Affordable caring
Andrea Sisko et al.
Health Affairs, October 2014, Pages 1841-1850
Abstract:
In 2013 health spending growth is expected to have remained slow, at 3.6 percent, as a result of the sluggish economic recovery, the effects of sequestration, and continued increases in private health insurance cost-sharing requirements. The combined effects of the Affordable Care Act’s coverage expansions, faster economic growth, and population aging are expected to fuel health spending growth this year and thereafter (5.6 percent in 2014 and 6.0 percent per year for 2015–23). However, the average rate of increase through 2023 is projected to be slower than the 7.2 percent average growth experienced during 1990–2008. Because health spending is projected to grow 1.1 percentage points faster than the average economic growth during 2013–23, the health share of the gross domestic product is expected to rise from 17.2 percent in 2012 to 19.3 percent in 2023.
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The Effect of Malpractice Reform on Emergency Department Care
Daniel Waxman et al.
New England Journal of Medicine, 16 October 2014, Pages 1518-1525
Background: Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.
Methods: Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.
Results: For eight of the nine state–outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.
Conclusions: Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates.
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Sharing in Childhood as a Precursor to Support for National Health Insurance
Curtis Dunkel
Basic and Applied Social Psychology, forthcoming
Abstract:
The relationship between sharing in childhood and political identity and opinions on national health insurance in adulthood were examined. It was found that sharing at age 5 was positively associated with a liberal political identity and endorsement of national health insurance at ages 23 and 32. These results remained after controlling for sex, ethnicity, socioeconomic status, ego-control, ego-resiliency, maternal egalitarian parenting attitudes, and paternal egalitarian parenting attitudes. In addition, analyses showed that the relationship between sharing and endorsement of national health insurance was independent of political identity.
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Steven Craig & Larry Howard
Regional Science and Urban Economics, November 2014, Pages 164–178
Abstract:
We examine whether state government responses to rising Medicaid costs cause reduced low income assistance, overall state budget cuts, or higher taxes. We segment Medicaid recipient groups into families, the disabled, and the elderly. Using GMM estimation, we instrument for endogenous program participation using federally directed program recipients in a panel of 47 states from 1976-2004. We find half of cost increases for elderly recipients are financed by own benefit decreases. We find that the disabled increase Medicaid for all through cuts in other government expenditure, family recipients erode Medicaid benefits and cash assistance, Medicaid only for families is increased because of AFDC matching elimination, and taxpayers fund no cost increases.
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Health Benefits In 2014: Stability In Premiums And Coverage For Employer-Sponsored Plans
Gary Claxton et al.
Health Affairs, October 2014, Pages 1851-1860
Abstract:
The annual Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey found that in 2014 the average annual premium (employer and worker contributions combined) for single coverage was $6,025, similar to 2013. The premium for family coverage was $16,834—3 percent higher than a year ago. Average deductibles and most other cost-sharing amounts were similar to those in 2013. On average, in 2014 covered workers paid nearly $5,000 per year for family health insurance premiums, and 18 percent of covered workers were in a plan with an annual single coverage deductible of $2,000 or more. Fifty-five percent of employers offered health benefits in 2014, similar to 2013. The Affordable Care Act has not yet led to substantial changes in the employer-based market. However, the next few years could present a different picture as delayed provisions and other changes take effect. This year’s survey included new questions on firms’ policies related to enrolling spouses and dependents, enrollment in private exchanges, and the use of narrow networks and financial incentives for wellness programs.
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The Early Impact of the Affordable Care Act State-By-State
Amanda Kowalski
NBER Working Paper, October 2014
Abstract:
I examine the impact of state policy decisions on the early impact of the ACA using data through the first half of 2014. I focus on the individual health insurance market, which includes plans purchased through exchanges as well as plans purchased directly from insurers. In this market, at least 13.2 million people were covered in the second quarter of 2014, representing an increase of at least 4.2 million beyond pre-ACA state-level trends. I use data on coverage, premiums, and costs and a model developed by Hackmann, Kolstad, and Kowalski (2013) to calculate changes in selection and markups, which allow me to estimate the welfare impact of the ACA on participants in the individual health insurance market in each state. I then focus on comparisons across groups of states. The estimates from my model imply that market participants in the five “direct enforcement” states that ceded all enforcement of the ACA to the federal government are experiencing welfare losses of approximately $245 per participant on an annualized basis, relative to participants in all other states. They also imply that the impact of setting up a state exchange depends meaningfully on how well it functions. Market participants in the six states that had severe exchange glitches are experiencing welfare losses of approximately $750 per participant on an annualized basis, relative to participants in other states with their own exchanges. Although the national impact of the ACA is likely to change over the course of 2014 as coverage, costs, and premiums evolve, I expect that the differential impacts that we observe across states will persist through the rest of 2014.
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Measuring Returns to Hospital Care: Evidence from Ambulance Referral Patterns
Joseph Doyle et al.
Journal of Political Economy, forthcoming
Abstract:
We consider whether hospitals that receive higher payments from Medicare improve patient outcomes, using exogenous variation in ambulance-company assignment among patients who live near one another. Using Medicare data from 2002-2010 on assignment across ambulance companies and New York State date from 2002-2006 on assignment across area boundaries, we find that patients who are brought to higher cost hospitals achieve better outcomes. Our estimates imply that a one standard deviation increase in Medicare reimbursement leads to a 4 percentage point (or 10 percent) reduction in mortality; the implied cost per at least one year of life saved is approximately $80,000.
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Medicare Part D: Are Insurers Gaming the Low Income Subsidy Design?
Francesco Decarolis
American Economic Review, forthcoming
Abstract:
This paper shows how in Medicare Part D insurers’ gaming of the subsidy paid to low income enrollees distorts premiums and raises the program cost. Using plan level data from the first five years of the program, I find multiple instances of pricing strategy distortions for the largest insurers. Instrumental variable estimates indicate that the changes in a concentration index measuring the manipulability of the subsidy can explain a large share of the premium growth observed between 2006 and 2011. Removing this distortion could reduce the cost of the program without worsening consumer welfare.
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The Empirics of Learning from Failure
Victor Bennett & Jason Snyder
University of Southern California Working Paper, October 2014
Abstract:
The ability to learn from experience is central to an organization’s performance. A recent literature has attempted to disentangle organizations’ and individuals’ learning from success and from failure. Using the strategy literature’s standard empirical approach to identifying learning from failure, we find strong evidence of learning from failure on randomly generated placebo data sets where there should be none, implying that the results in the literature may be driven mechanically by the specification rather than by real effects. We explain why the standard specification produces these results and propose alternate specifications for testing the effects of past failure on future performance that do not generate results mechanically. We implement our improved specifications using data on liver transplantation and find no direct evidence of learning from failure, though we do find evidence of administrative response to failure, in the form of delaying future procedures, and patterns consistent with failure increasing a transplant center’s risk-aversion.
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Huseyin Naci et al.
Medical Care, November 2014, Pages 951-956
Background: Disabled Americans who qualify for Medicare coverage typically have multiple chronic conditions, are highly dependent on effective drug therapy, and have limited financial resources, putting them at risk for cost-related medication nonadherence (CRN). Since 2006, the Part D benefit has helped Medicare beneficiaries afford medications.
Design and Subjects: We estimated annual rates of medication affordability among nonelderly disabled participants in a nationally representative survey (2006–2011, n=14,091 person-years) using multivariate logistic regression analyses.
Results: In the 6 years following Part D implementation, the proportion of disabled Medicare beneficiaries reporting CRN ranged from 31.6% to 35.6%, while the reported prevalence of spending less on other basic needs to afford medicines ranged from 17.7% to 21.8%. Across study years, those with multiple chronic conditions had consistently worse affordability problems. In 2011, the prevalence of CRN was 37.3% among disabled beneficiaries with ≥3 morbidities as compared with 28.1% among those with fewer morbidities; for spending less on basic needs, the prevalence was 25.4% versus 15.7%, respectively. There were no statistically detectable changes in either measure when comparing 2011 with 2007.
Conclusions: Disabled Medicare beneficiaries continue to struggle to afford prescription medications. There is an urgent need for focused policy attention on this vulnerable population, which has inadequate financial access to drug treatments, despite having drug coverage under Medicare Part D.
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Physician Practice Competition and Prices Paid by Private Insurers for Office Visits
Laurence Baker et al.
Journal of the American Medical Association, 22/29 October 2014, Pages 1653-1662
Objective: To assess the relationship between physician competition and prices paid by private preferred provider organizations (PPOs) for 10 types of office visits in 10 prominent specialties.
Design and Setting: Retrospective study in 1058 US counties in urbanized areas, representing all 50 states, examining the relationship between measured physician competition and prices paid for office visits in 2010 and the relationship between changes in competition and prices between 2003 and 2010, using regression analysis to control for possible confounding factors.
Exposures: Variation in the mean Hirschman-Herfindahl Index (HHI) of physician practices within a county by specialty (HHIs range from 0, representing maximally competitive markets, to 10 000 in markets served by a single [monopoly] practice).
Main Outcomes and Measures: Mean price paid by county to physicians in each specialty by private PPOs for intermediate office visits with established patients (Current Procedural Terminology [CPT] code 99213) and a price index measuring the county-weighted mean price for 10 types of office visits with new and established patients (CPT codes 99201-99205, 99211-99215) relative to national mean prices.
Results: In 2010, across all specialties studied, HHIs were 3 to 4 times higher in the 90th-percentile county than the 10th-percentile county (eg, for family practice: 10th percentile HHI = 1023 and 90th percentile HHI = 3629). Depending on specialty, mean price for a CPT code 99213 visit was between $70 and $75. After adjustment for potential confounders, depending on specialty, prices at the 90th-percentile HHI were between $5.85 (orthopedics; 95% CI, $3.46-$8.24) and $11.67 (internal medicine; 95% CI, $9.13-$14.21) higher than at the 10th percentile. Including all types of office visits, price indexes at the 90th-percentile HHI were 8.3% (orthopedics; 95% CI, 5.0%-11.6%) to 16.1% (internal medicine; 95% CI, 12.8%-19.5%) higher. Between 2003 and 2010, there were larger price increases in areas that were less competitive in 2002 than in initially more competitive areas.
Conclusions and Relevance: More competition among physicians is related to lower prices paid by private PPOs for office visits. These results may inform work on policies that influence practice competition.
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Saving Patient Ryan — Can Advanced Electronic Medical Records Make Patient Care Safer?
Muhammad Zia Hydari, Rahul Telang & William Marella
Carnegie Mellon University Working Paper, September 2014
Abstract:
Patient safety is one of the foremost problems in US healthcare, affecting hundreds of thousands of patients and costing tens of billions of dollars every year. Advanced electronic medical records (EMRs) are widely expected to improve patient safety, but the evidence of advanced EMRs' impact on patient safety is inconclusive. A key challenge to evaluating EMRs' impact on safety has been the lack of reliable and comprehensive data. We overcome this challenge by constructing a panel of Pennsylvania hospitals over 2005-2012 using data from several sources. In particular, we source confidential patient safety data from the Pennsylvania Patient Safety Authority (PSA). Since mid-2004, Pennsylvania state law has mandated that hospitals report a broad range of patient safety events to the PSA. Using a differences-in-differences identification strategy, we find that advanced EMRs lead to a 27 percent decline in patient safety events. This overall decline is driven by declines in several important subcategories — 30 percent decline in events due to medication errors and 25 percent decline in events due to complications. Our results hold against a number of robustness checks, including, but not limited to, falsification test with non-clinical IT and falsification test with a subcategory of events that is not expected to benefit from advanced EMRs. Overall, we provide evidence to policy makers, hospital administrators, and other stakeholders that hospitals' adoption of advanced EMRs improves patient safety.
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Aaron Chatterji & Kira Fabrizio
Strategic Management Journal, forthcoming
Abstract:
Prior work argues that the “market for ideas” supports an open system of innovation, allowing for efficient development of technology across firms. Although this literature has described important features of this market, how it influences the rate and direction of innovation remains an open question. We exploit an exogenous shock to a subset of U.S. medical device firms to study this question. We first document the breakdown in the market for ideas after a federal investigation made it more difficult for the leading orthopedic firms to work with physician-inventors. We then present evidence of a dramatic decline in the rate of innovation for these firms. Further, a marked shift in direction occurs toward lower-quality inventions and away from product categories where physician knowledge is critical.
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Investment Subsidies and the Adoption of Electronic Medical Records in Hospitals
David Dranove et al.
NBER Working Paper, October 2014
Abstract:
In February 2009 the U.S. Congress unexpectedly passed the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH provides up to $27 billion to promote adoption and appropriate use of Electronic Medical Records (EMR) by hospitals. We measure the extent to which HITECH incentive payments spurred EMR adoption by independent hospitals. Adoption rates for all independent hospitals grew from 48 percent in 2008 to 77 percent by 2011. Absent HITECH incentives, we estimate that the adoption rate would have instead been 67 percent in 2011. When we consider that HITECH funds were available for all hospitals and not just marginal adopters, we estimate that the cost of generating an additional adoption was $48 million. We also estimate that in the absence of HITECH incentives, the 77 percent adoption rate would have been realized by 2013, just 2 years after the date achieved due to HITECH.
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Association Between Availability of Health Service Prices and Payments for These Services
Christopher Whaley et al.
Journal of the American Medical Association, 22/29 October 2014, Pages 1670-1676
Objective: To determine whether the use of an employer-sponsored private price transparency platform was associated with lower claims payments for 3 common medical services.
Design: Payments for clinical services provided were compared between patients who searched a pricing website before using the service with patients who had not researched prior to receiving this service. Multivariable generalized linear model regressions with propensity score adjustment controlled for demographic, geographic, and procedure differences. To test for selection bias, payments for individuals who used the platform to search for services (searchers) were compared with those who did not use the platform to search for services (nonsearchers) in the period before the platform was available. The exposure was the use of the price transparency platform to search for laboratory tests, advanced imaging services, or clinician office visits before receiving care for that service.
Setting and Participants: Medical claims from 2010-2013 of 502 949 patients who were insured in the United States by 18 employers who provided a price transparency platform to their employees.
Main Outcomes and Measures: The primary outcome was total claims payments (the sum of employer and employee spending for each claim) for laboratory tests, advanced imaging services, and clinician office visits.
Results: Following access to the platform, 5.9% of 2 988 663 laboratory test claims, 6.9% of 76 768 advanced imaging claims, and 26.8% of 2 653 227 clinician office visit claims were associated with a prior search on the price transparency platform. Before having access to the price transparency platform, searchers had higher claims payments than nonsearchers for laboratory tests (4.11%; 95% CI, 1.87%-6.41%), higher payments for advanced imaging services (5.57%; 95% CI, 1.83%-9.44%), and no difference in payments for clinician office visits (0.26%; 95% CI; 0.53%-0.005%). Following access to the price transparency platform, relative claim payments for searchers were lower for searchers than nonsearchers by 13.93% (95% CI, 10.28%-17.43%) for laboratory tests, 13.15% (95% CI, 9.49%-16.66%) for advanced imaging, and 1.02% (95% CI, 0.57%-1.47%) for clinician office visits. The absolute payment differences were $3.45 (95% CI, $1.78-$5.12) for laboratory tests, $124.74 (95% CI, $83.06-$166.42) for advanced imaging services, and $1.18 (95% CI, $0.66-$1.70) for clinician office visits.
Conclusions and Relevance: Use of price transparency information was associated with lower total claims payments for common medical services. The magnitude of the difference was largest for advanced imaging services and smallest for clinical office visits. Patient access to pricing information before obtaining clinical services may result in lower overall payments made for clinical care.
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Sei-Hill Kim et al.
Journal of Health Communication, forthcoming
Abstract:
This content analysis examines how the American news media have presented the problem of high and rising health care costs, looking particularly at the question of who is responsible. More specifically, the authors examine how often the media have discussed the 5 major causes of the problem: (a) patients, (b) health care providers, (c) insurance companies, (d) the government, and (d) pharmaceutical companies. Results revealed that patients were most often mentioned as the cause of increasing health care costs. The authors also found that the media's attribution of responsibility to patients has increased over the years. Overall, media coverage of rising health care costs peaked in 1993, 2004, and 2009, suggesting that coverage was influenced by newsworthy events (e.g., the president endorsing legislation or signing a bill into law) that draw the public's attention.
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Expanding Patients' Property Rights In Their Medical Records
Laurence Baker, Kate Bundorf & Daniel Kessler
NBER Working Paper, October 2014
Abstract:
Although doctors and hospitals own their patients' medical records, state and federal laws require that they provide patients with a copy at "reasonable cost." We examine the effects of state laws that cap the fees that doctors and hospitals are allowed to charge patients for a copy of their records. We test whether these laws affected patients' propensity to switch doctors and the prices of new- and existing-patient visits. We also examine the effect of laws on hospitals' adoption of electronic medical record (EMR) systems. We find that patients from states adopting caps on copy fees were significantly more likely to switch doctors, and that hospitals in states adopting caps were significantly more likely to install an EMR. We also find that laws did not have a systematic, significant effect on prices.
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The Effects of Price Transparency Regulation on Prices in the Healthcare Industry
Hans Bonde Christensen, Eric Floyd & Mark Maffett
University of Chicago Working Paper, August 2014
Abstract:
We provide empirical evidence on the causal effects of price transparency regulation (PTR) in the healthcare industry. Using micro data on actual healthcare purchases, and exploiting both between- and within-state variation to address endogeneity concerns, we find that PTR reduces the price charged for common, elective medical procedures by approximately 5% and increases the sensitivity of demand to a 1% change in charge prices by 0.5%. However, the effect of PTR on the actual prices paid by insured patients is limited to the relatively small fraction of patients that have the greatest incentives to directly consider the costs of care.
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James Robinson & Kelly Miller
Journal of the American Medical Association, 22/29 October 2014, Pages 1663-1669
Objective: To determine whether total expenditures per patient were higher in physician organizations (integrated medical groups and independent practice associations) owned by local hospitals or multihospital systems compared with groups owned by participating physicians.
Design and Setting: Data were obtained on total expenditures for the care provided to 4.5 million patients treated by integrated medical groups and independent practice associations in California between 2009 and 2012. The patients were covered by commercial health maintenance organization (HMO) insurance and the data did not include patients covered by commercial preferred provider organization (PPO) insurance, Medicare, or Medicaid.
Main Outcomes and Measures: Total expenditures per patient annually, measured in terms of what insurers paid to the physician organizations for professional services, to hospitals for inpatient and outpatient procedures, to clinical laboratories for diagnostic tests, and to pharmaceutical manufacturers for drugs and biologics.
Exposures: Annual expenditures per patient were compared after adjusting for patient illness burden, geographic input costs, and organizational characteristics.
Results: Of the 158 organizations, 118 physician organizations (75%) were physician-owned and provided care for 3 065 551 patients, 19 organizations (12%) were owned by local hospitals and provided care for 728 608 patients, and 21 organizations (13%) were owned by multihospital systems and provided care for 693 254 patients. In 2012, physician-owned physician organizations had mean expenditures of $3066 per patient (95% CI, $2892 to $3240), hospital-owned physician organizations had mean expenditures of $4312 per patient (95% CI, $3768 to $4857), and physician organizations owned by multihospital systems had mean expenditures of $4776 (95% CI, $4349 to $5202) per patient. After adjusting for patient severity and other factors over the period, local hospital–owned physician organizations incurred expenditures per patient 10.3% (95% CI, 1.7% to 19.7%) higher than did physician-owned organizations (adjusted difference, $435 [95% CI, $105 to $766], P = .02). Organizations owned by multihospital systems incurred expenditures 19.8% (95% CI, 13.9% to 26.0%) higher (adjusted difference, $704 [95% CI,$512 to $895], P < .001) than physician-owned organizations. The largest physician organizations incurred expenditures per patient 9.2% (95% CI, 3.8% to 15.0%, P = .001) higher than the smallest organizations (adjusted difference, $130 [95% CI, $−32 to $292]).
Conclusions and Relevance: From the perspective of the insurers and patients, between 2009 and 2012, hospital-owned physician organizations in California incurred higher expenditures for commercial HMO enrollees for professional, hospital, laboratory, pharmaceutical, and ancillary services than physician-owned organizations. Although organizational consolidation may increase some forms of care coordination, it may be associated with higher total expenditures.
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Value Based Purchasing and Hospital Acquired Conditions: Are We Seeing Improvement?
Aaron Spaulding, Rob Haley & Mei Zhao
Health Policy, forthcoming
Objective: To determine if the Value-Based Purchasing Performance Scoring system correlates with hospital acquired condition quality indicators.
Data Sources/Study Setting: This study utilizes the following secondary data sources: the American Hospital Association (AHA) annual survey, and the Centers for Medicare and Medicaid (CMS) Value-Based Purchasing and Hospital Acquired Conditions databases.
Study Design: Zero-inflated negative binomial regression was used to examine the effect of CMS total performance score on counts of hospital acquired conditions. Hospital structure variables including size, ownership, teaching status, payer mix, case mix, and location were utilized as control variables.
Principal Findings: Total performance scores, which are used to determine if hospitals should receive incentive money, do not correlate well with quality outcome in the form of hospital acquired conditions.
Conclusions: Value-based purchasing does not appear to correlate with improved quality and patient safety as indicated by Hospital Acquired Condition (HAC) scores. This leads us to believe that either the total performance score does not measure what it should, or the quality outcome measurements do not reflect the quality the total performance scores measure.
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Josephine Lau et al.
JAMA Pediatrics, forthcoming
Objective: To examine the ACA’s initial effects on young adults’ receipt of preventive care.
Design, Setting, and Participants: Secondary data analysis using a pre-post design that compared health care use by young adults (aged 18 to 25 years) from 2009 and 2011 Medical Expenditure Panel Surveys. Data were collected through computer-assisted personal interviews of a nationally representative sample of the noninstitutionalized US population.
Main Outcomes and Measures: Differences by year in rates of receiving a routine examination in the past year, blood pressure screening, cholesterol screening, influenza vaccination, and annual dental visit. Three logistic regression models were developed to (1) compare pre-ACA (2009) and post-ACA (2011) rates of receiving preventive care and (2) determine if post-ACA increases in insurance coverage accounted for changes in preventive care rates. Model 1 was a bivariate model to determine differences in preventive care rates by year; model 2, a multivariable model adding insurance status (full-year private, full-year public, partial-year uninsured, and full-year uninsured) to determine whether insurance accounted for survey year differences; and model 3, a multivariable model adding covariates (usual source of care and sociodemographic variables) to determine whether they further accounted for differences by survey year or insurance status.
Results: After ACA, young adults had significantly higher rates of receiving a routine examination (47.8% vs 44.1%; P < .05), blood pressure screening (68.3% vs 65.2%; P < .05), cholesterol screening (29.1% vs 24.3%; P < .001), and annual dental visit (60.9% vs 55.2%; P < .001) but not an influenza vaccination (22.1% vs 21.5%; P = .70). Full-year private insurance coverage increased (50.1% vs 43.4%; P < .001), and rates of lacking insurance decreased (partial-year uninsured, 18.4% vs 20.7%; P = .03; and full-year uninsured, 22.2% vs 27.1%; P < .001). Full-year public insurance rates remained stable (9.4% vs 8.8%; P = .53). Insurance status fully accounted for the pre- and post-ACA differences in routine examination and blood pressure screening and partially accounted for year differences for cholesterol screening and annual dental visits. Covariate adjustment did not affect year differences.
Conclusions and Relevance: The ACA provisions appear to increase insurance coverage and receipt of preventive services among young adults. Further studies are needed to replicate these findings as other ACA provisions are implemented.
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Population-Level Cost-Effectiveness of Implementing Evidence-Based Practices into Routine Care
John Fortney, Jeffrey Pyne & James Burgess
Health Services Research, forthcoming
Objective: The objective of this research was to apply a new methodology (population-level cost-effectiveness analysis) to determine the value of implementing an evidence-based practice in routine care.
Data Sources/Study Setting: Data are from sequentially conducted studies: a randomized controlled trial and an implementation trial of collaborative care for depression. Both trials were conducted in the same practice setting and population (primary care patients prescribed antidepressants).
Data Collection/Extraction Methods: The randomized controlled trial collected quality-adjusted life years (QALYs) from survey and medication possession ratios (MPRs) from administrative data. The implementation trial collected MPRs and intervention costs from administrative data and implementation costs from survey.
Principal Findings: In the randomized controlled trial, MPRs were significantly correlated with QALYs (p = .03). In the implementation trial, patients at implementation sites had significantly higher MPRs (p = .01) than patients at control sites, and by extrapolation higher QALYs (0.00188). Total costs (implementation, intervention) were nonsignificantly higher ($63.76) at implementation sites. The incremental population-level cost-effectiveness ratio was $33,905.92/QALY (bootstrap interquartile range −$45,343.10/QALY to $99,260.90/QALY).
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C.J. Krizan, Adela Luque & Alice Zawacki
U.S. Census Bureau Working Paper, April 2014
Abstract:
Whether or not small businesses offer health insurance to their employees is a critical factor in the health care coverage of many Americans, yet many entrepreneurs and decision makers fear that the cost of offering health care coverage to their employees will diminish the growth and survival of small firms. While there is an emerging consensus among economists that small businesses both create and destroy a disproportionately large number of jobs, less is known about the relationship between health care costs and business growth. We examine this latter issue prior to the passage of the Affordable Care Act in 2010. We first review information on the relationship between small employers’ decisions to offer health insurance prior to 2010 and i) financial factors (including premium variability and tax advantages), ii) labor markets with a focus on employee characteristics and the demand for employer's health insurance, iii) insurance markets and products, discussing access and insurance options with lower premium costs, and iv) the health insurance regulatory environment with an examination of state-level reform and health insurance mandates. We then discuss employer reactions to rising health care costs, followed by a review of factors other than rising health care costs that often affect the growth and survival of a small business. In the remaining sections, we describe our longitudinal analysis of how health insurance offering (HIO) affected the expansion and survival of small businesses. Using 2001-05 linked data from the Longitudinal Business Database (LBD) and the Insurance Component of the Medical Expenditure Panel Survey (MEPS-IC), we look at how HIO affected four measures of business performance (growth in employment, growth in payroll, growth in average wage, and survival) – after controlling for business characteristics and relevant state-level variables. We employ instrumental variable two-stage least squares estimation to address the endogeneity that permeates the question at hand. We find that young businesses (both large and small) that offer health insurance grow at not significantly different rates as those that do not, possibly due to selection effects. Older businesses offering health insurance – both small and large – seem to have higher employment and payroll growth. Survival is strongly and positively correlated with HIO for older establishments at both large and small firms. However, these results should be interpreted with extreme caution due the concerns we raise about the available testing methodology for our context.
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Aaron Dawes et al.
Health Services Research, forthcoming
Objective: To examine the effect of Medicaid enrollment on the diagnosis, treatment, and survival of six surgically relevant cancers among poor and underserved Californians.
Data Sources: California Cancer Registry (CCR), California's Patient Discharge Database (PDD), and state Medicaid enrollment files between 2002 and 2008.
Study Design: We linked clinical and administrative records to differentiate patients continuously enrolled in Medicaid from those receiving coverage at the time of their cancer diagnosis. We developed multivariate logistic regression models to predict death within 1 year for each cancer after controlling for sociodemographic and clinical variables.
Data Collection/Extraction Methods: All incident cases of six cancers (colon, esophageal, lung, pancreas, stomach, and ovarian) were identified from CCR. CCR records were linked to hospitalizations (PDD) and monthly Medicaid enrollment.
Principal Findings: Continuous enrollment in Medicaid for at least 6 months prior to diagnosis improves survival in three surgically relevant cancers. Discontinuous Medicaid patients have higher stage tumors, undergo fewer definitive operations, and are more likely to die even after risk adjustment.
Conclusions: Expansion of continuous insurance coverage under the Affordable Care Act is likely to improve both access and clinical outcomes for cancer patients in California.
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Estimating the Value Added of Attending Physicians on Patient Outcomes
Jason Fletcher, Leora Horwitz & Elizabeth Bradley
NBER Working Paper, October 2014
Abstract:
Despite increasing calls for value-based payments, existing methodologies for determining physicians’ “value added” to patient health outcomes have important limitations. We incorporate methods from the value added literature in education research into a health care setting to present the first value added estimates of health care providers in the literature. Like teacher value added measures that calculate student test score gains, we estimate physician value added based on changes in health status during the course of a hospitalization. We then tie our measures of physician value added to patient outcomes, including length of hospital stay, total charges, health status at discharge, and readmission. The estimated value added varied substantially across physicians and was highly stable for individual physicians. Patients of physicians in the 75th versus 25th percentile of value added had, on average, shorter length of stay (4.76 vs 5.08 days), lower total costs ($17,811 vs $19,822) and higher discharge health status (8% of a standard deviation). Our findings provide evidence to support a new method of determining physician value added in the context of inpatient care that could have wide applicability across health care setting and in estimating value added of other health care providers (nurses, staff, etc).
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Anupam Jena, Lena Schoemaker & Jay Bhattacharya
Health Affairs, October 2014, Pages 1832-1840
Abstract:
In 2003, work hours for physicians-in-training (residents) were capped by regulation at eighty hours per week, leading to the hotly debated but unexplored issue of whether physicians today are less well trained as a result of these work-hour reforms. Using a unique database of nearly all hospitalizations in Florida during 2000–09 that were linked to detailed information on the medical training history of the physician of record for each hospitalization, we studied whether hospital mortality and patients’ length-of-stay varied according to the number of years a physician was exposed to the 2003 duty-hour regulations during his or her residency. We examined this database of practicing Florida physicians, using a difference-in-differences analysis that compared trends in outcomes of junior physicians (those with one-year post-residency experience) pre- and post-2003 to a control group of senior physicians (those with ten or more years of post-residency experience) who were not exposed to these reforms during their residency. We found that the duty-hour reforms did not adversely affect hospital mortality and length-of-stay of patients cared for by new attending physicians who were partly or fully exposed to reduced duty hours during their own residency. However, assessment of the impact of the duty-hour reforms on other clinical outcomes is needed.
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Nurse Value-Added and Patient Outcomes in Acute Care
Olga Yakusheva, Richard Lindrooth & Marianne Weiss
Health Services Research, forthcoming
Objective: The aims of the study were to (1) estimate the relative nurse effectiveness, or individual nurse value-added (NVA), to patients’ clinical condition change during hospitalization; (2) examine nurse characteristics contributing to NVA; and (3) estimate the contribution of value-added nursing care to patient outcomes.
Data Sources/Study Setting: Electronic data on 1,203 staff nurses matched with 7,318 adult medical–surgical patients discharged between July 1, 2011 and December 31, 2011 from an urban Magnet-designated, 854-bed teaching hospital.
Study Design: Retrospective observational longitudinal analysis using a covariate-adjustment value-added model with nurse fixed effects.
Principal Findings: Nurse effects were jointly significant and explained 7.9 percent of variance in patient clinical condition change during hospitalization. NVA was positively associated with having a baccalaureate degree or higher (0.55, p = .04) and expertise level (0.66, p = .03). NVA contributed to patient outcomes of shorter length of stay and lower costs.
Conclusions: Nurses differ in their value-added to patient outcomes. The ability to measure individual nurse relative value-added opens the possibility for development of performance metrics, performance-based rankings, and merit-based salary schemes to improve patient outcomes and reduce costs.
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Association Between Hospital Conversions to For-Profit Status and Clinical and Economic Outcomes
Karen Joynt, John Orav & Ashish Jha
Journal of the American Medical Association, 22/29 October 2014, Pages 1644-1652
Objective: To examine characteristics of US acute care hospitals associated with conversion to for-profit status and changes following conversion.
Design, Setting, and Participants: Retrospective cohort study conducted among 237 converting hospitals and 631 matched control hospitals. Participants were 1 843 764 Medicare fee-for-service beneficiaries at converting hospitals and 4 828 138 at control hospitals.
Exposures: Conversion to for-profit status, 2003-2010.
Main Outcomes and Measures: Financial performance measures, quality process measures, mortality rates, Medicare volume, and patient population for the 2 years prior and the 2 years after conversion, excluding the conversion year, assessed using difference-in-difference models.
Results: Hospitals that converted to for-profit status were more often small or medium in size, located in the south, in an urban or suburban location, and were less often teaching institutions. Converting hospitals improved their total margins (ratio of net income to net revenue plus other income) more than controls (2.2% vs 0.4% improvement; difference in differences, 1.8% [ 95% CI, 0.5% to 3.1%]; P = .007). Converting hospitals and controls both improved their process quality metrics (6.0% vs 5.6%; difference in differences, 0.4% [95% CI, −1.1% to 2.0%]; P = .59). Mortality rates did not change at converting hospitals relative to controls for Medicare patients overall (increase of 0.1% vs 0.2%; difference in differences, −0.2% [95% CI, −0.5% to 0.2%], P = .42) or for dual-eligible or disabled patients. There was no change in converting hospitals relative to controls in annual Medicare volume (−111 vs −74 patients; difference in differences, −37 [95% CI, −224 to 150]; P = .70), Disproportionate Share Hospital Index (1.7% vs 0.4%; difference in differences, 1.3% [95% CI, −0.9% to 3.4%], P = .26), the proportion of patients with Medicaid (−0.2% vs 0.4%; difference in differences, −0.6% [95% CI, −2.0% to 0.8%]; P = .38) or the proportion of patients who were black (−0.4% vs −0.1%; difference in differences, −0.3% [95% CI, −1.9% to 1.3%]; P = .72) or Hispanic (0.1% vs −0.1%; difference in differences, 0.2% [95% CI, −0.3% to 0.7%]; P = .50).
Conclusions and Relevance: Hospital conversion to for-profit status was associated with improvements in financial margins but not associated with differences in quality or mortality rates or with the proportion of poor or minority patients receiving care.