Vitals
Social security and the rise in health spending
Kai Zhao
Journal of Monetary Economics, forthcoming
Abstract:
In a quantitative model of Social Security with endogenous health, I argue that Social Security increases the aggregate health spending of the economy because it redistributes resources to the elderly whose marginal propensity to spend on health is high. I show by using computational experiments that the expansion of US Social Security can account for over a third of the dramatic rise in US health spending from 1950 to 2000. In addition, Social Security has a spill-over effect on Medicare. As Social Security increases health spending, it also increases the payments from Medicare, thus raising its financial burden.
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Love, Toil, and Health Insurance: Why American Husbands Retire When They Do
Joshua Congdon-Hohman
Contemporary Economic Policy, forthcoming
Abstract:
The provision of health insurance has previously been shown to be an important determinant of retirement timing among older Americans, but the existing literature has largely ignored some aspects of the interspousal dependence of health insurance benefits. Specifically, the literature examines only how retirement may affect the health insurance available to the potential retiree but not how it might affect a spouse's options. Using data from the Health and Retirement Study, I find that the impact a husband's retirement might have on a wife's health insurance options has a statistically significant impact on a husband's rate of retirement that is independent of considerations of his own health insurance options. In households where the wife is the only one at risk of losing affordable health insurance if the husband retires, the husband is 30% less likely to retire than if neither spouse is at risk (a 5 percentage point decrease in the retirement rate). Based on these findings, prior research is missing one avenue that changes to the Medicare eligibility age and health insurance policy changes through the Affordable Care Act might impact the labor supply of older workers.
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The ACA: Some Unpleasant Welfare Arithmetic
Casey Mulligan
NBER Working Paper, March 2014
Abstract:
Under the Affordable Care Act, between six and eleven million workers would increase their disposable income by cutting their weekly work hours. About half of them would primarily do so by making themselves eligible for the ACA's federal assistance with health insurance premiums and out-of-pocket health costs, despite the fact that subsidized workers are not able to pay health premiums with pre-tax dollars. The remainder would do so primarily by relieving their employers from penalties, or the threat of penalties, pursuant to the ACA's employer mandate. Women, especially those who are not married, are more likely than men to have their short-term financial reward to full-time work eliminated by the ACA. Additional workers, beyond the six to eleven million, could increase their disposable income by using reduced hours to climb one of the "cliffs" that are part of the ACA's mapping from household income to federal assistance.
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Steven Hill et al.
Health Affairs, April 2014, Pages 691-699
Abstract:
The Affordable Care Act (ACA) has dramatically increased the number of low-income nonelderly adults eligible for Medicaid. Starting in 2014, states can elect to cover individuals and families with modified adjusted gross incomes below a threshold of 133 percent of federal poverty guidelines, with a 5 percent income disregard. We used simulation methods and data from the Medical Expenditure Panel Survey to compare nondisabled adults enrolled in Medicaid prior to the ACA with two other groups: adults who were eligible for Medicaid but not enrolled in it, and adults who were in the income range for the ACA’s Medicaid expansion and thus newly eligible for coverage. Although differences in health across the groups were not large, both the newly eligible and those eligible before the ACA but not enrolled were healthier on several measures than pre-ACA enrollees. Twenty-five states have opted not to use the ACA to expand Medicaid eligibility. If these states reverse their decisions, their Medicaid programs might not enroll a population that is sicker than their pre-ACA enrollees. By expanding Medicaid eligibility, states could provide coverage to millions of healthier adults as well as to millions who have chronic conditions and who need care.
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Who Benefits when the Government Pays More? Pass-Through in the Medicare Advantage Program
Mark Duggan, Amanda Starc & Boris Vabson
NBER Working Paper, March 2014
Abstract:
Governments contract with private firms to provide a wide range of services. While a large body of previous work has estimated the effects of that contracting, surprisingly little has investigated how those effects vary with the generosity of the contract. In this paper we examine this issue in the Medicare Advantage (MA) program, through which the federal government contracts with private insurers to coordinate and finance health care for more than 15 million Medicare recipients. To do this, we exploit a substantial policy-induced increase in MA reimbursement in metropolitan areas with a population of 250 thousand or more relative to MSAs just below this threshold. Our results demonstrate that the additional reimbursement leads more private firms to enter this market and to an increase in the share of Medicare recipients enrolled in MA plans. Our findings also reveal that only about one-fifth of the additional reimbursement is passed through to consumers in the form of better coverage. A somewhat larger share accrues to private insurers in the form of higher profits and we find suggestive evidence of a large impact on advertising expenditures. Our results have implications for a key feature of the Affordable Care Act that will reduce reimbursement to MA plans by $156 billion from 2013 to 2022.
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The doctor will be with you ... shortly?
Lindsey Woodworth
Journal of Regulatory Economics, April 2014, Pages 138-174
Abstract:
The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that Medicare-participating hospitals screen and stabilize all individuals appearing in their emergency departments, regardless of expected compensation. To counter the incentive to prioritize revenue-generating patients, the law also prohibits facilities from delaying care to under-insured individuals. I estimate whether timeliness of emergency care is, in fact, unaffected by payer source as mandated. Using the National Hospital Ambulatory Medical Care Survey, I first examine the direct effect of under-insurance and find that under-insurance is associated with an approximately 6–10 % increase in emergency department wait time. Because of concerns that the effects of under-insurance may be mediated by triage assignment, I subsequently estimate the relationship between under-insurance and triage assignment, using the office hours of general practitioners as an exogenous source of variation in payer source. Instrumental variable results suggest that under-insured patients are inexplicably assigned higher triage scores which are known to lengthen waits. Contrary to the stipulations of EMTALA, discrepancies in timeliness of care do exist. Yet, this noncompliance is not readily apparent; roughly 80 % of the increase in under-insured individuals’ wait times are masked by adjustments to triage scores.
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Robert Kaestner, Cuiping Long & Caleb Alexander
NBER Working Paper, February 2014
Abstract:
We examine whether obtaining prescription drug insurance through the Medicare Part D program affected hospital admissions, expenditures associated with those admissions, and mortality. We use a large, geographically diverse sample of Medicare beneficiaries and exploit the natural experiment of Medicare Part D to obtain estimates of the effect of prescription drug insurance on hospitalizations and mortality. Results indicate that obtaining prescription drug insurance through Medicare Part D was associated with an 8% decrease in the number of hospital admissions, a 7% decrease in Medicare expenditures, and a 12% decrease in total resource use. Gaining prescription drug insurance through Medicare Part D was not significantly associated with mortality.
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Benjamin Sommers et al.
Health Affairs, April 2014, Pages 700-707
Abstract:
Under the Affordable Care Act (ACA), changes in income and family circumstances are likely to produce frequent transitions in eligibility for Medicaid and health insurance Marketplace coverage for low- and middle-income adults. We provide state-by-state estimates of potential eligibility changes (“churning”) if all states expanded Medicaid under health reform, and we identify predictors of rates of churning within states. Combining longitudinal survey data with state-specific weighting and small-area estimation techniques, we found that eligibility changes occurred frequently in all fifty states. Higher-income states and states that had more generous Medicaid eligibility criteria for nonelderly adults before the ACA experienced more churning, although the differences were small. Even in states with the least churning, we estimated that more than 40 percent of adults likely to enroll in Medicaid or subsidized Marketplace coverage would experience a change in eligibility within twelve months. Policy options for states to reduce the frequency and impact of coverage changes include adopting twelve-month continuous eligibility for adults in Medicaid, creating a Basic Health Program, using Medicaid funds to subsidize Marketplace coverage for low-income adults, and encouraging the same health insurers to offer plans in Medicaid and the Marketplaces.
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Jason Abaluck et al.
NBER Working Paper, March 2014
Abstract:
We develop a model of the efficiency of medical testing based on the frequency of negative CT scans for pulmonary embolism. The model is estimated using a 20% sample of Medicare claims from 2000-2009. We document enormous heterogeneity in testing conditional on patient population. Less experienced physicians and those practicing in high spending areas test more low-risk patients. Assessing the efficiency of current practices requires calibration assumptions regarding the costs of testing, the benefits of treatment and the likelihood of false positives. While we cannot tell whether any particular testing decision was mistaken in the context of our model, we find that collectively – given these additional calibration assumptions – there are systematic differences between doctor testing practices and the recommendations of our model of optimal testing. According to our model, 90-99% of doctors test even when costs exceed expected benefits; optimal testing thresholds would increase social welfare by 20-35%. Shifting doctor practice to weight risk factors differently could increase net welfare in our model by 275%.
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Cost-Effectiveness Analysis and Insurance Coverage: Solving a Puzzle
Mark Pauly
Health Economics, forthcoming
Abstract:
The conventional model for the use of cost-effectiveness analysis for health programs involves determining whether the cost per unit of effectiveness of the program is lower than some socially determined maximum acceptable cost per unit of effectiveness. If a program is better by this criterion, the policy implication is that it should be implemented by full coverage of its cost by insurance; if not, the program should not be implemented. This paper examines the unanswered question of how cost-effectiveness analysis should be performed and interpreted when insurance coverage may involve cost sharing. It explores the question of how cost sharing should be related to the magnitude of a cost-effectiveness ratio. A common view that cost sharing should vary inversely with program cost-effectiveness is shown to be incorrect. A key issue in correct analysis is whether there is heterogeneity in marginal effectiveness of care that cannot be perceived by the social planner but is known by the demander. It is possible that some programs that would fail the social efficiency test at full coverage will be acceptable with positive cost sharing. Combining individual and social preferences affects both the choice of programs and the extent of cost sharing.
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Taxpayer Willingness to Pay for Health Insurance Reform: A Contingent Valuation Analysis
Kurt Lavetti, Kosali Simon & William White
Economic Inquiry, forthcoming
Abstract:
A key criterion for evaluating policies to expand health insurance coverage is weighing the costs of such policies against the willingness of the public to pay for coverage expansions. We use new panel survey data from New York State to estimate residents' willingness to pay (WTP) to expand public insurance coverage. Using a nonparametric double-bounded contingent valuation (CV) approach, we specifically ask residents about their WTP to reduce the rate of uninsurance in the state. Our results imply an aggregate lower-bound WTP of over $2,800 per year to cover one person. We also analyze heterogeneity in WTP by sub-group and changes in individual WTP over time between 2008 and 2010. We find that a large majority of residents are willing to pay additional taxes to reduce the number of uninsured in the state, and that average WTP remained remarkably stable despite the economic downturn and the politically polarized discussions surrounding the Affordable Care Act. Decomposing the changes in individual WTP, we find that economic factors related to the recession, including changes in income and employment status, cannot explain changes in individual WTP, whereas individual changes in political opinions about health insurance reform between 2008 and 2010 are strongly correlated with changes in WTP.
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Preparedness of Americans for the Affordable Care Act
Silvia Helena Barcellos et al.
Proceedings of the National Academy of Sciences, forthcoming
Abstract:
This paper investigates whether individuals are sufficiently informed to make reasonable choices in the health insurance exchanges established by the Affordable Care Act (ACA). We document knowledge of health reform, health insurance literacy, and expected changes in healthcare using a nationally representative survey of the US population in the 5 wk before the introduction of the exchanges, with special attention to subgroups most likely to be affected by the ACA. Results suggest that a substantial share of the population is unprepared to navigate the new exchanges. One-half of the respondents did not know about the exchanges, and 42% could not correctly describe a deductible. Those earning 100–250% of federal poverty level (FPL) correctly answered, on average, 4 out of 11 questions about health reform and 4.6 out of 7 questions about health insurance. This compares with 6.1 and 5.9 correct answers, respectively, for those in the top income category (400% of FPL or more). Even after controlling for potential confounders, a low-income person is 31% less likely to score above the median on ACA knowledge questions, and 54% less likely to score above the median on health insurance knowledge than a person in the top income category. Uninsured respondents scored lower on health insurance knowledge, but their knowledge of ACA is similar to the overall population. We propose that simplified options, decision aids, and health insurance product design to address the limited understanding of health insurance contracts will be crucial for ACA’s success.
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The Nature of Surgeon Human Capital Depreciation
Jason Hockenberry & Lorens Helmchen
NBER Working Paper, March 2014
Abstract:
To test how practice interruptions affect worker productivity, we estimate how temporal breaks affect surgeons’ performance of coronary artery bypass grafting (CABG). Using a sample of 188 surgeons who performed 56,315 CABG procedures in Pennsylvania between 2006 and 2010, we find that a surgeon’s additional day away from the operating room raised patients’ inpatient mortality risk by up to 0.067 percentage points (2.4% relative effect) but reduced total hospitalization costs by up to 0.59 percentage points. In analyses of 93 high-volume surgeons treating 9,853 patients admitted via an emergency department, where temporal distance effects are most plausibly exogenous, an additional day away raised mortality risk by 0.398 percentage points (11.4% relative effect) but reduced cost by up to 1.396 percentage points. These estimates imply a cost per life-year saved ranging from $7,871 to $18,500, rendering additional treatment intensity within surgery cost-effective at conventional cutoffs. Our findings are consistent with the hypothesis that after returning from temporal breaks surgeons may be less likely to recognize and address life-threatening complications, in turn reducing resource use. This form of human capital loss would explain the decrease in worker productivity and the simultaneous reduction in input use.
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A Tale of Two Cities? The Heterogeneous Impact of Medicaid Managed Care
James Marton, Aaron Yelowitz & Jeffery Talbert
Journal of Health Economics, forthcoming
Abstract:
Evaluating Accountable Care Organizations is difficult because there is a great deal of heterogeneity in terms of their reimbursement incentives and other programmatic features. We examine how variation in reimbursement incentives and administration among two Medicaid managed care plans impacts utilization and spending. We use a quasi-experimental approach exploiting the timing and county-specific implementation of Medicaid managed care mandates in two contiguous regions of Kentucky. We find large differences in the relative success of each plan in reducing utilization and spending that are likely driven by important differences in plan design. The plan that capitated primary care physicians and contracted out many administrative responsibilities to an experienced managed care organization achieved significant reductions in outpatient and professional utilization. The plan that opted for a fee-for-service reimbursement scheme with a group withhold and handled administration internally saw a much more modest reduction in outpatient utilization and an increase in professional utilization.
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How Has the Affordable Care Act’s Medical Loss Ratio Regulation Affected Insurer Behavior?
Jean Abraham, Pinar Karaca-Mandic & Kosali Simon
Medical Care, April 2014, Pages 370-377
Background: Starting in 2011, the Affordable Care Act stipulates that insurers meet the minimum medical loss ratio (MLR) standards or issue rebates. An MLR is the proportion of premium revenues spent on clinical benefits, and must be at least 80% in the individual and small-group markets. Although some insurers have issued rebates, it is unclear whether they also adjusted MLRs and their components in ways to move toward compliance.
Objective: To investigate early responses of individual and small-group insurers’ MLR-related outcomes to the Affordable Care Act provisions.
Results: In 2010, only 44.3% of individual market insurers reported MLRs of at least the stipulated level; by 2011, this percentage was 63.2%. Among small-group insurers, 74.9% had 2010 MLRs at or above the stipulated level, with little change in 2011. Individual insurers with 2010 MLRs >10 percentage points below the minimum exhibited the largest increases in MLRs, with changes occurring through increases in claims and indirectly through decreases in administrative expenses.
Conclusions: Early responses to MLR regulation seem more pronounced in the individual versus small-group market, with insurers using both direct and indirect strategies for compliance. Because insurers learned of final MLR regulations only in late 2010, early responses may be limited and skewed more toward greater use of rebates than other adjustments.
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Sara Parker Lue
Rutgers Working Paper, January 2014
Abstract:
This paper examines the potential for conflicts of interest to influence managers, specifically in the context of health care. Managers in all types of firms may be expected to have relationships with outside firms such as vendors in the course of performing their duties. Yet these relationships open managers to the possibility of conflicts of interest as well, to the extent that this contact is persuasive rather than informational. The possibility for a conflict of interest becomes particularly concerning in the presence of a financial relationship between a firm’s employees and its suppliers. I examine this possibility in the context of health care, where physician contact with pharmaceutical companies (key vendors for hospitals) is important for clinical decision-making, but also presents the possibility of conflict of interest. I examine physician prescribing behavior after the termination of a financial relationship with a pharmaceutical company in order to identify the persuasive (rather than informational) effect of the relationship, and find that affected physicians do significantly alter their behavior, confirming the presence of a persuasive and non-informational effect.
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How Much Favorable Selection Is Left in Medicare Advantage?
Joseph Newhouse et al.
NBER Working Paper, March 2014
Abstract:
There are two types of selection models in the health economics literature. One focuses on choice between a fixed set of contracts. Consumers with greater demand for medical care services prefer contracts with more generous reimbursement, resulting in a suboptimal proportion of consumers in such contracts in equilibrium. In extreme cases more generous contracts may disappear (the “death spiral”). In the other model insurers tailor the contracts they offer consumers to attract profitable consumers. An equilibrium may or may not exist in such models, but if it exists it is not first best. The Medicare Advantage program offers an opportunity to study these models empirically, although unlike the models in the economics literature there is a regulator with various tools to address selection. One such tool is risk adjustment, or making budget neutral transfers among insurers using observable characteristics of enrollees that predict spending. Medicare drastically changed its risk adjustment program starting in 2004 and made a number of other changes to reduce selection as well. Previous work has argued that the changes worsened selection. We show, using a much larger data set, that this was not the case, but that some inherent selection may remain.
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Can We Trust Online Physician Ratings? Evidence from Cardiac Surgeons in Florida
Susan Lu & Huaxia Rui
University of Rochester Working Paper, March 2014
Abstract:
Despite heated debate about the pros and cons of online physician ratings, very little systematic work examines the correlation between physicians’ online ratings and their actual medical performance. Using patients’ ratings of physicians at RateMDs website and the Florida Hospital Discharge data, we investigate whether online ratings reflect physicians’ medical skill by means of a two-stage model that takes into account patients’ ratings-based selection of cardiac surgeons. Estimation results suggest that five-star surgeons perform significantly better and are more likely to be selected by sicker patients than lower-rated surgeons. Our findings suggest that we can trust online physician reviews, at least of cardiac surgeons.
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The Effects of Medicare on Medical Expenditure Risk and Financial Strain
Silvia Helena Barcellos & Mireille Jacobson
NBER Working Paper, March 2014
Abstract:
We estimate the current impact of Medicare on medical expenditure risk and financial strain. At age 65, out-of-pocket expenditures drop by 33% at the mean and 53% among the top 5% of spenders. The fraction of the population with out-of-pocket medical expenditures above income drops by more than half. Medical-related financial strain, such as problems paying bills, is dramatically reduced. Using a stylized expected utility framework, the gain from reducing out-of-pocket expenditures alone accounts for 18% of the social costs of financing Medicare. This calculation ignores the benefits of reduced financial strain and direct health improvements due to Medicare.
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The impact of risk preference on health insurance and health expenditures in the United States
Simon Condliffe & Gregory Fiorentino
Applied Economics Letters, Spring 2014, Pages 613-616
Abstract:
The Affordable Care Act includes an individual mandate whereby persons are required to carry health insurance. This mandate will bring currently uninsured persons into the insurance pool. The uninsured are a heterogeneous group that includes persons with diverse risk preferences. It is important, therefore, to understand the role risk preference plays in (1) the likelihood of being uninsured and (2) the health care expenditures. Using the recently available data from the Medical Expenditure Panel Survey (MEPS), we analyse eight years of US data using multivariate regression and quantify the role of risk preference in insurance and expenditure equations. The results provide evidence that a person with high risk preference is less likely to hold health insurance, and spends less on healthcare even when controlling for insurance.
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Do IT students prefer doctors who use IT?
James Wolf
Computers in Human Behavior, June 2014, Pages 287–294
Abstract:
Several studies suggest that clinical decision support systems (CDSSs) reduce physician diagnostic errors, decrease medical costs, and improve the quality of patient care. However, despite the many potential benefits, physicians have been slow to adopt CDSSs and fail to use them when they are available. Some researchers have speculated that physicians are reluctant to adopt these diagnostic aids, in part, due to the widespread psychological bias that patients and peers feel against physicians who use them. This bias has been well documented among the general public. Many have assumed that this human-is-better attitude is limited to older and less computer savvy populations. We test this assumption with two vignette-based experiments. Our data suggest that, when it comes to physicians, even young participants with positive attitudes towards computers (i.e., IT students) have a human-is-better bias.
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Young Adults' Health Care Utilization and Expenditures Prior to the Affordable Care Act
Josephine Lau et al.
Journal of Adolescent Health, forthcoming
Purpose: To examine young adults' health care utilization and expenditures prior to the Affordable Care Act.
Methods: We used 2009 Medical Expenditure Panel Survey to (1) compare young adults' health care utilization and expenditures of a full-spectrum of health services to children and adolescents and (2) identify disparities in young adults' utilization and expenditures, based on access (insurance and usual source of care) and other sociodemographic factors, including race/ethnicity and income.
Results: Young adults had (1) significantly lower rates of overall utilization (72%) than other age groups (83%–88%, p < .001), (2) the lowest rate of office-based utilization (55% vs. 67%–77%, p < .001) and (3) higher rate of emergency room visits compared with adolescents (15% vs. 12%, p < .01). Uninsured young adults had high out-of-pocket expenses. Compared with the young adults with private insurance, the uninsured spent less than half on health care ($1,040 vs. $2,150/person, p < .001) but essentially the same out-of-pocket expenses ($403 vs. $380/person, p = .57). Among young adults, we identified significant disparities in utilization and expenditures based on the presence/absence of a usual source of care, race/ethnicity, home language, and sex.
Conclusions: Young adults may not be utilizing the health care system optimally by having low rates of office-based visits and high rates of emergency room visits. The Affordable Care Act provision of insurance for those previously uninsured or under-insured will likely increase their utilization and expenditures and lower their out-of-pocket expenses. Further effort is needed to address noninsurance barriers and ensure equal access to health services.
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What The Affordable Care Act Means For People With Jail Stays
Marsha Regenstein & Sara Rosenbaum
Health Affairs, March 2014, Pages 448-454
Abstract:
About one in six people expected to enroll in Medicaid under health reform expansions and nearly one in ten expected to enroll in qualified health plans through the health insurance Marketplaces will have spent some time in jail during the past year. People who have spent time in jail frequently cycle in and out of incarceration; have high rates of chronic physical, mental health, and substance use conditions; and historically have been uninsured and without access to continuous health care. The Affordable Care Act may not change the quality of health care in jails, but its provision of better access to care before and after people are incarcerated could have positive long-term effects on both the health of those individuals and overall health care costs. Achieving these results will require careful planning and coordination among jail health care programs, Medicaid, and Marketplace health plans. The use of electronic health records by jails and community providers could help ensure that treatments are consistent no matter where a patient resides. Policy makers and health plans could also ensure continuity of care by including in their networks some of the same safety-net providers that are under contract to furnish care to jail inmates.
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Merve Cebi & Stephen Woodbury
Health Economics, May 2014, Pages 501–515
Abstract:
The Omnibus Budget Reconciliation Act of 1990 enacted a refundable tax credit for low-income working families who purchased health insurance coverage for their children. This health insurance tax credit (HITC) existed during tax years 1991, 1992, and 1993, and was then rescinded. A difference-in-differences estimator applied to Current Population Survey data suggests that adoption of the HITC, along with accompanying increases in the Earned Income Tax Credit (EITC), was associated with a relative increase of about 4.7 percentage points in the private health insurance coverage of working single mothers with high school or less education. Also, a difference-in-difference-in-differences estimator, which attempts to net out the possible influence of the EITC increases but which requires strong assumptions, suggests that the HITC was responsible for about three-quarters (3.6 percentage points) of the total increase. The latter estimate implies a price elasticity of health insurance take-up of −0.42.
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Ellen Meara et al.
JAMA Psychiatry, April 2014, Pages 404-411
Objective: To evaluate the association between health insurance coverage expansions and use of hospital-based care among young adults with behavioral health diagnoses.
Design, Setting, and Participants: Quasi-experimental analyses of community hospital inpatient and emergency department use from 2003-2009 based on hospital discharge data, comparing differential changes in service use among young adults with behavioral health diagnoses in Massachusetts vs other states before and after Massachusetts’ 2006 health reform. This population-based sample included inpatient admissions (n = 2 533 307, representing 12 821 746 weighted admissions across 7 years) nationwide and emergency department visits (n = 6 817 855 across 7 years) from Maryland and Massachusetts for 12- to 25-year-old patients.
Main Outcomes and Measures: Inpatient admission rates per 1000 population for primary diagnosis of any behavioral health disorder by diagnosis; emergency department visit rates per 1000 population by behavioral health diagnosis; and insurance coverage for hospital discharges.
Results: After 2006, uninsurance among 19- to 25-year-old individuals in Massachusetts decreased from 26% to 10% (16 percentage points; 95% CI, 13-20). Young adults experienced relative declines in inpatient admission rates of 2.0 per 1000 for primary diagnoses of any behavioral health disorder (95% CI, 0.95-3.2), 0.38 for depression (95% CI, 0.18-0.58), and 1.3 for substance use disorder (95% CI, 0.68-1.8). The increase in emergency department visits with any behavioral health diagnosis after 2006 was lower among young adults in Massachusetts compared with Maryland (16.5 per 1000; 95% CI, 11.4-21.6). Among young adults in Massachusetts, the percentage of behavioral health discharges that were uninsured decreased by 5.0 (95% CI, 3.0-7.2) percentage points in inpatient settings and 5.0 (95% CI, 1.7-7.8) percentage points in emergency departments relative to other states.
Conclusions and Relevance: Expanded health insurance coverage for young adults was not associated with large increases in hospital-based care for behavioral health, but it increased financial protection for young adults with behavioral health diagnoses and for the hospitals that care for them.
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Richard Matulewicz et al.
Journal of Urology, forthcoming
Purpose: In addition to excellent patient care, the focus of academic medicine has traditionally been resident training. The changing landscape of healthcare has put an increased focus on objective outcomes. As a result, the surgical training process has come under scrutiny for its influence on patients care. We seek to elucidate resident involvement’s effect on patients’ outcomes.
Materials/Methods: A retrospective analysis was performed on data collected from the 2005 - 2011 National Surgical Quality Improvement Program’s (NSQIP) participant use database. Patients were separated into two cohorts by resident participation (RP) or lack thereof. The cohorts were compared based on preoperative comorbidities, demographic characteristics, and intraoperative factors. Confounders were adjusted for using propensity score modification and complications were analyzed using perioperative variables as predictors.
Results: Forty thousand patients met inclusion criteria. Raw data analysis showed cases with RP to have higher rates of overall complications. However, with propensity score modification, there were no significant differences in overall, medical, or surgical complications in cases with RP. Resident participation was associated with decreased odds (0.85) of overall complications. Operative times (159m vs. 98m) were found to be significantly longer in cases with RP.
Conclusions: We demonstrated that urology resident involvement is not associated with increased overall and surgical complications and may even be protective when adjusted for appropriate factors such as case mix, complexity and operative time.
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Economies of Scale and Scope: The Case of Specialty Hospitals
Kathleen Carey, James Burgess & Gary Young
Contemporary Economic Policy, forthcoming
Abstract:
The recent growth of physician-owned hospitals specializing in orthopedic and surgical specialty services in the United States has generated considerable controversy, yet there is little understanding of the economic logic of organizing hospital services around these single specialties. This article takes a multiple output hospital cost function approach to an empirical investigation of whether single specialty hospitals (SSHs) exhibit economies of scale and economies of scope as keys to new insights into that logic. We applied generalized estimating equation techniques to a sample of 80 SSHs and 883 general hospital competitors over the 1998–2008 period. Results indicated large underlying scale differences across the organizational types. Simulation analysis revealed the potential for exploitation of economies of scope gained from shifting output from SSHs to general hospitals.
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How Important is Governance? Evidence from Heart Attack Survival
Jonathan Kalodimos
University of Washington Working Paper, April 2014
Abstract:
The effect of internal governance on performance is economically significant but difficult to estimate because of noisy measures of performance, confounding external governance mechanisms, and the endogenous choice of strength of governance. This study addresses these difficulties by using nonprofit hospitals as an economic environment with muted external governance mechanisms and using patient survival of a heart attack as an unambiguous measure of performance. To establish a causal relationship I use governance spillovers of geographically local public firms to instrument for nonprofit hospital governance. I find that a one standard deviation increase in strength of governance reduces the probability of death by 0.86 percentage points after controlling for patient characteristics.