Under the coverage
Bargaining in the Shadow of a Giant: Medicare's Influence on Private Payment Systems
Jeffrey Clemens & Joshua Gottlieb
NBER Working Paper, October 2013
Abstract:
We analyze Medicare's influence on private payments for physicians' services. Using a large administrative change in payments for surgical procedures relative to other medical services, we find that private payments follow Medicare's lead. On average, a $1 change in Medicare's relative payments results in a $1.30 change in private payments. We find that Medicare similarly moves the level of private payments when it alters fees across the board. Medicare thus strongly influences both relative valuations and aggregate expenditures on physicians' services. We show further that Medicare's price transmission is strongest in markets with large numbers of physicians and low provider consolidation. Transaction and bargaining costs may lead the development of payment systems to suffer from a classic coordination problem. By extension, improvements in Medicare's payment models may have the qualities of public goods.
----------------------
The Public’s Anger: White Racial Attitudes and Opinions Toward Health Care Reform
Antoine Banks
Political Behavior, forthcoming
Abstract:
Pundits and politicians debated whether race was implicated in the rancorous public forums and demonstrations over health care reform. Research suggests that for many white Americans, racial predispositions play a greater role in their opinions on health care than non-racial predispositions. Building on this work, I examine the extent to which anger uniquely activates white racial attitudes and increases their effect on preferences for health care reform. My theory suggests this effect occurs because anger and thoughts about race are tightly linked in memory. Using a nationally representative experiment over two waves, I induced several emotions to elicit anger, fear, enthusiasm, or relaxation. The results show that anger uniquely pushes racial conservatives to be more opposing of health care reform while it triggers more support among racial liberals. On the other hand, anger does not enhance the effect of race-neutral principles on health care reform.
----------------------
High-Intensity Emergency Department Visits Increased In California, 2002–09
Andrew Herring et al.
Health Affairs, October 2013, Pages 1811-1819
Abstract:
Increasing use of the emergency department (ED) is well documented, but little is known about the type and severity of ED visits or their distribution across safety-net and non-safety-net hospitals. We examined the rates of high-intensity ED visits — characterized by their use of advanced imaging, consultations with specialists, the evaluation of multiple systems, and highly complex medical decision making — by patients with a severe, potentially life-threatening illness in California from 2002 through 2009. Total annual ED visits increased by 25 percent, from 9.0 million to 11.3 million, but high-intensity ED visits nearly doubled, increasing 87 percent from 778,000 to 1.5 million per year. The percentage of ED visits with high-intensity care increased from 9 percent to 13 percent (a relative increase of 44 percent). Annual ED admissions increased by 39 percent overall; most of this increase was attributable to high-intensity ED admissions, which increased by 88 percent. Safety-net EDs experienced an increase in high-intensity visits of 157 percent, compared to an increase of 61 percent at non-safety-net EDs. These findings suggest a trend toward intensification of ED care, particularly at safety-net hospitals, whose patients may have limited access to care outside the ED.
----------------------
How Does Retiree Health Insurance Influence Public Sector Employee Saving?
Robert Clark & Olivia Mitchell
NBER Working Paper, October 2013
Abstract:
Economic theory predicts that employer-provided retiree health insurance benefits crowd-out household wealth accumulation. Nevertheless, there is little research on the impacts of retiree health insurance on wealth accruals, so this paper utilizes a unique data file on three baseline cohorts from the Health and Retirement Study to explore how employer-provided retiree health insurance may influence net household wealth among public sector employees, where retiree healthcare benefits are still quite prevalent. We find that most full-time public sector employees who anticipate receiving employer-provided health insurance coverage in retirement save less than their private sector uncovered counterparts.
----------------------
The Quality Of Care Delivered To Patients Within The Same Hospital Varies By Insurance Type
Christine Spencer, Darrell Gaskin & Eric Roberts
Health Affairs, October 2013, Pages 1731-1739
Abstract:
In attempting to explain why hospitals vary in the quality of care delivered to patients, a considerable body of health policy research points to differences in hospital characteristics such as ownership, safety-net status, and geographic location as the most important contributing factors. This article examines the extent to which a patient’s type or lack of insurance may also play a role in determining the quality of care received at any given hospital. We compared within-hospital quality, as measured by risk-adjusted mortality rates, for patients according to their insurance status. We examined the Agency for Healthcare Research and Quality’s innovative Inpatient Quality Indicators and pooled 2006–08 State Inpatient Database records from eleven states. We found that privately insured patients had lower risk-adjusted mortality rates than did Medicare enrollees for twelve out of fifteen quality measures examined. To a lesser extent, privately insured patients also had lower risk-adjusted mortality rates than those in other payer groups. Medicare patients appeared particularly vulnerable to receiving inferior care. These findings suggest that to help reduce care disparities, public payers and hospitals should measure care quality for different insurance groups and monitor differences in treatment practices within hospitals.
----------------------
Katherine Baicker et al.
NBER Working Paper, October 2013
Abstract:
In 2008, a group of uninsured low-income adults in Oregon was selected by lottery for the chance to apply for Medicaid. We use this randomized design and 2009 administrative data to evaluate the effect of Medicaid on labor market outcomes and participation in other social safety net programs. We find no significant effect of Medicaid on employment or earnings: our 95 percent confidence intervals allow us to reject that Medicaid causes a decline in employment of more than 4.4 percentage points, or an increase of more than 1.2 percentage points. We find that Medicaid increases receipt of food stamps, but has little, if any, impact on receipt of other government benefits, including SSDI.
----------------------
The Impact of the Partnership Long-Term Care Insurance Program on Private Coverage
Haizhen Lin & Jeffrey Prince
Journal of Health Economics, forthcoming
Abstract:
We examine the impact of U.S. states’ adoption of the partnership long-term care (LTC) insurance program on households’ purchases of private coverage. Targeting middle-class households, this program increases the benefits of privately insuring via a higher asset threshold for Medicaid eligibility for LTC coverage. We find that the program generates few new purchases of LTC insurance, and that those it generates are almost entirely by wealthy individuals.
----------------------
Carolina-Nicole Herrera et al.
Health Affairs, October 2013, Pages 1715-1722
Abstract:
Little is known about the trends in health care spending for the 156 million Americans who are younger than age sixty-five and enrolled in employer-sponsored health insurance. Using a new source of health insurance claims data, we estimated per capita spending, utilization, and prices for this population between 2007 and 2011. During this period per capita spending on employer-sponsored insurance grew at historically slow rates, but still faster than per capita national health expenditures. Total per capita spending for employer-sponsored insurance grew at an average annual rate of 4.9 percent, with prescription spending growing at 3.3 percent and medical spending growing at 5.3 percent. Out-of-pocket medical spending increased at an average annual rate of 8.0 percent, whereas out-of-pocket prescription drug spending growth was flat. Growth in the use of medical services and prescription drugs slowed. Medical price growth accelerated, and prescription price growth decelerated. As a result, changes in utilization contributed less than changes in price did to overall spending growth for those with employer-sponsored insurance.
----------------------
Identifying the Health Production Function: The Case of Hospitals
John Romley & Neeraj Sood
NBER Working Paper, October 2013
Abstract:
Estimates of the returns to medical care may reflect not only the efficacy of more intensive care, but also unmeasured differences in patient severity or the productivity of health-care providers. We use a variety of instruments that are plausibly orthogonal to heterogeneity among providers as well as patients to analyze the intensity of care and 30-day survival among Medicare patients hospitalized for heart attack, congestive heart failure and pneumonia. We find that the intensity of care is endogenous for two out of three conditions. The elasticity of 30-day mortality with respect to care intensity increases in magnitude from -0.27 to -0.71 for pneumonia and from -0.16 to -0.33 for congestive heart failure, when we address the identification problem. This finding is consistent with the hypotheses that care intensity at hospitals tends to decrease with hospital productivity, or increase with unmeasured patient severity.
----------------------
Rong Hai
University of Chicago Working Paper, September 2013
Abstract:
I develop and structurally estimate a non-stationary overlapping generations equilibrium model of employment and workers' health insurance and wage compensation, to investigate the determinants of rising inequality in health insurance and wages in the U.S. over the last 30 years. I find that skill-biased technological change and the rising cost of medical care services are the two most important determinants, while the impact of Medicaid eligibility expansion is quantitatively small. I conduct counterfactual policy experiments to analyze key features of the 2010 Patient Protection and Affordable Care Act, including employer mandates and further Medicaid eligibility expansion. I find that (i) an employer mandate reduces both wage and health insurance coverage inequality, but also lowers the employment rate of less educated individuals; and (ii) further Medicaid eligibility expansion increases employment rate of less educated individuals, reduces health insurance coverage disparity, but also causes larger wage inequality.
----------------------
When Medicare Cuts Hospital Prices, Seniors Use Less Inpatient Care
Chapin White & Tracy Yee
Health Affairs, October 2013, Pages 1789-1795
Abstract:
The Affordable Care Act permanently slows the growth in Medicare hospital prices. To better understand the effects of those price cuts, we used data from ten states for the period 1995–2009 to examine the market-level relationship between Medicare prices and hospital utilization among the elderly. Regression analyses indicate that a 10 percent reduction in the Medicare price was associated with a 4.6 percent reduction in discharges among the elderly. This volume response to price cuts appears to be accomplished through hospitals’ reduction in their numbers of staffed beds. They did not leave beds empty; instead, they reduced their scale of operations. Based on our results, we conclude that the Affordable Care Act will help reduce inpatient hospital utilization in the future. From a federal budgetary standpoint, lower utilization is good news, but the implications for patient care and health outcomes are not yet clear.
----------------------
Amelia Bond & Chapin White
Health Services Research, forthcoming
Objective: To examine whether expanding coverage for the nonelderly affects primary care utilization among Medicare beneficiaries.
Data Source: Zip code–level files from Dartmouth Atlas for Massachusetts and surrounding states, including Medicare utilization for 2005 (pre expansion) and 2007 (post expansion), and health insurance coverage for 2005.
Study Design: We use two zip code–level outcomes: arc percent change in primary care visits per Medicare beneficiary per year, and percentage point change in the share of beneficiaries with one or more primary care visits. We use a regression-based difference-in-difference analysis that compares Massachusetts with surrounding states, and zip codes with high, medium, and low uninsurance rates in 2005. The 2005 uninsurance rates correspond to the size of Massachusetts' coverage expansion. We use propensity scores for identification of comparable zip codes and for weighting.
Principal Findings: In areas of Massachusetts with the highest uninsurance rates — where insurance expansion had the largest impact — visits per beneficiary fell 6.9 percent (p < .001) relative to areas of Massachusetts with the smallest uninsurance rates.
Conclusions: The expansion of coverage for the nonelderly reduced primary care visits, but it did not reduce the percent of beneficiaries with at least one visit. These results could imply restricted access, increased efficiency, or some blend.
----------------------
Reductions in Medicare Payments and Patient Outcomes: An Analysis of 5 Leading Medicare Conditions
Yu-Chu Shen & Vivian Wu
Medical Care, November 2013, Pages 970-977
Background: The Affordable Care Act enacted significant Medicare payment reductions to providers, yet the effects of such major reductions on patients remain unclear. We used the Balanced Budget Act (BBA) of 1997 as a natural experiment to study the long-term consequence of major payment reductions on patient outcomes.
Objectives: To analyze whether mortality trends diverge over the years between hospitals facing different levels of payment cuts because of the BBA for 5 leading conditions: acute myocardial infarction, congestive heart failure, stroke, pneumonia, and hip fracture.
Research Design: Using 100% Medicare claims between 1995 and 2005, hospital database, and published reports on BBA policy components, we compared changes in outcomes between hospitals facing small and large BBA payment reductions across 3 periods (pre-BBA, initial-BBA, and post-BBA) using instrumental variable hospital fixed-effects regression models.
Setting: All general, acute, nonrural, short-stay hospitals in the United States 1995—2005.
Main Outcome Measures: Hospital risk-adjusted mortality rates (7, 30, 90 d, and 1 y).
Results: Mortality trends between hospitals in small and large payment-cut categories were similar between pre-BBA and initial-BBA periods, but diverged in the post-BBA period. Relative to the small-cut hospitals, hospitals in the large-cut category experienced smaller decline in 1-year mortality rates in the post-BBA period compared with their pre-BBA trends by 0.8–1.4 percentage points, depending on the condition (P<0.05 for all conditions, except for hip fracture).
Conclusion: We found consistent evidence across multiple conditions that reductions in Medicare payments are associated with slower improvement in mortality outcomes.
----------------------
Adrianne Haggins et al.
Academic Emergency Medicine, October 2013, Pages 1026–1032
Objectives: Emergency and outpatient department use was examined after the State Children's Health Insurance Program (CHIP) coverage expansion, focusing on adolescents (a major target group for CHIP) versus young adults (not targeted). The hypothesis was that coverage would increase use of outpatient services, and ED use would decrease.
Methods: Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), the years 1992–1996 were analyzed as baseline and then compared to use patterns in 1999–2009, after the CHIP launch. Primary outcomes were population-adjusted annual visits to ED versus nonemergency outpatient settings. Interrupted time series were performed on use rates to ED and outpatient departments between adolescents (11 to 18 years old) and young adults (19 to 29 years old) in the pre-CHIP and CHIP periods. Outpatient-to-ED ratios were calculated and compared across time periods. A stratified analysis by payer and sex was also performed.
Results: The mean number of outpatient adolescent visits increased by 299 visits per 1,000 persons (95% confidence interval [CI] = 140 to 457), while there was no statistically significant increase in young adult outpatient visits across time periods. There was no statistically significant change in the mean number of adolescent ED visits across time periods, while young adult ED use increased by 48 visits per 1,000 persons (95% CI = 24 to 73). The adolescent outpatient-to-ED ratio increased by 1.0 (95% CI = 0.49 to 1.6), while the young adults ratio decreased by 0.53 across time periods (95% CI = –0.90 to –0.16).
Conclusions: Since CHIP, adolescent non-ED outpatient visits have increased, while ED visits have remained unchanged. In comparison to young adults, expanding insurance coverage to adolescents improved use of health care services and suggests a shift to non-ED settings. Expanding insurance through the Affordable Care Act of 2010 will likely increase use of outpatient services, but may not decrease ED volumes.
----------------------
James Kirby & Toshiko Kaneda
Health Affairs, October 2013, Pages 1766-1772
Abstract:
Eliminating disparities in health and health care is a long-standing objective of the US government. Racial and ethnic differences in insurance coverage pose a major obstacle to achieving this objective. With important coverage provisions of the Affordable Care Act beginning to take effect, we propose a new way of conceptualizing and quantifying the racial and ethnic disadvantages of uninsurance over the course of a lifetime. Using a life expectancy approach, we estimate the number of years whites, blacks, and Hispanics can expect to live in insurance “double jeopardy”: being uninsured while also in lesser health and, therefore, at higher risk of needing medical care. Our measures indicate that compared to whites, Hispanics and blacks are more likely not only to be uninsured at any point throughout most of their lives, but also to spend more years uninsured and spend more of these uninsured years at high risk of needing medical care. These life expectancy measures — designed for ease of use by policy makers, researchers, and the general public — have the potential to reframe the discussion of disparities and monitor progress toward their elimination.
----------------------
Amount of Savings Needed for Health Expenses for People Eligible for Medicare: More Rare Good News
Paul Fronstin, Dallas Salisbury & Jack VanDerhei
Employee Benefit Research Institute Working Paper, October 2013
Abstract:
This paper updates previous estimates by the Employee Benefit Research Institute on savings needed to cover health insurance premiums and health care expenses in retirement. Much like EBRI’s 2012 report, this analysis finds that the savings targets for a 65-year-old retiring in 2013 were not higher than the savings targets for a 65-year-old in the previous year. In fact, these particular savings targets have continued to fall, with the decline ranging from 6-11 percent. This report discusses the model, the savings targets, and continued reasons for the decline in savings targets. In 2010, Medicare covered 62 percent of the cost of health care services for Medicare beneficiaries age 65 and older, while out-of-pocket spending accounted for 12 percent, and private insurance covered 13 percent. Individuals can expect to pay a greater share of their costs out-of-pocket in the future because of the combination of the financial condition of the Medicare program and cutbacks to employment-based retiree health programs. Because women have longer life expectancies than men, women will generally need larger savings than men to cover health insurance premiums and health care expenses in retirement post-65 when examining needed savings regardless of the savings targets. In 2013, a man would need $65,000 in savings and a woman would need $86,000 if each had a goal of having a 50 percent chance of having enough money saved to cover health care expenses in retirement. If either instead wanted a 90 percent chance of having enough savings, $122,000 would be needed for a man and $139,000 would be needed for a woman. Savings targets declined between 6 percent and 11 percent between 2012 and 2013 for a person or couple age 65. For a married couple both with drug expenses at the 90th percentile throughout retirement who wanted a 90 percent chance of having enough money saved for health care expenses in retirement by age 65, targeted savings fell from $387,000 in 2012 to $360,000 in 2013.
----------------------
John Romley et al.
Health Services Research, forthcoming
Objective: To determine the association between hospital costs and risk-adjusted inpatient mortality among children undergoing surgery for congenital heart disease (CHD) in U.S. acute-care hospitals.
Data Sources/Study Settings: Retrospective cohort study of 35,446 children in 2003, 2006, and 2009 Kids' Inpatient Database (KID).
Study Design: Cross-sectional logistic regression of risk-adjusted inpatient mortality and hospital costs, adjusting for a variety of patient-, hospital-, and community-level confounders.
Data Collection/Extraction Methods: We identified relevant discharges in the KID using the AHRQ Pediatric Quality Indicator for pediatric heart surgery mortality, and linked these records to hospital characteristics from American Hospital Association Surveys and community characteristics from the Census.
Principal Findings: Children undergoing CHD surgery in higher cost hospitals had lower risk-adjusted inpatient mortality (p = .002). An increase from the 25th percentile of treatment costs to the 75th percentile was associated with a 13.6 percent reduction in risk-adjusted mortality.
Conclusions: Greater hospital costs are associated with lower risk-adjusted inpatient mortality for children undergoing CHD surgery. The specific mechanisms by which greater costs improve mortality merit further exploration.
----------------------
Risk Selection and Cost Shifting in a Prospective Physician Payment System: Evidence from Ontario
Jasmin Kantarevic & Boris Kralj
Health Policy, forthcoming
Abstract:
We study the risk-selection and cost-shifting behavior of physicians in a unique capitation payment model in Ontario, using the incentive to enroll and care for complex and vulnerable patients as a case study. This incentive, which is incremental to the regular capitation payment, ceases after the first year of patient enrollment and may therefore impact on the physician's decision to continue to enroll the patient. Furthermore, because the enrolled patients in Ontario can seek care from any provider, the enrolling physician may shift some treatment costs to other providers. Using longitudinal administrative data and a control group of physicians in the fee-for-service model who were eligible for the same incentive, we find no evidence of either patient ‘dumping’ or cost shifting. These results highlight the need to re-examine the conventional wisdom about risk selection for physician payment models that significantly deviate from the stylized capitation model.
----------------------
Impact of Changes in Medicaid Coverage on Physician Provision of Safety Net Care
Lindsay Sabik & Sabina Gandhi
Medical Care, November 2013, Pages 978-984
Background: The Patient Protection and Affordable Care Act will expand Medicaid coverage substantially, with the goal of improving the health of low-income individuals and reducing disparities in coverage and access. Whether insurance expansions are successful in achieving this goal will depend in part on physician response to changes in insurance coverage mix and the effect of this response on access to care for low-income safety net populations.
Objectives: The objective of the study was to consider the impact of changes in market-level Medicaid coverage on measures of physician participation in care for safety net populations.
Research Design: We use 4 waves of the Community Tracking Study Physician Survey from 1996 to 2005. We estimate both market-level and physician-level fixed effects models, to consider changes in market-level Medicaid rates on measures of physician acceptance of new patients (both Medicaid patients and uninsured patients unable to pay), revenue from Medicaid, and provision of charity care. We also stratify the sample to investigate whether effects differ among office-based versus facility-based physicians.
Results: Increases in Medicaid coverage are associated with statistically significant decreases in the likelihood that physicians will accept new uninsured patients who are unable to pay, particularly among office-based physicians. Increases in Medicaid coverage are not associated with changes in acceptance of new Medicaid patients.
Conclusions: Past changes in Medicaid coverage rates are not associated with changes in physician acceptance of new Medicaid patients or provision of charity care, although they are associated with lower acceptance of new uninsured patients, particularly among office-based physicians.
----------------------
Hospital Length of Stay and Readmission: An Early Investigation
Kathleen Carey & Meng-Yun Lin
Medical Care Research and Review, forthcoming
Abstract:
This article is an investigation into the relationship between length of stay and readmission within 30 days of discharge from an acute care hospitalization. We estimated probability models for heart attack and for heart failure patients using generalized estimating techniques applied to hospital administrative data from California for calendar year 2008. The key independent variable was length of stay in the initial hospitalization. We found negative associations between length of stay and readmission probability, particularly in the case of heart attack. Simulated values of predicted readmissions based on a 1-day increase in length of stay yielded estimated reductions in readmission rates in the 7% to 18% range for heart attack patients and the 1% to 8% range for heart failure patients. Increasing length of stay for some patients may be a means of improving quality of care by reducing readmission during the 30-day postdischarge period.
----------------------
Keith Marzilli Ericson & Amanda Starc
NBER Working Paper, October 2013
Abstract:
Standardization of complex products is touted as improving consumer decisions and intensifying price competition, but evidence on standardization is limited. We examine a natural experiment: the standardization of health insurance plans on the Massachusetts Health Insurance Exchange. Pre-standardization, firms had wide latitude to design plans. A regulatory change then required firms to standardize the cost-sharing parameters of plans and offer seven defined options; plans remained differentiated on network, brand, and price. Standardization led consumers on the HIX to choose more generous health insurance plans and led to substantial shifts in brands' market shares. We decompose the sources of this shift into three effects: price, product availability, and valuation. A discrete choice model shows that standardization changed the weights consumers attach to plan attributes (a valuation effect), increasing the salience of tier. The availability effect explains the bulk of the brand shifts. Standardization increased consumer welfare in our models, but firms captured some of the surplus by reoptimizing premiums. We use hypothetical choice experiments to replicate the effect of standardization and conduct alternative counterfactuals.
----------------------
Pinar Karaca-Mandic, Jean Abraham & Kosali Simon
Health Economics, forthcoming
Abstract:
Effective January 1, 2011, individual market health insurers must meet a minimum medical loss ratio (MLR) of 80%. This law aims to encourage ‘productive’ forms of competition by increasing the proportion of premium dollars spent on clinical benefits. To date, very little is known about the performance of firms in the individual health insurance market, including how MLRs are related to insurer and market characteristics. The MLR comprises one component of the price–cost margin, a traditional gauge of market power; the other component is percent of premiums spent on administrative expenses. We use data from the National Association of Insurance Commissioners (2001–2009) to evaluate whether the MLR is a good target measure for regulation by comparing the two components of the price–cost margin between markets that are more competitive versus those that are not, accounting for firm and market characteristics. We find that insurers with monopoly power have lower MLRs. Moreover, we find no evidence suggesting that insurers' administrative expenses are lower in more concentrated insurance markets. Thus, our results are largely consistent with the interpretation that the MLR could serve as a target measure of market power in regulating the individual market for health insurance but with notable limited ability to capture product and firm heterogeneity.
----------------------
Underreporting High-Risk Prescribing Among Medicare Advantage Plans: A Cross-sectional Analysis
Alicia Cooper et al.
Annals of Internal Medicine, 1 October 2013, Pages 456-462
Background: Although Medicare Advantage plans are required to report clinical performance using Healthcare Effectiveness Data and Information Set (HEDIS) quality indicators, the accuracy of plan-reported performance rates is unknown.
Objective: To compare calculated and reported rates of high-risk prescribing among Medicare Advantage plans.
Patients: A random sample of beneficiaries in 172 Medicare Advantage plans in 2006 (n = 177 227) and 2007 (n = 173 655).
Measurements: Plan-reported HEDIS rates of high-risk prescribing among elderly persons were compared with rates calculated from Medicare Advantage plans’ Part D claims by using the same measure specifications and source population.
Results: The mean rate of high-risk prescribing derived from Part D claims was 26.9% (95% CI, 25.9% to 28.0%), whereas the mean plan-reported rate was 21.1% (CI, 20.0% to 22.3%). Approximately 95% of plans underreported rates of high-risk prescribing relative to calculated rates derived from Part D claims. The differences in the calculated and reported rates negatively affected quality rankings for the plans that most accurately reported rates. For example, the 9 plans that reported rates of high-risk prescribing within 1 percentage point of calculated rates were ranked 43.4 positions lower when reported rates were used instead of calculated rates. Among 103 680 individuals present in both the sample of Part D claims and HEDIS data in 2006, Medicare Advantage plans incorrectly excluded 10.3% as ineligible for the HEDIS high-risk prescribing measure. Among those correctly included in the high-risk prescribing denominator, the reported rate of high-risk prescribing was 21.9% and the calculated rate was 26.2%.
Conclusion: Medicare Advantage plans underreport rates of high-risk prescribing, suggesting a role for routine audits to ensure the validity of publicly reported quality measures.
----------------------
Lauren Block et al.
Journal of Hospital Medicine, forthcoming
Abstract:
Etiquette-based communication may improve the inpatient experience but is not universally practiced. We sought to determine the extent to which internal medicine interns practice behaviors that characterize etiquette-based medicine. Trained observers evaluated the use of 5 key communication strategies by internal medicine interns during inpatient clinical encounters: introducing one's self, explaining one's role in the patient's care, touching the patient, asking open-ended questions, and sitting down with the patient. Participants at 1 site then completed a survey estimating how frequently they performed each of the observed behaviors. A convenience sample of 29 interns was observed on a total of 732 patient encounters. Overall, interns introduced themselves 40% of the time and explained their role 37% of the time. Interns touched patients on 65% of visits, asked open-ended questions on 75% of visits, and sat down with patients during 9% of visits. Interns at 1 site estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P < 0.01; 80% vs 37%, P < 0.01; and 58% vs 9%, P < 0.01, respectively). Resident physicians introduced themselves to patients, explained their role, and sat down with patients infrequently during observed inpatient encounters. Residents surveyed tended to overestimate their own practice of etiquette-based medicine.
----------------------
Andrew Rosenkrantz
Journal of the American College of Radiology, forthcoming
Purpose: A 2008 federal report expressed concern regarding substantial regional variation in imaging expenditures. The aims of this study were to evaluate trends in regional variation in Medicare imaging utilization and expenditures from 2007 to 2011 and to compare these trends with regional variation in other health service categories.
Methods: Data were based on CMS's Chronic Condition Data Warehouse and organized on the basis of 306 US health referral regions (HRRs). Imaging costs per beneficiary, standardized for regional differences in reimbursement rates, and imaging utilization per beneficiary were recorded per HRR from 2007 through 2011. Costs and utilization were also recorded for other service categories in 2011. Regional variation was assessed via relative risk (RR; the ratio between the highest and lowest HRRs) and coefficient of variation (CV; the standard deviation divided by the mean among all HRRs). Correlations between imaging and other service categories were assessed using Pearson's correlation coefficient.
Results: There was minimal change in regional variation in imaging costs or utilization between 2007 and 2011. Regional variation in imaging costs (RR, 5.70−5.88; CV, 33.0%−33.3%) was considerably greater than variation in imaging utilization (RR, 2.11%−2.25%; CV, 14.2%−14.6%). Imaging costs and utilization showed moderate to strong correlations with those of other service categories (r = 0.572−0.869). In 2011, regional variation in imaging utilization (RR, 2.25; CV, 14.2%) was considerably lower than variation in utilization of other service categories (RR, 2.80−10.78; CV, 20.9%−33.3%).
Conclusions: Regional variation in imaging utilization is considerably lower than both variation in imaging costs and variation in utilization of other major service categories. It is unclear whether variation in imaging utilization provides an optimal individual target for major policy decisions.
----------------------
Is Emergency Department Crowding Associated With Increased "Bounceback" Admissions?
Renee Hsia et al.
Medical Care, November 2013, Pages 1008-1014
Objective: Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient’s likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these “bounceback” admissions.
Methods: We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission.
Results: We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00).
Conclusions: Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.
----------------------
Using Quantile Regression to Examine Health Care Expenditures during the Great Recession
Jie Chen et al.
Health Services Research, forthcoming
Objective: To examine the association between the Great Recession of 2007–2009 and health care expenditures along the health care spending distribution, with a focus on racial/ethnic disparities.
Data Sources/Study Setting: Secondary data analyses of the Medical Expenditure Panel Survey (2005–2006 and 2008–2009).
Study Design: Quantile multivariate regressions are employed to measure the different associations between the economic recession of 2007–2009 and health care spending. Race/ethnicity and interaction terms between race/ethnicity and a recession indicator are controlled to examine whether minorities encountered disproportionately lower health spending during the economic recession.
Principal Findings: The Great Recession was significantly associated with reductions in health care expenditures at the 10th–50th percentiles of the distribution, but not at the 75th–90th percentiles. Racial and ethnic disparities were more substantial at the lower end of the health expenditure distribution; however, on average the reduction in expenditures was similar for all race/ethnic groups. The Great Recession was also positively associated with spending on emergency department visits.
Conclusion: This study shows that the relationship between the Great Recession and health care spending varied along the health expenditure distribution. More variability was observed in the lower end of the health spending distribution compared to the higher end.
----------------------
What Are the Characteristics That Explain Hospital Quality? A Longitudinal Pridit Approach
Robert Lieberthal & Dominique Comer
Risk Management and Insurance Review, forthcoming
Abstract:
Health outcomes vary substantially between high- and low-quality institutions, meaning the difference between life and death in some cases. The prior literature has identified a number of variables that can be used to determine hospital quality, but methodologies for combining variables into an overall measure of hospital quality are not well developed. This analysis builds on the prior investigation of hospital quality by evaluating a method originally developed for the detection of health-care fraud, Pridit, in the context of determining hospital quality. We developed a theoretical model to justify the application of Pridit to the hospital quality setting and then applied the Pridit method to a national, multiyear data set on U.S. hospital quality variables and outcomes. The results demonstrate how the Pridit method can be used predictively, in order to predict future health outcomes based on currently available quality measures. These results inform the use of Pridit, and other unsupervised learning methods, in fraud detection and other settings where valid and reliable outcomes variables are difficult to obtain. The empirical results obtained in this study may also be of use to health insurers and policymakers who aim to improve quality in the hospital setting.
----------------------
Nurse Overestimation of Patients' Health Literacy
Carolyn Dickens et al.
Journal of Health Communication, Fall 2013, Pages 62-69
Abstract:
Patient education and effective communication are core elements of the nursing profession; therefore, awareness of a patient's health literacy is integral to patient care, safety, education, and counseling. Several past studies have suggested that health care providers overestimate their patient's health literacy. In this study, the authors compare inpatient nurses' estimate of their patient's health literacy to the patient's health literacy using Newest Vital Sign as the health literacy measurement. A total of 65 patients and 30 nurses were enrolled in this trial. The results demonstrate that nurses incorrectly identify patients with low health literacy. In addition, overestimates outnumber underestimates 6 to 1. The results reinforce previous evidence that health care providers overestimate a patient's health literacy. The overestimation of a patient's health literacy by nursing personnel may contribute to the widespread problem of poor health outcomes and hospital readmission rates.
----------------------
Difficulty in seeking information about health care quality and costs: The field of dreams fallacy
Kirby Goidel et al.
Social Science Journal, forthcoming
Abstract:
While government agencies and health organizations have increased efforts to provide online information about health care quality and costs, we know little about whether individuals seek out or understand this information. Using results from a Louisiana telephone survey (N = 1030), we examine intent to use a website devoted to information about health care quality and costs and self-reported difficulty in finding this information. Intent to use a website is driven primarily by prior Internet use while difficulty in learning about health care quality is associated with greater choice in health care providers and dissatisfaction with current care.