Friday, April 9, 2010
Life Support
The Effect of Health Insurance Coverage on the Use of Medical Services
Michael Anderson, Carlos Dobkin & Tal Gross
NBER Working Paper, March 2010
Abstract:
Substantial uncertainty exists regarding the causal effect of health insurance on the utilization of care. Most studies cannot determine whether the large differences in healthcare utilization between the insured and the uninsured are due to insurance status or to other unobserved differences between the two groups. In this paper, we exploit a sharp change in insurance coverage rates that results from young adults "aging out" of their parents' insurance plans to estimate the effect of insurance coverage on the utilization of emergency department (ED) and inpatient services. Using the National Health Interview Survey (NHIS) and a census of emergency department records and hospital discharge records from seven states, we find that aging out results in an abrupt 5 to 8 percentage point reduction in the probability of having health insurance. We find that not having insurance leads to a 40 percent reduction in ED visits and a 61 percent reduction in inpatient hospital admissions. The drop in ED visits and inpatient admissions is due entirely to reductions in the care provided by privately owned hospitals, with particularly large reductions at for profit hospitals. The results imply that expanding health insurance coverage would result in a substantial increase in care provided to currently uninsured individuals.
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Claus Wendt, Jürgen Kohl, Monika Mischke & Michaela Pfeifer
European Sociological Review, April 2010, Pages 177-192
Abstract:
In this article we analyse the relationship between the institutional set-up of healthcare systems and patterns of public support. Two dimensions are distinguished, namely, state responsibility for healthcare provision and satisfaction with healthcare systems. Using data on 14 European countries from the Eurobarometer survey, we find only small effects of institutional indicators on preferences for a strong role of the state. Almost everywhere in Europe, there is high public support for state responsibility in healthcare. Satisfaction with the healthcare system, in contrast, is more strongly related to specific institutional arrangements. In healthcare systems with lower levels of expenditure, fewer general practitioners and higher co-payments, the overall level of satisfaction is lower. This is especially the case in Southern Europe where more pronounced differences between social groups also become apparent. In contrast, healthcare systems with a long tradition of comprehensive coverage regardless of occupation or income seem to generate rather homogenous attitudinal patterns. These characteristics hold for the Scandinavian systems and for the British National Health Service, and therefore, these healthcare systems still seem to live up to the promise of treating all members of the society equally. Countries with high levels of expenditure, high density of general practitioners, and free choice of doctors, which is mainly the case in Social Health Insurance systems, finally, show the highest levels of satisfaction but also more pronounced differences between social classes.
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Medicare Part B reimbursement and the perceived quality of physician care
Christopher Brunt & Gail Jensen
International Journal of Health Care Finance and Economics, June 2010, Pages 149-170
Abstract:
The maximum amount physicians can charge Medicare patients for Part B services depends on Medicare reimbursement rates and on federal and state restrictions regarding balance billing. This study evaluates whether Part B payment rates, state restrictions on balance billing beyond the federal limit, and physician balance billing influence how beneficiaries rate the quality of their doctor's care. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper finds strong evidence that Medicare reimbursement rates, and state balance billing restrictions influence a wide range of perceived care quality measures. Lower Medicare reimbursement and restrictions on physicians' ability to balance bill significantly reduce the perceived quality of care under Part B.
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The economic crisis and medical care usage
Annamaria Lusardi, Daniel Schneider & Peter Tufano
NBER Working Paper, March 2010
Abstract:
We use a unique, nationally representative cross-national dataset to document the reduction in individuals' usage of routine non-emergency medical care in the midst of the economic crisis. A substantially larger fraction of Americans have reduced medical care than have individuals in Great Britain, Canada, France, and Germany, all countries with universal health care systems. At the national level, reductions in medical care are related to the degree to which individuals must pay for it, and within countries are strongly associated with exogenous shocks to wealth and employment.
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Health Care, Health Insurance, and the Distribution of American Incomes
Gary Burtless & Pavel Svaton
Forum for Health Economics & Policy, 2010
Abstract:
Cash income offers an incomplete picture of the resources available to finance household consumption. Most American families are covered by an insurance plan that pays for some or all of the health care they consume. Only a comparatively small percentage of families pays for the full cost of this insurance out of their cash incomes. As health care has claimed a growing share of consumption, the percentage of care that is financed out of household incomes has declined. Because health care consumption is more important for some groups in the population than others, the growth in spending and changes in the payment system for medical care have reduced the value of standard income measures for assessing relative incomes of the rich and poor and the young and old. More than a seventh of total personal consumption now consists of health care that is purchased with government insurance and employer contributions to employee health plans. This paper combines health care spending and insurance reimbursement data in the Medical Expenditure Panel Study and money income and health coverage data in the Current Population Survey to assess the impact of health insurance on the distribution of income. Our estimates imply that gross money income significantly understates the resources available to finance household purchases. The estimates imply that a more complete measure of resources would show less inequality than the income measures that are currently used. The addition of estimates of the value of health insurance to countable incomes reduces measured inequality in the population and the income gap between young and old. If the analysis were extended over a longer period, it would show a sizeable impact of insurance on inequality trends in the United States.
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Lisa Angus & Jennifer DeVoe
Health Affairs, April 2010, Pages 690-698
Abstract:
The 2005 federal Deficit Reduction Act made proof of citizenship a requirement for Medicaid eligibility. We examined the effects on visits to Oregon's Medicaid family planning services eighteen months after the citizenship requirement was implemented. We analyzed 425,381 records of visits that occurred between May 2005 and April 2008 and found that, compared to the eighteen-month period before the mandate went into effect, visits declined by 33 percent. We conclude that Medicaid citizenship documentation requirements have been burdensome for Oregon Family Planning Expansion Project patients and costly for health care providers, reducing access to family planning and preventive measures and increasing the strain on the safety net.
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Some unintended effects of teamwork in healthcare
Rachael Finn, Mark Learmonth & Patrick Reedy
Social Science & Medicine, April 2010, Pages 1148-1154
Abstract:
Teamwork has been emphasised as a key feature of health service reform, essential for safe, efficient and patient-centred care. Bringing together literatures from the sociology of healthcare and organizational theory, we examine how the teamwork phenomenon plays out in practice. Drawing upon material from two ethnographic studies, conducted in an operating theatre and a medical-records department in separate UK NHS hospitals, we explore some of the discursive teamwork practices of healthcare staff. Our analysis presents a very different picture from the normative, evangelistic promotion of teamwork within much management and health policy writing. We reveal how the ambiguity of teamwork opens up opportunities for a complex, diverse range of responses to the managerial discourse among diverse occupational groups, mobilizing the discourse to enact identity in different ways. We highlight how teamwork discourse can be instrumentally co-opted in the reproduction of the very occupational divisions it is designed to ameliorate, or simply ignored as irrelevant when compared to more attractive forms of collective identity. These responses challenge both those who believe that teamwork is a solution to problems in healthcare, as well as those concerned about the oppressive effects of pervasive managerialism.
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State political cultures and the mortality of African Americans and American Indians
Stephen Kunitz, Martin McKee & Ellen Nolte
Health & Place, May 2010, Pages 558-566
Purpose: To test the hypothesis that mortality of African Americans is responsive to political cultures of particular states in which they reside whereas mortality of American Indians is unrelated to the political culture of the state but associated instead with cultural differences and with differences in the history of contact with Europeans.
Results: African American mortality rates are significantly correlated with the scale measure of political culture but there is no such association with American Indian mortality.
Conclusions: The differing relationship of these two minority populations with the federal and state governments has shaped their mortality rates in significantly different ways.
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Amy Wang, Christopher McCoy, Mohammad Hassan Murad & Victor Montori
British Medical Journal, 18 Mar 2010, c1344
Objective: To explore a possible link between authors' financial conflicts of interest and their position on the association of rosiglitazone with increased risk of myocardial infarction in patients with diabetes.
Data sources: On 10 April 2009, we searched Web of Science and Scopus for articles citing and commenting on either of two index publications that contributed key data to the controversy (a meta-analysis of small trials and a subsequent large trial).
Data selection: Articles had to comment on rosiglitazone and the risk of myocardial infarction. Guidelines, meta-analyses, reviews, clinical trials, letters, commentaries, and editorials were included.
Data extraction: For each article, we sought information about the authors' financial conflicts of interest in the report itself and elsewhere (that is, in all publications within two years of the original publication and online). Two reviewers blinded to the authors' financial relationships independently classified each article as presenting a favourable (that is, rosiglitazone does not increase the risk of myocardial infarction), neutral, or unfavourable view on the risk of myocardial infarction with rosiglitazone and on recommendations on the use of the drug.
Results: Of the 202 included articles, 108 (53%) had a conflict of interest statement. Ninety authors (45%) had financial conflicts of interest. Authors who had a favourable view of the risk of myocardial infarction with rosiglitazone were more likely to have financial conflicts of interest with manufacturers of antihyperglycaemic agents in general, and with rosiglitazone manufacturers in particular, than authors who had an unfavourable view (rate ratio 3.38, 95% CI 2.26 to 5.06 and 4.29, 2.63 to 7. 02, respectively). There was likewise a strong association between favourable recommendations on the use of rosiglitazone and financial conflicts of interest (3.36, 1.94 to 5.83). These links persisted when articles rather than authors were used as the unit of analysis (4.69, 2.84 to 7.72), when the analysis was restricted to opinion articles (6.29, 2.15 to 18.38) or to articles in which the rosiglitazone controversy was the main focus (6.50, 2.56 to 16.53), and both in articles published before and after the Food and Drug Administration issued a safety warning for rosiglitazone (3.43, 0.99 to 11.82 and 4.95, 2.87 to 8.53, respectively).
Conclusions: Disclosure rates for financial conflicts of interest were unexpectedly low, and there was a clear and strong link between the orientation of authors' expressed views on the rosiglitazone controversy and their financial conflicts of interest with pharmaceutical companies. Although these findings do not necessarily indicate a causal link between the position taken on the cardiac risk of rosiglitazone in patients with diabetes and the authors' financial conflicts of interest, they underscore the need for further changes in disclosure procedures in order for the scientific record to be trusted.
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Yue Li & Dana Mukamel
American Journal of Public Health, April 2010, Pages S256-S262
Objectives: We examined racial disparities in receipt and documentation of influenza and pneumococcus vaccinations among nursing-home residents.
Methods: We performed secondary analyses of data from a nationally representative survey of White (n=11448) and Black (n=1174) nursing-home residents in 2004. Bivariate and multivariate analyses determined racial disparities in receipt of influenza vaccination in 2003 and 2004, receipt of pneumococcus vaccination ever, and having a documented history for each vaccination.
Results: The overall vaccination rate was 76.2% for influenza and 48.5% for pneumococcus infection. Compared with Whites, Blacks showed a 13% lower vaccination rate and a 5% higher undocumentation rate for influenza, and a 15% lower vaccination rate and a 7% higher undocumentation rate for pneumococcus. For influenza, the odds ratio (OR) for Blacks being unvaccinated was 1.84 (P≤.001), and the OR for Blacks having undocumented vaccination was 1.85 (P=.001). For pneumococcus infection, the OR for Blacks being unvaccinated was 1.70 (P≤.001), and the OR for Blacks having undocumented vaccination was 1.95 (P≤.001). Stratified analyses confirmed persistent racial disparities among subpopulations.
Conclusions: Racial disparities exist in vaccination coverage among US nursing-home residents. Targeted interventions to improve vaccination coverage for minority nursing-home residents are warranted.
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The Effect of Malpractice Liability on the Specialty of Obstetrics and Gynecology
Jessica Wolpaw Reyes
NBER Working Paper, March 2010
Abstract:
Using data from a 2003 survey of 1,476 obstetrician-gynecologists, the effects of malpractice pressure on the specialty are investigated. Physicians report having made substantial changes to their practice in response to the general environment and to liability pressures. Regression analysis finds that liability pressure increases reports of income and practice reductions, but direct effects on actual income and productivity are less clear. Liability pressures may lead to a specialization effect, with some physicians concentrating more in obstetrics and others in gynecological surgery. Overall, the evidence suggests that liability pressure has moderate but significant effects on the specialty.
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The Sound of Silence: Observational Learning in the U.S. Kidney Market
Juanjuan Zhang
Marketing Science, March-April 2010, Pages 315-335
Abstract:
Mere observation of others' choices can be informative about product quality. This paper develops an individual-level dynamic model of observational learning and applies it to a novel data set from the U.S. kidney market, where transplant candidates on a waiting list sequentially decide whether to accept a kidney offer. We find strong evidence of observational learning: patients draw negative quality inferences from earlier refusals in the queue, thus becoming more inclined towards refusal themselves. This self-reinforcing chain of inferences leads to poor kidney utilization despite the continual shortage in kidney supply. Counterfactual policy simulations show that patients would have made more efficient use of kidneys had the concerns behind earlier refusals been shared. This study yields a set of marketing implications. In particular, we show that observational learning and information sharing shape consumer choices in markedly different ways. Optimal marketing strategies should take into account how consumers learn from others.
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Neo-liberal economic practices and population health: A cross-national analysis, 1980-2004
Melissa Tracy, Margaret Kruk, Christine Harper & Sandro Galea
Health Economics, Policy and Law, April 2010, Pages 171-199
Abstract:
Although there has been substantial debate and research concerning the economic impact of neo-liberal practices, there is a paucity of research about the potential relation between neo-liberal economic practices and population health. We assessed the extent to which neo-liberal policies and practices are associated with population health at the national level. We collected data on 119 countries between 1980 and 2004. We measured neo-liberalism using the Fraser Institute's Economic Freedom of the World (EFW) Index, which gives an overall score as well as a score for each of five different aspects of neo-liberal economic practices: (1) size of government, (2) legal structure and security of property rights, (3) access to sound money, (4) freedom to exchange with foreigners and (5) regulation of credit, labor and business. Our measure of population health was under-five mortality. We controlled for potential mediators (income distribution, social capital and openness of political institutions) and confounders (female literacy, total population, rural population, fertility, gross domestic product per capita and time period). In longitudinal multivariable analyses, we found that the EFW index did not have an effect on child mortality but that two of its components: improved security of property rights and access to sound money were associated with lower under-five mortality (p = 0.017 and p = 0.024, respectively). When stratifying the countries by level of income, less regulation of credit, labor and business was associated with lower under-five mortality in high-income countries (p = 0.001). None of the EFW components were significantly associated with under-five mortality in low-income countries. This analysis suggests that the concept of ‘neo-liberalism' is not a monolithic entity in its relation to health and that some ‘neo-liberal' policies are consistent with improved population health. Further work is needed to corroborate or refute these findings.
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Coverage and Framing of Racial and Ethnic Health Disparities in US Newspapers, 1996-2005
Annice Kim, Shiriki Kumanyika, Daniel Shive, Uzy Igweatu & Son-Ho Kim
American Journal of Public Health, forthcoming
Objectives: We examined how causes of and solutions to racial/ethnic health disparities are covered and framed in newspapers over time.
Methods: We used LexisNexis to identify articles on racial/ethnic health disparities published from 1996 through 2005 in 40 US newspapers. We coded articles for diseases and racial/ethnic groups mentioned; whether causes and solutions were framed as genetic, behavioral, health care, or societal responsibility; and whether a social-justice rationale for eliminating racial/ethnic health disparities was invoked.
Results: We identified 3823 racial/ethnic health disparity articles. Coverage peaked in 1998 and has declined since. Disparities in HIV/AIDS, cardiovascular disease, and cancer generated the most coverage. Articles focused primarily on African Americans. Only 30% of articles provided causal or solution explanations, with academic researchers providing the most causal explanations and advocacy groups providing the most solutions. For both causes and solutions, behavioral explanations dominated the discourse, followed by societal, health care, and genetic explanations. Only 4% of articles invoked a social-justice rationale.
Conclusions: The dominance of behavioral explanations may limit public support for policy solutions to eliminate racial/ethnic health disparities. Future research should examine the design and dissemination of effective messages about the social determinants of health.
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Regulating Abortion: Impact on Patients and Providers in Texas
Silvie Colman & Theodore Joyce
NBER Working Paper, March 2010
Abstract:
The state of Texas began enforcement of the Woman's Right to Know (WRTK) Act on January 1, 2004. The law requires that all abortions at 16 weeks gestation or later be performed in an ambulatory surgical center (ASC). In the month the law went into effect, not one of Texas's 54 non-hospital abortion providers met the requirements of a surgical center. The effect was immediate and dramatic. The number of abortions performed in Texas at 16 weeks gestation or later dropped 88 %, from 3642 in 2003 to 446 in 2004, while the number of residents who left the state for a late abortion almost quadrupled. By 2006, an ASC had opened in 4 major cities down from 9 in 2003 but the abortion rate 16 weeks or more gestation remained 50 percent below its pre-Act level. Regulations of abortion providers that require new facilities or costly renovations could have profound effects on the market for second trimester abortions.
