Playing doctor
The Articulation Effect of Government Policy: Health Insurance Mandates Versus Taxes
Keith Marzilli Ericson & Judd Kessler
NBER Working Paper, March 2013
Abstract:
We examine how the articulation of government policy affects behavior. Our experiment compares a government mandate to purchase health insurance to a financially equivalent tax on the uninsured. Participants report their probability of purchasing health insurance under one of the two articulations of the policy. The experiment was conducted in four waves, from December 2011 to November 2012. We document the controversy over the Affordable Care Act's insurance mandate provision that changed the political discourse during the year. Pre-controversy, articulating the policy as a mandate, rather than a financially equivalent tax, increased probability of insurance purchase by 10.6 percentage points - an effect comparable to a $1000 decrease in annual premiums. After the controversy, the mandate is no more effective than the tax. Our results show that how a policy is articulated affects behavior and that persuasion and public opinion management can help achieve policy objectives at lower cost.
----------------------
The Hazards of Correcting Myths About Health Care Reform
Brendan Nyhan, Jason Reifler & Peter Ubel
Medical Care, February 2013, Pages 127-132
Context: Misperceptions are a major problem in debates about health care reform and other controversial health issues.
Methods: We conducted an experiment to determine if more aggressive media fact-checking could correct the false belief that the Affordable Care Act would create "death panels." Participants from an opt-in Internet panel were randomly assigned to either a control group in which they read an article on Sarah Palin's claims about "death panels" or an intervention group in which the article also contained corrective information refuting Palin.
Findings: The correction reduced belief in death panels and strong opposition to the reform bill among those who view Palin unfavorably and those who view her favorably but have low political knowledge. However, it backfired among politically knowledgeable Palin supporters, who were more likely to believe in death panels and to strongly oppose reform if they received the correction.
Conclusions: These results underscore the difficulty of reducing misperceptions about health care reform among individuals with the motivation and sophistication to reject corrective information.
----------------------
Karen Joynt et al.
Health Affairs, March 2013, Pages 571-578
Abstract:
Critics of Massachusetts's health reform, a model for the Affordable Care Act, have argued that insurance expansion probably had a negative spillover effect leading to worse outcomes among already insured patients, such as vulnerable Medicare patients. Using Medicare data from 2004 to 2009, we examined trends in preventable hospitalizations for conditions such as uncontrolled hypertension and diabetes - markers of access to effective primary care - in Massachusetts compared to control states. We found that after Massachusetts's health reform, preventable hospitalization rates for Medicare patients actually decreased more in Massachusetts than in control states (a reduction of 101 admissions per 100,000 patients per quarter compared to a reduction of 83 admissions). Therefore, we found no evidence that Massachusetts's insurance expansion had a deleterious spillover effect on preventable hospitalizations among the previously insured. Our findings should offer some reassurance that it is possible to expand access to uninsured Americans without negatively affecting important clinical outcomes for those who are already insured.
----------------------
Mark Duggan & Tamara Hayford
Journal of Policy Analysis and Management, forthcoming
Abstract:
From 1991 to 2009, the fraction of Medicaid recipients enrolled in HMOs and other forms of Medicaid managed care (MMC) increased from 11 percent to 71 percent. This increase was largely driven by state and local mandates that required most Medicaid recipients to enroll in an MMC plan. Theoretically, it is ambiguous whether the shift from fee-for-service into managed care would lead to an increase or a reduction in Medicaid spending. This paper investigates this effect using a data set on state- and local-level MMC mandates and detailed data from the Centers for Medicare and Medicaid Services (CMS) on state Medicaid expenditures. The findings suggest that shifting Medicaid recipients from fee-for-service into MMC did not on average reduce Medicaid spending. If anything, our results suggest that the shift to MMC increased Medicaid spending and that this effect was especially present for risk-based HMOs. However, the effects of the shift to MMC on Medicaid spending varied significantly across states as a function of the generosity of the state's baseline Medicaid provider reimbursement rates.
----------------------
Do Patients "Like" Good Care?: Measuring Hospital Quality via Facebook
Alex Timian et al.
American Journal of Medical Quality, forthcoming
Abstract:
With the growth of Facebook, public health researchers are exploring the platform's uses in health care. However, little research has examined the relationship between Facebook and traditional hospital quality measures. The authors conducted an exploratory quantitative analysis of hospitals' Facebook pages to assess whether Facebook "Likes" were associated with hospital quality and patient satisfaction. The 30-day mortality rates and patient recommendation rates were used to quantify hospital quality and patient satisfaction; these variables were correlated with Facebook data for 40 hospitals near New York, NY. The results showed that Facebook "Likes" have a strong negative association with 30-day mortality rates and are positively associated with patient recommendation. These exploratory findings suggest that the number of Facebook "Likes" for a hospital may serve as an indicator of hospital quality and patient satisfaction. These findings have implications for researchers and hospitals looking for a quick and widely available measure of these traditional indicators.
----------------------
Elbert Huang & Kenneth Finegold
Health Affairs, March 2013, Pages 614-621
Abstract:
The Affordable Care Act's expansion of insurance coverage is expected to increase demand for primary care services. We estimate that the national increase in demand for such services will require 7,200 additional primary care providers, or 2.5 percent of the current supply. On average, that increased demand is unlikely to prove disruptive. But when we examined how this increased demand will be experienced in different areas of the country, we found considerable variability: Seven million people live in areas where the expected increase in demand for providers is greater than 10 percent of baseline supply, and forty-four million people live in areas with an expected increase in demand above 5 percent of baseline supply. These findings highlight the need to promote policies that encourage more primary care providers and community health centers to practice in areas with the greatest expected need for services.
----------------------
U.S. Graduate Medical Education and Physician Specialty Choice
Paul Jolly, Clese Erikson & Gwen Garrison
Academic Medicine, April 2013, Pages 468-474
Purpose: The United States is facing a critical physician shortage. It will only get worse as many more Americans gain insurance coverage under the Affordable Care Act and as additional millions enter the Medicare system. There is a serious concern that the pipeline for the production of the physician workforce is inadequate to meet future needs. It is imperative to continue to monitor the structure and size of this pipeline-the purpose of the research reported here.
Method: This descriptive analysis uses data derived from the National Graduate Medical Education Census, which includes reports on the entire population of residents in programs accredited by the Accreditation Council for Graduate Medical Education. Data for the years 2001 to 2010 are reported both on specialties which can be entered directly from medical school or with one preliminary year and on subspecialty residencies and fellowships, which require completion of an earlier residency program. Estimates of the number of new trainees who will practice primary care are provided.
Results: In 2010, there were 4,754 residents reported in preliminary programs, 89,142 residents in core specialty and combined specialty programs, and 20,007 in subspecialty and sub-subspecialty programs. Between 2001 and 2010, there was a 13.6% (13,655) increase in all residents. Since 2001, there has been a 6.3% (540) decrease in the number expected to enter primary care.
Conclusions: Without a substantially accelerated growth in graduate medical education, the physician workforce will fall short of the nation's needs, and competition for available residency positions will radically increase.
----------------------
Geoffrey Lamb et al.
Health Affairs, March 2013, Pages 536-543
Abstract:
Public reporting of how physicians and hospitals perform on certain quality of care measures is increasingly common, but little is known about whether such disclosures have an impact on the quality of care delivered to patients. We analyzed fourteen publicly reported quality of ambulatory care measures from 2004 to 2009 for the Wisconsin Collaborative for Healthcare Quality, a voluntary consortium of physician groups. We also fielded a survey of the collaborative's members and analyzed Medicare billing data to independently compare members' performance to that of providers in the rest of Wisconsin, neighboring states, and the rest of the United States. We found that physician groups in the collaborative improved their performance during the study period on many measures, such as cholesterol control and breast cancer screening. Physician groups reported on the survey that publicly reported performance data motivated them to act on some, but not all, of the quality measures. Our study suggests that large group practices will engage in quality improvement efforts in response to public reporting, especially when comparative performance is displayed, as it was in this case on the collaborative's website.
----------------------
Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries
Katy Backes Kozhimannil et al.
American Journal of Public Health, April 2013, Pages e113-e121
Objectives: We compared childbirth-related outcomes for Medicaid recipients who received prenatal education and childbirth support from trained doulas with outcomes from a national sample of similar women and estimated potential cost savings.
Methods: We calculated descriptive statistics for Medicaid-funded births nationally (from the 2009 Nationwide Inpatient Sample; n = 279 008) and births supported by doula care (n = 1079) in Minneapolis, Minnesota, in 2010 to 2012; used multivariate regression to estimate impacts of doula care; and modeled potential cost savings associated with reductions in cesarean delivery for doula-supported births.
Results: The cesarean rate was 22.3% among doula-supported births and 31.5% among Medicaid beneficiaries nationally. The corresponding preterm birth rates were 6.1% and 7.3%, respectively. After control for clinical and sociodemographic factors, odds of cesarean delivery were 40.9% lower for doula-supported births (adjusted odds ratio = 0.59; P < .001). Potential cost savings to Medicaid programs associated with such cesarean rate reductions are substantial but depend on states' reimbursement rates, birth volume, and current cesarean rates.
Conclusions: State Medicaid programs should consider offering coverage for birth doulas to realize potential cost savings associated with reduced cesarean rates.
----------------------
Amy Kelley et al.
Health Affairs, March 2013, Pages 552-561
Abstract:
Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53-105 days before death. Using data from the Health and Retirement Study, 2002-08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53-105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1-7, 8-14, and 15-30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.
----------------------
Determinants of Health Care Decisions: Insurance, Utilization, and Expenditures
Chan Shen
Review of Economics and Statistics, March 2013, Pages 142-153
Abstract:
This paper studies three interrelated health care decisions: insurance, utilization, and expenditures. The model treats insurance as an endogenous variable with respect to both utilization and expenditures, addresses potential selection issues, and takes into account that the decisions to use health care and the level of treatment are determined by different decision makers. We employ semiparametric methods to avoid making distributional assumptions. Using the Medical Expenditure Panel Survey 2005 data, the semiparametric approach predicts insurance to increase the level of expenditures by 48%, a number in accord with an important experimental study and less than half that obtained using parametric methods.
----------------------
Health insurance as a two-part pricing contract
Darius Lakdawalla & Neeraj Sood
Journal of Public Economics, forthcoming
Abstract:
Monopolies appear throughout health care. We show that health insurance operates like a conventional two-part pricing contract that allows monopolists to extract profits without inefficiently constraining quantity. When insurers are free to offer a range of insurance contracts to different consumer types, health insurance markets perfectly eliminate deadweight losses from upstream health care monopolies. Frictions limiting the sorting of different consumer types into different insurance contracts restore some of these upstream monopoly losses, which manifest as higher rates of uninsurance, rather than as restrictions in quantity utilized by insured consumers. Empirical analysis of pharmaceutical patent expiration supports the prediction that heavily insured markets experience little or no efficiency loss under monopoly, while less insured markets exhibit behavior more consistent with the standard theory of monopoly.
----------------------
Rocio Garcia-Retamero & Ulrich Hoffrage
Social Science & Medicine, April 2013, Pages 27-33
Abstract:
Doctors and patients have difficulty inferring the predictive value of a medical test from information about the prevalence of a disease and the sensitivity and false-positive rate of the test. Previous research has established that communicating such information in a format the human mind is adapted to - namely natural frequencies - as compared to probabilities, boosts accuracy of diagnostic inferences. In a study, we investigated to what extent these inferences can be improved - beyond the effect of natural frequencies - by providing visual aids. Participants were 81 doctors and 81 patients who made diagnostic inferences about three medical tests on the basis of information about prevalence of a disease, and the sensitivity and false-positive rate of the tests. Half of the participants received the information in natural frequencies, while the other half received the information in probabilities. Half of the participants only received numerical information, while the other half additionally received a visual aid representing the numerical information. In addition, participants completed a numeracy scale. Our study showed three important findings: (1) doctors and patients made more accurate inferences when information was communicated in natural frequencies as compared to probabilities; (2) visual aids boosted accuracy even when the information was provided in natural frequencies; and (3) doctors were more accurate in their diagnostic inferences than patients, though differences in accuracy disappeared when differences in numerical skills were controlled for. Our findings have important implications for medical practice as they suggest suitable ways to communicate quantitative medical data.
----------------------
Gayle Shier et al.
Health Affairs, March 2013, Pages 544-551
Abstract:
A growing evidence base suggests services that address social factors with an impact on health, such as transportation and caregiver support, must be integrated into new models of care if the Institute for Healthcare Improvement's Triple Aim is to be realized. We examined early evidence from seven innovative care models currently in use, each with strong social support services components. The evidence suggests that coordinated efforts to identify and meet the social needs of patients can lead to lower health care use and costs, and better outcomes for patients. For example, Senior Care Options - a Massachusetts program that coordinates the direct delivery of social support services for patients with chronic conditions and adults with disabilities - reported that hospital days per 1,000 members were just 55 percent of those generated by comparable patients not receiving the program's extended services. More research is required to determine which social service components yield desired outcomes for specific patient populations. Gaining these deeper insights and disseminating them widely offer the promise of considerable benefit for patients and the health care system as a whole.
----------------------
Stéphanie Lluis & Jean Abraham
Industrial Relations, April 2013, Pages 541-581
Abstract:
Key provisions within healthcare reform will likely further increase the cost of employer-sponsored insurance. Theory suggests that workers pay for their health insurance through a wage offset. We investigate this issue using data from the Medical Expenditure Panel Survey. GMM estimates aimed at correcting for endogenous worker mobility reveal evidence of a trade-off for workers who are offered health insurance as the only fringe benefit. On the other hand, employees in establishments with a more comprehensive set of benefits enjoy higher wages relative to employees in establishments that offer no benefits. Health also affects the wage-health insurance trade-off.
----------------------
Ann Kutney-Lee, Douglas Sloane & Linda Aiken
Health Affairs, March 2013, Pages 579-586
Abstract:
An Institute of Medicine report has called for registered nurses to achieve higher levels of education, but health care policy makers and others have limited evidence to support a substantial increase in the number of nurses with baccalaureate degrees. Using Pennsylvania nurse survey and patient discharge data from 1999 and 2006, we found that a ten-point increase in the percentage of nurses holding a baccalaureate degree in nursing within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients - and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients. We estimate that if all 134 hospitals in our study had increased the percentage of their nurses with baccalaureates by ten points during our study's time period, some 500 deaths among general, orthopedic, and vascular surgery patients might have been prevented. The findings provide support for efforts to increase the production and employment of baccalaureate nurses.
----------------------
The impact of health insurance mandates on drug innovation: Evidence from the United States
Natalie Chun & Minjung Park
European Journal of Health Economics, April 2013, Pages 323-344
Abstract:
An important health policy issue is the low rate of patient enrollment into clinical trials, which may slow down the process of clinical trials and discourage their supply, leading to delays in innovative life-saving drug treatments reaching the general population. In the US, patients' cost of participating in a clinical trial is considered to be a major barrier to patient enrollment. In order to reduce this barrier, some states in the US have implemented policies requiring health insurers to cover routine care costs for patients enrolled in clinical trials. This paper evaluates empirically how effective these policies were in increasing the supply of clinical trials and speeding up their completion, using data on cancer clinical trials initiated in the US between 2001 and 2007. Our analysis indicates that the policies did not lead to an increased supply in the number of clinical trials conducted in mandate states compared to non-mandate states. However, we find some evidence that once clinical trials are initiated, they are more likely to finish their patient recruitment in a timely manner in mandate states than in non-mandate states. As a result, the overall length to completion was significantly shorter in mandate states than in non-mandate states for cancer clinical trials in certain phases. The findings hint at the possibility that these policies might encourage drug innovation in the long run.
----------------------
Deverick Anderson et al.
American Journal of Infection Control, forthcoming
Background: State-specific, health care-associated infection (HAI) cost estimates have not been calculated to guide Department of Public Health efforts and investments.
Methods: We completed a cost identification study by conducting a survey of 117 acute care hospitals in NC to collect surveillance data on patient-days, device-days, and surgical procedures during 1 year. We then calculated expected rates and direct hospital costs of surgical site infections (SSI), Clostridium difficile infection, and 3 selected device-related HAIs for hospitals and the entire state using reference data sets such as the National Healthcare Safety Network.
Results: In total, 67 (53%) hospitals responded to the survey. The median bed size of respondent hospitals was 140 (interquartile range, 66-350). A "standard" NC hospital diagnosed approximately 100 HAI each year with estimated costs of $985,000 to $2.7 million. The most common HAI was SSI (73%). Costs related to SSI accounted for 87% to 91% of overall costs. In total, the overall direct annual cost of these 5 selected HAIs was estimated to be between $124.1 and $347.8 million in 2009 for the state of NC.
Conclusion: Using conservative estimates, HAI led to costs of more than $100 million in acute care hospitals in the state of NC in 2009. The majority of costs were due to SSI.
----------------------
Katy Backes Kozhimannil, Michael Law & Beth Virnig
Health Affairs, March 2013, Pages 527-535
Abstract:
Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.
----------------------
Isabel Cáceres et al.
PLoS ONE, March 2013
Objective: We examined the extent to which differences in hospital-level cesarean delivery rates in Massachusetts were attributable to hospital-level, rather than maternal, characteristics.
Methods: Birth certificate and maternal in-patient hospital discharge records for 2004-06 in Massachusetts were linked. The study population was nulliparous, term, singleton, and vertex births (NTSV) (n = 80,371) in 49 hospitals. Covariates included mother's age, race/ethnicity, education, infant birth weight, gestational age, labor induction (yes/no), hospital shift at time of birth, and preexisting health conditions. We estimated multilevel logistic regression models to assess the likelihood of a cesarean delivery
Results: Overall, among women with NTSV births, 26.5% births were cesarean, with a range of 14% to 38.3% across hospitals. In unadjusted models, the between-hospital variance was 0.103 (SE 0.022); adjusting for demographic, socioeconomic and preexisting medical conditions did not reduce any hospital-level variation 0.108 (SE 0.023).
Conclusion: Even after adjusting for both socio-demographic and clinical factors, the chance of a cesarean delivery for NTSV pregnancies varied according to hospital, suggesting the importance of hospital practices and culture in determining a hospital's cesarean rate.
----------------------
Misrecognition of need: Women's experiences of and explanations for undergoing cesarean delivery
Kristin Tully & Helen Ball
Social Science & Medicine, May 2013, Pages 103-111
Abstract:
International rates of operative delivery are consistently higher than the World Health Organization determined is appropriate. This suggests that factors other than clinical indications contribute to cesarean section. Data presented here are from interviews with 115 mothers on the postnatal ward of a hospital in Northeast England during February 2006 to March 2009 after the women underwent either unscheduled or scheduled cesarean childbirth. Using thematic content analysis, we found women's accounts of their experiences largely portrayed cesarean section as everything that they had wanted to avoid, but necessary given their situations. Contrary to popular suggestion, the data did not indicate impersonalized medical practice, or that cesareans were being performed ‘on request.' The categorization of cesareans into ‘emergency' and ‘elective' did not reflect maternal experiences. Rather, many unscheduled cesareans were conducted without indications of fetal distress and most scheduled cesareans were not booked because of ‘choice.' The authoritative knowledge that influenced maternal perceptions of the need to undergo operative delivery included moving forward from ‘prolonged' labor and scheduling cesarean as a prophylactic to avoid anticipated psychological or physical harm. In spontaneously defending themselves against stigma from the ‘too posh to push' label that is currently common in the media, women portrayed debate on the appropriateness of cesarean childbirth as a social critique instead of a health issue. The findings suggest the ‘need' for some cesareans is due to misrecognition of indications by all involved. The factors underlying many cesareans may actually be modifiable, but informed choice and healthful outcomes are impeded by lack of awareness regarding the benefits of labor on the fetal transition to extrauterine life, the maternal desire for predictability in their parturition and recovery experiences, and possibly lack of sufficient experience for providers in a variety of vaginal delivery scenarios (non-progressive labor, breech presentation, and/or after previous cesarean).
----------------------
David Kindig & Erika Cheng
Health Affairs, March 2013, Pages 451-458
Abstract:
Researchers increasingly track variations in health outcomes across counties in the United States, but current ranking methods do not reflect changes in health outcomes over time. We examined trends in male and female mortality rates from 1992-96 to 2002-06 in 3,140 US counties. We found that female mortality rates increased in 42.8 percent of counties, while male mortality rates increased in only 3.4 percent. Several factors, including higher education levels, not being in the South or West, and low smoking rates, were associated with lower mortality rates. Medical care variables, such as proportions of primary care providers, were not associated with lower rates. These findings suggest that improving health outcomes across the United States will require increased public and private investment in the social and environmental determinants of health - beyond an exclusive focus on access to care or individual health behavior.
----------------------
When Is Prevention More Profitable than Cure? The Impact of Time-Varying Consumer Heterogeneity
Michael Kremer & Christopher Snyder
NBER Working Paper, March 2013
Abstract:
We argue that in pharmaceutical markets, variation in the arrival time of consumer heterogeneity creates differences between a producer's ability to extract consumer surplus with preventives and treatments, potentially distorting R&D decisions. If consumers vary only in disease risk, revenue from treatments - sold after the disease is contracted, when disease risk is no longer a source of private information - always exceeds revenue from preventives. The revenue ratio can be arbitrarily high for sufficiently skewed distributions of disease risk. Under some circumstances, heterogeneity in harm from a disease, learned after a disease is contracted, can lead revenue from a treatment to exceed revenue from a preventative. Calibrations suggest that skewness in the U.S. distribution of HIV risk would lead firms to earn only half the revenue from a vaccine as from a drug. Empirical tests are consistent with the predictions of the model that vaccines are less likely to be developed for diseases with substantial disease-risk heterogeneity.
----------------------
The Economics of FTC v. Lundbeck: Why Drug Mergers May Not Raise Prices
Gregory Werden
Journal of Competition Law & Economics, March 2013, Pages 89-95
Abstract:
In Federal Trade Commission v. Lundbeck, the courts rejected a challenge to a consummated acquisition that had placed under common control the only two drugs for treating a serious heart condition in newborns. Clinical studies showed that the two drugs were equally effective, and the only alternative, surgery, was not a good substitute. Moreover, prices shot up immediately after the acquisition. Yet the courts ruled that the FTC failed to demonstrate substitutability in response to a price difference between the drugs. This article explains why the much-criticized result and rationale of the case plausibly were correct. Analysis of a bespoke model of competition between therapeutic substitute drugs reveals that: (1) competition plausibly results in monopoly pricing, and if not, (2) competition plausibly results in near-monopoly pricing.
----------------------
Proximity to safety-net clinics and HPV vaccine uptake among low-income, ethnic minority girls
Jennifer Tsui et al.
Vaccine, 12 April 2013, Pages 2028-2034
Purpose: Human Papillomavirus (HPV) vaccine uptake remains low. Although publicly funded programs provide free or low cost vaccines to low-income children, barriers aside from cost may prevent disadvantaged girls from getting vaccinated. Prior studies have shown distance to health care as a potential barrier to utilizing pediatric preventive services. This study examines whether HPV vaccines are geographically accessible for low-income girls in Los Angeles County and whether proximity to safety-net clinics is associated with vaccine initiation.
Methods: Interviews were conducted in multiple languages with largely immigrant, low-income mothers of girls ages 9 to 18 via a county health hotline to assess uptake and correlates of uptake. Addresses of respondents and safety-net clinics that provide the HPV vaccine for free or low cost were geo-coded and linked to create measures of geographic proximity. Logistic regression models were estimated for each proximity measure on HPV vaccine initiation while controlling for other factors.
Results: On average, 83% of the 468 girls had at least one clinic within 3-miles of their residence. The average travel time on public transportation to the nearest clinic among all girls was 21 min. Average proximity to clinics differed significantly by race/ethnicity. Latinas had both the shortest travel distances (2.2 miles) and public transportation times (16 min) compared to other racial/ethnic groups. The overall HPV vaccine initiation rate was 25%. Increased proximity to the nearest clinic was not significantly associated with initiation. By contrast, mother's awareness of HPV and daughter's age were significantly associated with increased uptake.
Conclusions: This study is among the first to examine geographic access to HPV vaccines for underserved girls. Although the majority of girls live in close proximity to safety-net vaccination services, rates of initiation were low. Expanding clinic outreach in this urban area is likely more important than increasing geographic access to the vaccine for this population.
----------------------
Policy Resistance Undermines Superspreader Vaccination Strategies for Influenza
Chad Wells, Eili Klein & Chris Bauch
PLoS Computational Biology, March 2013
Abstract:
Theoretical models of infection spread on networks predict that targeting vaccination at individuals with a very large number of contacts (superspreaders) can reduce infection incidence by a significant margin. These models generally assume that superspreaders will always agree to be vaccinated. Hence, they cannot capture unintended consequences such as policy resistance, where the behavioral response induced by a new vaccine policy tends to reduce the expected benefits of the policy. Here, we couple a model of influenza transmission on an empirically-based contact network with a psychologically structured model of influenza vaccinating behavior, where individual vaccinating decisions depend on social learning and past experiences of perceived infections, vaccine complications and vaccine failures. We find that policy resistance almost completely undermines the effectiveness of superspreader strategies: the most commonly explored approaches that target a randomly chosen neighbor of an individual, or that preferentially choose neighbors with many contacts, provide at best a relative improvement over their non-targeted counterpart as compared to when behavioral feedbacks are ignored. Increased vaccine coverage in super spreaders is offset by decreased coverage in non-superspreaders, and superspreaders also have a higher rate of perceived vaccine failures on account of being infected more often. Including incentives for vaccination provides modest improvements in outcomes. We conclude that the design of influenza vaccine strategies involving widespread incentive use and/or targeting of superspreaders should account for policy resistance, and mitigate it whenever possible.
----------------------
Wellness Incentives In The Workplace: Cost Savings Through Cost Shifting To Unhealthy Workers
Jill Horwitz, Brenna Kelly & John DiNardo
Health Affairs, March 2013, Pages 468-476
Abstract:
The Affordable Care Act encourages workplace wellness programs, chiefly by promoting programs that reward employees for changing health-related behavior or improving measurable health outcomes. Recognizing the risk that unhealthy employees might be punished rather than helped by such programs, the act also forbids health-based discrimination. We reviewed results of randomized controlled trials and identified challenges for workplace wellness programs to function as the act intends. For example, research results raise doubts that employees with health risk factors, such as obesity and tobacco use, spend more on medical care than others. Such groups may not be especially promising targets for financial incentives meant to save costs through health improvement. Although there may be other valid reasons, beyond lowering costs, to institute workplace wellness programs, we found little evidence that such programs can easily save costs through health improvement without being discriminatory. Our evidence suggests that savings to employers may come from cost shifting, with the most vulnerable employees - those from lower socioeconomic strata with the most health risks - probably bearing greater costs that in effect subsidize their healthier colleagues.