such as partial expansion of Medicaid - could cover as many people at lower costs to states. With fourteen states opting out, we estimate that 3.6 million fewer people would be insured, federal transfer payments to those states could fall by $8.4 billion, and state spending on uncompensated care could increase by $1 billion in 2016, compared to what would be expected if all states participated in the expansion. These effects were only partially mitigated by alternative options we considered. We conclude that in terms of coverage, cost, and federal payments, states would do best to expand Medicaid.
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Ronald Gimbel et al.
Medical Care, July 2013, Pages 628-632
Background: It is estimated that 20%-40% of advanced medical imaging in the United States is unnecessary, resulting in patient overexposure to radiation and increasing the cost of care. Previous imaging utilization studies have focused on clinical appropriateness. An important contributor to excessive use of advanced imaging may be a physician "knowledge gap" regarding the safety and cost of the tests.
Objectives: To determine whether safety and cost information will change physician medical image decision making.
Research Design: Double-blinded, randomized controlled trial. Following standardized case presentation, physicians made an initial imaging choice. This was followed by the presentation of guidelines, radiation exposure and health risk, and cost information.
Results: Approximately half (57 of 112, 50.9%) of participants initially selected computed tomography (CT). When presented with guideline recommendations, participants did not modify their initial imaging choice (P=0.197). A significant reduction (56.3%, P<0.001) in CT ordering occurred after presentation of radiation exposure/health risk information; ordering changed to magnetic resonance imaging or ultrasound (US). A significant reduction (48.3%, P<0.001) in CT and magnetic resonance imaging ordering occurred after presentation of Medicare reimbursement information; ordering changed to US. The majority of physicians (31 of 40, 77.5%) selecting US never modified their ordering. No significant relationship between physician demographics and decision making was observed.
Conclusions: This study suggests that physician decision making can be influenced by safety and cost information and the order in which information is provided to physicians can affect their decisions.
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Joanne Spetz et al.
Medical Care Research and Review, forthcoming
Abstract:
This study tests whether changes in licensed nurse staffing led to changes in patient safety, using the natural experiment of 2004 California implementation of minimum staffing ratios. We calculated counts of six patient safety outcomes from California Patient Discharge Data from 2000 through 2006, using the Agency for Healthcare Research and Quality Patient Safety Indicators (PSI) software. For patients experiencing nonmortality-related PSIs, we measured mean lengths of stay. We estimated difference-in-difference equations of changes in PSIs using Poisson models and calculated the marginal impact of nurse staffing on outcomes from fixed-effect Poisson regressions. Licensed nurse staffing increased in the postregulation period, except for hospitals in the highest quartile of preregulation staffing. Growth in registered nurse staffing was associated with improvement for only one PSI and reduced length of stay for one PSI. Higher registered nurse staffing per patient day had a limited impact on adverse events in California hospitals.
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Peter Mullins, Munish Goyal & Jesse Pines
Academic Emergency Medicine, May 2013, Pages 479-486
Objectives: The authors describe national trends in use, reasons for visit, most common diagnoses, and resource utilization in patients admitted to intensive care units (ICUs) from hospital-based emergency departments (EDs) in the United States.
Methods: This was an observational study using data from the National Hospital Ambulatory Care Survey, a nationally representative, weighted sample of U.S. hospital-based EDs from 2002 through 2009. The sample comprised a total of 4,267 patients aged 18 years or older admitted to the ICU from the ED, which represent over 14.5 million ED encounters from 2002 through 2009.
Results: Over the study period, ICU admissions from EDs increased from 2.79 million in 2002/2003, to 4.14 million in 2008/2009, an absolute increase of 48.8% and a mean biennial increase of 14.2%. By comparison, overall ED visits increased a mean of 5.8% per biennial period. The three most common diagnoses for ICU admissions were unspecified chest pain, congestive heart failure, and pneumonia. Utilization rates of most tests and services delivered to patients admitted to the ICU from the ED increased, with the largest increase occurring in computed tomography (CT) and magnetic resonance imaging (MRI), which increased from 16.8% in 2002/2003 to 37.4% in 2008/2009, a 6.9% mean biennial increase. Across all years, mean ED length of stay (LOS) for ICU admissions was 304 minutes (95% confidence interval [CI] = 286 to 323 minutes), and mean hospital LOS was 6.6 days (95% CI = 6.2 to 7.0 days). There was no significant change in either mean ED or hospital LOS over the study period.
Conclusions: Intensive care unit admissions from EDs are increasing at a greater rate than both population growth and overall ED visits. ED resource use, specifically advanced diagnostic imaging, has increased markedly among ICU admissions. While mean ED and hospital LOS have not changed significantly, the mean ICU admission spends over 5 hours in the ED prior to transfer to an ICU bed. A greater emphasis on the ED-ICU interface and critical care delivered in the ED may be warranted.
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Rachel Werner et al.
Medical Care, June 2013, Pages 487-493
Background: The patient-centered medical home (PCMH) has increasingly been looked to by policy makers, health care providers, and private insurers as a potential solution to the fragmented and inefficient US health care system. Whether the PCMH achieves these goals is not known.
Objectives: To evaluate a PCMH demonstration project implemented in 2011 in 8 New Jersey primary care practices covering over 10,000 plan members.
Research Design: We conduct difference-in-differences analysis, comparing changes in outcomes at 8 medical home practices to a group of 24 comparison practices before (2010) and after (2011) the medical home implementation occurred. We use Mahalanobis distance matching to select the 24 comparison practices, matching on practice characteristics. We focus on the effect of the PCMH pilot on 3 groups of outcomes: health care utilization, costs, and quality.
Results: The study cohort included 35,059 members during the study period 2010-2011-10,004 in the 8 PCMH practices and 25,055 in the 24 comparison practices. Health care utilization and costs did not significantly change with adoption of the PCMH model. In testing for changes in Healthcare Effectiveness and Data Information Set (HEDIS) quality measures, rates of mammography increased in PCMH practices after PCMH implementation compared to non-PCMH practices, by 2.2 percentage points on a base of 69.5% (P<0.001). Rates of nephropathy screening also increased (by 6.6 percentage points on a base of 51.8%; P=0.05). Changes in 7 other HEDIS quality measures following PCMH implementation were not statistically significant.
Conclusions: We find little evidence of reductions in health care utilization or cost and minimal evidence of improvements in quality of care. Ongoing work is needed to understand why this model of care seems to work in some cases and not others and to evaluate how to improve the medical home.
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Alan Gerber et al.
Journal of Health Politics, Policy and Law, forthcoming
Abstract:
The Obama Administration has made a major investment in comparative effectiveness research (CER) to learn what treatments work best for which patients. CER has the potential to reduce wasteful medical spending and improve patient outcomes, but the political sustainability of this initiative remains unclear due to concerns that it will threaten the doctor-patient relationship. An unresolved question is whether it is possible to boost public support for the use of CER as a cost control strategy. We investigate one potential source of public support: Americans' trust in physicians as faithful agents of patient interests. We conducted two national surveys to explore the public's confidence in doctors compared to other groups. We find that doctors are viewed as harder workers, more trustworthy, and more caring than other professions. Through survey experiments, we demonstrate that the support of doctors' groups for proposals to control costs and use CER have a greater influence on aggregate public opinion than do cues from political actors including congressional Democrats, Republicans, and a bipartisan commission. Our survey results suggest that the medical profession's stance will be an important factor in shaping the political viability of efforts to use CER as a tool for health care cost control.
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Competition and Quality in Home Health Care Markets
Kyoungrae Jung & Daniel Polsky
Health Economics, forthcoming
Abstract:
Market-based solutions are often proposed to improve health care quality; yet evidence on the role of competition in quality in non-hospital settings is sparse. We examine the relationship between competition and quality in home health care. This market is different from other markets in that service delivery takes place in patients' homes, which implies low costs of market entry and exit for agencies. We use 6 years of panel data for Medicare beneficiaries during the early 2000s. We identify the competition effect from within-market variation in competition over time. We analyze three quality measures: functional improvements, the number of home health visits, and discharges without hospitalization. We find that the relationship between competition and home health quality is nonlinear and its pattern differs by quality measure. Competition has positive effects on functional improvements and the number of visits in most ranges, but in the most competitive markets, functional outcomes and the number of visits slightly drop. Competition has a negative effect on discharges without hospitalization that is strongest in the most competitive markets. This finding is different from prior research on hospital markets and suggests that market-specific environments should be considered in developing polices to promote competition.
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Antoinette Smith et al.
Decision Sciences, June 2013, Pages 483-516
Abstract:
As a result of a recent federal government mandate, an increasing number of hospitals have decided to adopt electronic medical record (EMR) systems. This initiative is expected to lead toward more efficient and higher quality health care; however, little is known about governance characteristics and organizational performance for EMR adopters. Our goal is to inform theory and practice by examining hospitals with a sophisticated EMR and comparing those hospitals to similar hospitals (with a less sophisticated EMR) to understand the association between information technology (IT) governance characteristics and the implications on financial performance. Leveraging elements of the upper echelon theory, we posit that hospitals in which the chief information officer (CIO) reports to the chief executive officer, CIO turnover is low, and an IT steering committee is present are more likely to have a sophisticated EMR. We argue that EMR sophistication leads to improved financial performance. Our results underscore the importance of continuity in the CIO position on successful EMR implementations. Results also show that hospital size and financial performance are strongly associated with EMR sophistication. In addition, we find that a sophisticated EMR appears to be a fundamental element in improving hospitals' revenue cycle management. Moreover, we find that hospitals with a sophisticated EMR appear to be more profitable. Finally, we observe that total payroll expense adjusted by total discharges drops among the sophisticated hospitals, potentially due to an increase in employee productivity. These insights can serve as a basis for tempering expectations relative to the financial impact of EMR adoption.
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A Randomized Trial of Nighttime Physician Staffing in an Intensive Care Unit
Meeta Prasad Kerlin et al.
New England Journal of Medicine, 6 June 2013, Pages 2201-2209
Background: Increasing numbers of intensive care units (ICUs) are adopting the practice of nighttime intensivist staffing despite the lack of experimental evidence of its effectiveness.
Methods: We conducted a 1-year randomized trial in an academic medical ICU of the effects of nighttime staffing with in-hospital intensivists (intervention) as compared with nighttime coverage by daytime intensivists who were available for consultation by telephone (control). We randomly assigned blocks of 7 consecutive nights to the intervention or the control strategy. The primary outcome was patients' length of stay in the ICU. Secondary outcomes were patients' length of stay in the hospital, ICU and in-hospital mortality, discharge disposition, and rates of readmission to the ICU. For length-of-stay outcomes, we performed time-to-event analyses, with data censored at the time of a patient's death or transfer to another ICU.
Results: A total of 1598 patients were included in the analyses. The median Acute Physiology and Chronic Health Evaluation (APACHE) III score (in which scores range from 0 to 299, with higher scores indicating more severe illness) was 67 (interquartile range, 47 to 91), the median length of stay in the ICU was 52.7 hours (interquartile range, 29.0 to 113.4), and mortality in the ICU was 18%. Patients who were admitted on intervention days were exposed to nighttime intensivists on more nights than were patients admitted on control days (median, 100% of nights [interquartile range, 67 to 100] vs. median, 0% [interquartile range, 0 to 33]; P<0.001). Nonetheless, intensivist staffing on the night of admission did not have a significant effect on the length of stay in the ICU (rate ratio for the time to ICU discharge, 0.98; 95% confidence interval [CI], 0.88 to 1.09; P=0.72), ICU mortality (relative risk, 1.07; 95% CI, 0.90 to 1.28), or any other end point. Analyses restricted to patients who were admitted at night showed similar results, as did sensitivity analyses that used different definitions of exposure and outcome.
Conclusions: In an academic medical ICU in the United States, nighttime in-hospital intensivist staffing did not improve patient outcomes.
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Responses to Medicare Drug Costs among Near-Poor versus Subsidized Beneficiaries
Vicki Fung et al.
Health Services Research, forthcoming
Objective: There is limited information on the protective value of Medicare Part D low-income subsidies (LIS). We compared responses to drug costs for LIS recipients with near-poor (≤200 percent of the Federal Poverty Level) and higher income beneficiaries without the LIS.
Data Sources/Study Setting: Medicare Advantage beneficiaries in 2008.
Study Design: We examined three drug cost responses using multivariate logistic regression: cost-reducing behaviors (e.g., switching to generics), nonadherence (e.g., not refilling prescriptions), and financial stress (e.g., going without necessities).
Data Collection: Telephone interviews in a stratified random sample (N = 1,201, 70 percent response rate).
Principal Findings: After adjustment, a comparable percentage of unsubsidized near-poor (26 percent) and higher income beneficiaries reported cost-reducing behaviors (23 percent, p = .63); fewer LIS beneficiaries reported cost-reducing behaviors (15 percent, p = .019 vs near-poor). Unsubsidized near-poor beneficiaries were more likely to reduce adherence (8.2 percent) than higher income (3.5 percent, p = .049) and LIS beneficiaries (3.1 percent, p = .027). Near-poor beneficiaries also more frequently experienced financial stress due to drug costs (20 percent) than higher income beneficiaries (11 percent, p = .050) and LIS beneficiaries (11 percent, p = .015).
Conclusions: Low-income subsidies provide protection from drug cost-related nonadherence and financial stress. Beneficiaries just above the LIS income threshold are most at risk for these potentially adverse behaviors.
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Bruce Stuart et al.
Health Services Research, forthcoming
Objective: Assess impact of Medicare Part D benefit phases on adherence with evidence-based medications after hospitalization for an acute myocardial infarction.
Data Source: Random 5 percent sample of Medicare beneficiaries.
Study Design: Difference-in-difference analysis of drug adherence by AMI patients stratified by low-income subsidy (LIS) status and benefit phase.
Data Collection/Extraction Methods: Subjects were identified with an AMI diagnosis in Medicare Part A files between April 2006 and December 2007 and followed until December 2008 or death (N = 8,900). Adherence was measured as percent of days covered (PDC) per month with four drug classes used in AMI treatment: angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, statins, and clopidogrel. Monthly exposure to Part D benefit phases was calculated from flags on each Part D claim.
Principal Findings: For non-LIS enrollees, transitioning from the initial coverage phase into the Part D coverage gap was associated with statistically significant reductions in mean PDC for all four drug classes: statins (-7.8 percent), clopidogrel (-7.0 percent), beta-blockers (-5.9 percent), and ACE inhibitor/ARBs (-5.1 percent). There were no significant changes in adherence associated with transitioning from the gap to the catastrophic coverage phase.
Conclusions: As the Part D doughnut hole is gradually filled in by 2020, Medicare Part D enrollees with critical diseases such as AMI who rely heavily on brand name drugs are likely to exhibit modest increases in adherence. Those reliant on generic drugs are less likely to be affected.
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The Disparate Impact of the ACA-Dependent Expansion across Population Subgroups
Brett O'Hara & Matthew Brault
Health Services Research, forthcoming
Objective: This study presents evidence on how the dependent provision in the Affordable Care Act (ACA) differentially affected coverage for young adults across states and population subgroups.
Study Design/Methods/Data: The data derive from the American Community Survey. Using a difference-in-difference design, we compare the target population (ages 19-25) with a control group (ages 26-29).
Principal Findings: Net private health insurance coverage increased by 4.6 percentage points and overall coverage increased by 4.2 percentage points for people aged 19-25; more for Whites than non-White subgroups.
Conclusions and Implications: Changes in coverage for states appear driven by demographics rather than the existence of prior dependent expansions by the state. Disparities in health care coverage remain, but the absolute level of coverage is improving.
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Do Changes in Hospital Outpatient Payments Affect the Setting of Care?
Daifeng He & Jennifer Mellor
Health Services Research, forthcoming
Objective: To examine whether decreases in Medicare outpatient payment rates under the Outpatient Prospective Payment System (OPPS) caused outpatient care to shift toward the inpatient setting.
Data Sources/Study Setting: Hospital inpatient and outpatient discharge files from the Florida Agency for Health Care Administration from 1997 through 2008.
Study Design: This study focuses on inguinal hernia repair surgery, one of the most commonly performed surgical procedures in the United States. We estimate multivariate regressions of inguinal hernia surgery counts in the outpatient setting and in the inpatient setting. The key explanatory variable is the time-varying Medicare payment rate specific to the procedure and hospital. Control variables include time-varying hospital and county characteristics and hospital and year-fixed effects.
Principal Findings: Outpatient hernia surgeries fell in response to OPPS-induced rate cuts. The volume of inpatient hernia repair surgeries did not increase in response to reductions in the outpatient reimbursement rate.
Conclusions: Potential substitution from the outpatient setting to the inpatient setting does not pose a serious threat to Medicare's efforts to contain hospital outpatient costs.