A world of hurt

Kevin Lewis

November 19, 2012

Racial Bias in Perceptions of Others' Pain

Sophie Trawalter, Kelly Hoffman & Adam Waytz
PLoS ONE, November 2012

The present work provides evidence that people assume a priori that Blacks feel less pain than do Whites. It also demonstrates that this bias is rooted in perceptions of status and the privilege (or hardship) status confers, not race per se. Archival data from the National Football League injury reports reveal that, relative to injured White players, injured Black players are deemed more likely to play in a subsequent game, possibly because people assume they feel less pain. Experiments 1-4 show that White and Black Americans - including registered nurses and nursing students - assume that Black people feel less pain than do White people. Finally, Experiments 5 and 6 provide evidence that this bias is rooted in perceptions of status, not race per se. Taken together, these data have important implications for understanding race-related biases and healthcare disparities.


State Unemployment In Recessions During 1991-2009 Was Linked To Faster Growth In Medicare Spending

Melissa Powell McInerney & Jennifer Mellor
Health Affairs, November 2012, Pages 2464-2473

During the US recession of 2007-09, overall health care spending growth fell, but Medicare spending growth increased. Using state-level data from the period 1991-2009, we show that these divergent trends were also observed within states. Furthermore, increases in state unemployment rates were associated with higher Medicare spending per capita and increased hospital use by Medicare beneficiaries. For example, a one-percentage-point point rise in the unemployment rate was associated with a $40 (0.7 percent) increase in Medicare spending per capita. Our results suggest that economic downturns contribute to Medicare spending and use. One of many possible explanations may be that health care providers have greater capacity, inclination, and financial incentive to treat Medicare patients during recessions as a result of slackening demand from the non-Medicare population.


Public Option versus the Market: Perceived Value Violations Drive Opposition to Healthcare Reform

Geoffrey Wetherell, Christine Reyna & Melody Sadler
Political Psychology, forthcoming

The debate over healthcare reform in the United States has been divisive. Research demonstrates that beliefs that policy beneficiaries violate values strongly predict opposition to these policies. Similar dynamics may be happening regarding opposition to healthcare reform. Specifically, this study tested the hypothesis that opposition to a public option in healthcare reform results from stereotypes that public-option beneficiaries violate values. In two studies utilizing three samples, beliefs about beneficiaries violating values of hard work consistently predicted opposition to a public option and an alternative market-based healthcare reform plan, often proposed by public-option opponents. Results also suggest that assertions that a public option would lead to bigger government increases opposition to a public option by indirectly masking underlying stereotypes about value violations.


Despite The Recession's Effects On Incomes And Jobs, The Share Of People With High Medical Costs Was Mostly Unchanged

Peter Cunningham
Health Affairs, November 2012, Pages 2563-2570

High medical cost burden is defined as spending more than 10 percent of family income on health care. Despite decreased family income and rising unemployment caused by the recession of 2007-09, the percentage of people under age sixty-five with high medical cost burdens remained largely unchanged between 2006 and 2009, at approximately 19 percent. That unexpected result, based on data from the Medical Expenditure Panel Surveys, contrasts with an increase from 14.4 percent to 19.2 percent in the share of people with high medical cost burdens between 2001 and 2006. The percentage did not change during the recent recession because decreased family income was offset by decreased out-of-pocket health spending. Virtually all of this decreased spending was because of lower spending on prescription drugs as people shifted from brand-name medications to less expensive generics.


Cost Effectiveness Analysis and the Design of Cost-Sharing in Insurance: Solving a Puzzle

Mark Pauly
NBER Working Paper, October 2012

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 better than some socially determined maximum acceptable cost per unit of effectiveness. If a program is better, the policy implication is that it should be implemented by full coverage of its cost by insurance; if not, no coverage should be provided and 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 can involve non-negligible cost sharing. It explores both the question of how cost effectiveness is affected by the presence of cost sharing, and the more fundamental question of cost effectiveness when cost sharing is itself set at the cost effective level. Both a benchmark model where only "societal" preferences (embodied in a threshold value of dollars per unit of health) matter and a model where individual willingness to pay can be combined with societal values are considered. 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 either in marginal effectiveness of care or marginal values of care that cannot be perceived by the social planner but is known by the demander. The cost effectiveness of a program is shown to depend upon the level of cost sharing; it is possible that some programs that would fail the social test at both zero coverage and 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.


A Simulation Shows Limited Savings From Meeting Quality Targets Under The Medicare Shared Savings Program

David Eddy & Roshan Shah
Health Affairs, November 2012, Pages 2554-2562

The Medicare Shared Savings Program, created under the Affordable Care Act, will reward participating accountable care organizations that succeed in lowering health care costs while improving performance. Depending on how the organizations perform on several quality measures, they will "share savings" in Medicare Part A and B payments - that is, they will receive bonus payments for lowering costs. We used a simulation model to analyze the effects of the Shared Savings Program quality measures and performance targets on Medicare costs in a simulated population of patients ages 65-75 with type 2 diabetes. We found that a ten-percentage-point improvement in performance on diabetes quality measures would reduce Medicare costs only by up to about 1 percent. After the costs of performance improvement, such as additional tests or visits, are accounted for, the savings would decrease or become cost increases. To achieve greater savings, accountable care organizations will have to lower costs by other means, such as through improved use of information technology and care coordination.


Endogenous cost-effectiveness analysis and health care technology adoption

Anupam Jena & Tomas Philipson
Journal of Health Economics, forthcoming

Increased health care spending has placed pressure on payers to prioritize spending. Cost-effectiveness (CE) analysis is the main tool used by payers to prioritize adoption of new therapies. We argue that reimbursement based on CE is subject to a form of the "Lucas critique"; the goals of CE policies may not materialize when firms affected by the policies respond optimally to them. Because "costs" in CE analysis reflect prices set optimally by producers rather than production costs, CE levels are endogenous. Observed CE levels will depend on demand factors of patients and providers and CE policies used by payers themselves. When CE is endogenously determined, policies aimed at lowering spending and improving overall CE may paradoxically raise spending and lead to the adoption of more resource-costly treatments. We empirically illustrate whether this may occur using data on public coverage decisions in the United Kingdom.


Ten Modifiable Health Risk Factors Are Linked To More Than One-Fifth Of Employer-Employee Health Care Spending

Ron Goetzel et al.
Health Affairs, November 2012, Pages 2474-2484

An underlying premise of the Affordable Care Act provisions that encourage employers to adopt health promotion programs is an association between workers' modifiable health risks and increased health care costs. Employers, consultants, and vendors have cited risk-cost estimates developed in the 1990s and wondered whether they still hold true. Examining ten of these common health risk factors in a working population, we found that similar relationships between such risks and total medical costs documented in a widely cited study published in 1998 still hold. Based on our sample of 92,486 employees at seven organizations over an average of three years, $82,072,456, or 22.4 percent, of the $366,373,301 spent annually by the seven employers and their employees in the study was attributed to the ten risk factors studied. This amount was similar to almost a quarter of spending linked to risk factors (24.9 percent) in the 1998 study. High risk for depression remained most strongly associated with increased per capita annual medical spending (48 percent, or $2,184, higher). High blood glucose, high blood pressure, and obesity were strongly related to increased health care costs (31.8 percent, 31.6 percent, and 27.4 percent higher, respectively), as were tobacco use, physical inactivity, and high stress. These findings indicate ongoing opportunities for well-designed and properly targeted employer-sponsored health promotion programs to produce substantial savings.


Reduced Mortality with Hospital Pay for Performance in England

Matt Sutton et al.
New England Journal of Medicine, 8 November 2012, Pages 1821-1828

Background: Pay-for-performance programs are being adopted internationally despite little evidence that they improve patient outcomes. In 2008, a program called Advancing Quality, based on the Hospital Quality Incentive Demonstration in the United States, was introduced in all National Health Service (NHS) hospitals in the northwest region of England (population, 6.8 million).

Methods: We analyzed 30-day in-hospital mortality among 134,435 patients admitted for pneumonia, heart failure, or acute myocardial infarction to 24 hospitals covered by the pay-for-performance program. We used difference-in-differences regression analysis to compare mortality 18 months before and 18 months after the introduction of the program with mortality in two comparators: 722,139 patients admitted for the same three conditions to the 132 other hospitals in England and 241,009 patients admitted for six other conditions to both groups of hospitals.

Results: Risk-adjusted, absolute mortality for the conditions included in the pay-for-performance program decreased significantly, with an absolute reduction of 1.3 percentage points (95% confidence interval [CI], 0.4 to 2.1; P=0.006) and a relative reduction of 6%, equivalent to 890 fewer deaths (95% CI, 260 to 1500) during the 18-month period. The largest reduction, for pneumonia, was significant (1.9 percentage points; 95% CI, 0.9 to 3.0; P<0.001), with nonsignificant reductions for acute myocardial infarction (0.6 percentage points; 95% CI, -0.4 to 1.7; P=0.23) and heart failure (0.6 percentage points; 95% CI, -0.6 to 1.8; P=0.30).

Conclusions: The introduction of pay for performance in all NHS hospitals in one region of England was associated with a clinically significant reduction in mortality. As compared with a similar U.S. program, the U.K. program had larger bonuses and a greater investment by hospitals in quality-improvement activities. Further research is needed on how implementation of pay-for-performance programs influences their effects.


Medical Care Price Indexes for Patients with Employer-Provided Insurance: Nationally Representative Estimates from MarketScan Data

Abe Dunn et al.
Health Services Research, forthcoming

Objective: Commonly observed shifts in the utilization of medical care services to treat diseases may pose problems for official price indexes at the Bureau of Labor Statistics (BLS) that do not account for service shifts. We examine how these shifts may lead to different price estimates than those observed in official price statistics at the BLS.

Data Sources: We use a convenience sample of enrollees with employer-provided insurance from the MarketScan database for the years 2003 to 2007. Population weights that consider the age, sex, and geographic distribution of enrollees are assigned to construct representative estimates.

Study Design: We compare two types of price indexes: (1) a Service Price Index (SPI) that is similar to the BLS index, which holds services fixed and measures the prices of the underlying treatments; (2) a Medical Care Expenditure Index (MCE) that measures the cost of treating diseases and allows for utilization shifts.

Principal Findings: Over the entire period of study the CAGR of the SPI grows 0.7 percentage points faster than the preferred MCE index.

Conclusions: Our findings suggest that the health component of inflation may be overstated by 0.7 percentage points per year, and real GDP growth may be understated by a similar amount. However, more work may be necessary to precisely replicate the indexes of the BLS to obtain a more accurate measure of these price differences.


Prices Need No Preferences: Social Trends Determine Decisions in Experimental Markets for Pain Relief

Ivo Vlaev et al.
Health Psychology, forthcoming

Objective: A standard view in health economics is that, although there is no market that determines the "prices" for health states, people can nonetheless associate health states with monetary values (or other scales, such as quality adjusted life year [QALYs] and disability adjusted life year [DALYs]). Such valuations can be used to shape health policy, and a major research challenge is to elicit such values from people; creating experimental "markets" for health states is a theoretically attractive way to address this. We explore the possibility that this framework may be fundamentally flawed-because there may not be any stable values to be revealed. Instead, perhaps people construct ad hoc values, influenced by contextual factors, such as the observed decisions of others.

Method: The participants bid to buy relief from equally painful electrical shocks to the leg and arm in an experimental health market based on an interactive second-price auction. Thirty subjects were randomly assigned to two experimental conditions where the bids by "others" were manipulated to follow increasing or decreasing price trends for one, but not the other, pain. After the auction, a preference test asked the participants to choose which pain they prefer to experience for a longer duration.

Results: Players remained indifferent between the two pain-types throughout the auction. However, their bids were differentially attracted toward what others bid for each pain, with overbidding during decreasing prices and underbidding during increasing prices.

Conclusion: Health preferences are dissociated from market prices, which are strongly referenced to others' choices. This suggests that the price of health care in a free-market has the capacity to become critically detached from people's underlying preferences.


Do Early Career Indicators of Clinical Skill Predict Subsequent Career Outcomes and Practice Characteristics for General Internists?

Bradley Gray et al.
Health Services Research, forthcoming

Objective: To study relationships between clinical skill measures assessed at the beginning of general internists' careers and their career outcomes and practice characteristics.

Data Sources: General Internist Community Tracking Study Physician Survey respondents (2000-2001, 2004-2005) linked with residency program evaluations and American Board of Internal Medicine board certification examination score records; n = 2,331.

Study Design: Cross-sectional regressions of career outcome and practice characteristic measures on board examination scores/success, residency evaluations interacted with residency type, and potential confounding variables.

Principal Findings: Failure to achieve board certification was associated with $27,206 (18 percent, p < .05) less income and 14.9 percent more minority patients relative to physicians scoring in the bottom quartile on their initial examination who eventually became certified (p < .01). Other skill measures were not associated with income. Scoring in the top rather than bottom quartile on the board certification examination was associated with 9 percent increased likelihood of reporting high career satisfaction (p < .05). Among physicians trained in community hospital residency programs, lower evaluations were associated with 14.5 percent higher share of minority patients (p < .05). Both skill measures were associated with practice type.

Conclusions: There are associations between early career skill measures and career outcomes. In addition, minority patients are more likely to be treated by physicians with lower early career clinical skills measures than nonminority patients.


Comparing Local and Regional Variation in Health Care Spending

Yuting Zhang et al.
New England Journal of Medicine, 1 November 2012, Pages 1724-1731

Background: Wide geographic variation in health care spending has generated both concern about inefficiency and policy debate about geographic-based payment reform. Evidence regarding variation has focused on hospital referral regions (HRRs), which incorporate numerous local hospital service areas (HSAs). If there is substantial variation across local areas within HRRs, then policies focusing on HRRs may be poorly targeted.

Methods: Using prescription drug and medical claims data from a 5% random sample of Medicare beneficiaries from 2006 through 2009, we compared variation in health care spending and utilization among 306 HRRs and 3436 HSAs. We adjusted for beneficiary-level demographic characteristics, insurance status, and clinical characteristics.

Results: There was substantial local variation in health care (drug and nondrug) utilization and spending. Furthermore, many of the low-spending HSAs were located in high-spending HRRs, and many of the high-spending HSAs were in low-spending HRRs. For drug spending, only 50.7% of the HSAs located within the borders of the highest-spending quintile of HRRs were in the highest-spending quintile of HSAs; conversely, only 51.5% of the highest-spending HSAs were located within the borders of the highest-spending HRRs. Similar patterns were observed for nondrug spending.

Conclusions: The effectiveness of payment reforms in reducing overutilization while maintaining access to high-quality care depends on the effectiveness of targeting. Our analysis suggests that HRR-based policies may be too crudely targeted to promote the best use of health care resources.


Physicians With The Least Experience Have Higher Cost Profiles Than Do Physicians With The Most Experience

Ateev Mehrotra et al.
Health Affairs, November 2012, Pages 2453-2463

Health plans and Medicare are using cost profiles to identify which physicians account for more health care spending than others. By identifying the costliest physicians, health plans and Medicare hope to craft policy interventions to reduce total health care spending. To identify which physician types, if any, might be costlier than others, we analyzed cost profiles created from health plan claims for physicians in Massachusetts. We found that physicians with fewer than ten years of experience had 13.2 percent higher overall costs than physicians with forty or more years of experience. We found no association between costs and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and the size of the group in which the physician practices. Although winners and losers are inevitable in any cost-profiling effort, physicians with less experience are more likely to be negatively affected by policies that use cost profiles, unless they change their practice patterns. For example, these physicians could be excluded from high-value networks or receive lower payments under Medicare's planned value-based payment program. We cannot fully explain the mechanism by which more-experienced physicians have lower costs, but our results suggest that the more costly practice style of newly trained physicians may be a driver of rising health care costs overall.


The Impact of Hospital Pay-for-Performance on Hospital and Medicare Costs

Gregory Kruse et al.
Health Services Research, December 2012, Pages 2118-2136

Objective: To evaluate the effects of Medicare's hospital pay-for-performance demonstration project on hospital revenues, costs, and margins and on Medicare costs.

Data Sources/Study Setting: All health care utilization for Medicare beneficiaries hospitalized for acute myocardial infarction (AMI; ICD-9-CM code 410.x1) in fiscal years 2002-2005 from Medicare claims, containing 420,211 admissions with AMI.

Study Design: We test for changes in hospital costs and revenues and Medicare payments among 260 hospitals participating in the Medicare hospital pay-for-performance demonstration project and a group of 780 propensity-score-matched comparison hospitals. Effects were estimated using a difference-in-difference model with hospital fixed effects, testing for changes in costs among pay-for-performance hospitals above and beyond changes in comparison hospitals.

Principal Findings: We found no significant effect of pay-for-performance on hospital financials (revenues, costs, and margins) or Medicare payments (index hospitalization and 1 year after admission) for AMI patients.

Conclusions: Pay-for-performance in the CMS hospital demonstration project had minimal impact on hospital financials and Medicare payments to providers. As P4P extends to all hospitals under the Affordable Care Act, these results provide some estimates of the impact of P4P and emphasize our need for a better understanding of the financial implications of P4P on providers and payers if we want to create sustainable and effective programs to improve health care value.


Labor Mobility of the Direct Care Workforce: Implications for the Provision of Long-Term Care

Reagan Baughman & Kristin Smith
Health Economics, December 2012, Pages 1402-1415

This study provides the first comprehensive analysis of the dynamics of labor supply of direct care workers, the lower-skill nursing workers who provide the bulk of long-term care for the elderly in the USA. Our estimates from the 1996 and 2001 panels of the Survey of Income and Program Participation (SIPP) show that the mean (median) duration of employment spells for the same direct care employer is only 9.7 (5.0) months. We find that fewer than one-third of direct care workers leave a job to take another job in the direct care field. There is also little indication of upward mobility in the health sector; direct care workers are approximately equally likely to transition to working as Registered Nurses as they are to working in household service jobs. Additionally, the rate at which spells end in work-limiting disability (5.4%) is very high compared with rates in similar occupations. We estimate duration models of direct care job spell length and find that, after correcting for the endogenous relationship between wages and tenure, wages appear to have a modest effect in preventing turnover; this effect is concentrated among the shortest spells.


Market size and innovation: Effects of Medicare Part D on pharmaceutical research and development

Margaret Blume-Kohout & Neeraj Sood
Journal of Public Economics, forthcoming

Recent evidence suggests that Medicare Part D increased prescription drug use among seniors, and increased pharmaceutical firms' revenues from sales. Previous studies also indicate that increases in market size induce pharmaceutical innovation. This paper assesses the impact of the Medicare Part D legislation on pharmaceutical research and development (R&D), using time-series data on the number of drugs entering preclinical and clinical development by therapeutic class and phase. We find that the passage and implementation of Medicare Part D is associated with significant increases in pharmaceutical R&D for therapeutic classes with higher Medicare market share.


A new prevention paradox: The trade-off between reducing incentives for risk selection and increasing the incentives for prevention for health insurers

Tim Kanters et al.
Social Science & Medicine, forthcoming

The Dutch risk equalization scheme has been improved over the years by including health related risk adjusters. The purpose of the Dutch risk equalization scheme is to prevent risk selection and to correct for predictable losses and gains for insurers. The objective of this paper is to explore the financial incentives for risk selection under the Dutch risk equalization scheme. We used a simulation model to estimate lifetime health care costs and risk equalization contributions for three cohorts (a smoking; an obese; and a healthy living cohort). Financial differences for the three cohorts were assessed by subtracting health care costs from risk equalization contributions. Even under an elaborate risk equalization system, the healthy living cohort was still most financially attractive for insurers. Smokers were somewhat less attractive, while the obese cohort was least attractive. Lifetime differences with healthy living individuals (revenues minus costs) were modest: €4,840 for obese individuals and €1,101 for smokers. Under a simple form of risk equalization these differences were higher, €8,542 and €4,620 respectively. Improvement of the risk equalization scheme reduced the gap between costs and revenues. Incentives for undesirable risk selection were reduced, but simultaneously incentives for health promotion were weakened. This highlights a new prevention paradox: improving the level playing field for health insurers will inevitably limit their incentives for promoting the health of their clients.


Health Insurance Coverage, Income Distribution and Healthcare Quality in Local Healthcare Markets

Damian Damianov & José Pagán
Health Economics, forthcoming

We develop a theoretical model of a local healthcare system in which consumers, health insurance companies, and healthcare providers interact with each other in markets for health insurance and healthcare services. When income and health status are heterogeneous, and healthcare quality is associated with fixed costs, the market equilibrium level of healthcare quality will be underprovided. Thus, healthcare reform provisions and proposals to cover the uninsured can be interpreted as an attempt to correct this market failure. We illustrate with a numerical example that if consumers at the local level clearly understand the linkages between health insurance coverage and the quality of local healthcare services, health insurance coverage proposals are more likely to enjoy public support.


Favorable Selection, Risk Adjustment, and the Medicare Advantage Program

Michael Morrisey et al.
Health Services Research, forthcoming

Objectives: To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees.

Data: From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures.

Study Design: Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period.

Findings: Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries.

Conclusions: Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees.


The Effects of State Medicaid Policies on the Dynamic Savings Patterns and Medicaid Enrollment of the Elderly

Lara Gardner & Donna Gilleskie
Journal of Human Resources, Fall 2012, Pages 1082-1127

Medicaid policies that may affect long-term care decisions vary across states and time. Using data from the 1993, 1995, 1998, and 2000 waves of the Assets and Health Dynamics Among the Oldest Old Survey, we estimate a dynamic empirical model of health insurance coverage, long-term care arrangement, asset and gift behavior, and health transitions over time. Long-run simulations from the estimated model reveal that most Medicaid eligibility and generosity policy variables associated with nursing home services have no effect on Medicaid enrollment and asset behavior. Those policies related to home- and community-based services, however, have a significant but small influence.


The Impact of the Affordable Care Act on Medicare Advantage Plan Availability and Enrollment

Christopher Afendulis, Mary Beth Landrum & Michael Chernew
Health Services Research, December 2012, Pages 2339-2352

Objective: To assess the impact of the Patient Protection and Affordable Care Act's (ACA) changes in Medicare Advantage (MA) payment rates on the availability of and enrollment in MA plans.

Data Sources: Secondary data on MA plan offerings, contract offerings, and enrollment by state and county, in 2010-2011.

Study Design: We estimated regression models of the change in the number of plans, the number of contracts, and enrollment as a function of quartiles of FFS spending and pre-ACA MA payment generosity. Counties in the lowest quartile of spending are treated most generously by the ACA.

Principal Findings: Relative to counties in the highest quartile of spending, the number of plans in counties in the first, second, and third quartiles rose by 12 percent, 7.6 percent, and 5.4 percent, respectively. Counties with more generous MA payment rates before the ACA lost significantly more plans. We did not find a similar impact on the change in contracts or enrollment.

Conclusions: The ACA-induced MA payment changes reduced the number of plan choices available for Medicare beneficiaries, but they have yet affected enrollment patterns.


Lifetime Earnings for Physicians Across Specialties

Paul Leigh et al.
Medical Care, December 2012, Pages 1093-1101

Background: Earlier studies estimated annual income differences across specialties, but lifetime income may be more relevant given physicians' long-term commitments to specialties.

Methods: Annual income and work hours data were collected from 6381 physicians in the nationally representative 2004-2005 Community Tracking Study. Data regarding years of residency were collected from AMA FREIDA. Present value models were constructed assuming 3% discount rates. Estimates were adjusted for demographic and market covariates. Sensitivity analyses included 4 alternative models involving work hours, retirement, exogenous variables, and 1% discount rate. Estimates were generated for 4 broad specialty categories (Primary Care, Surgery, Internal Medicine and Pediatric Subspecialties, and Other), and for 41 specific specialties.

Results: The estimates of lifetime earnings for the broad categories of Surgery, Internal Medicine and Pediatric Subspecialties, and Other specialties were $1,587,722, $1,099,655, and $761,402 more than for Primary Care. For the 41 specific specialties, the top 3 (with family medicine as reference) were neurological surgery ($2,880,601), medical oncology ($2,772,665), and radiation oncology ($2,659,657). The estimates from models with varying rates of retirement and including only exogenous variables were similar to those in the preferred model. The 1% discount model generated estimates that were roughly 150% larger than the 3% model.

Conclusions: There was considerable variation in the lifetime earnings across physician specialties. After accounting for varying residency years and discounting future earnings, primary care specialties earned roughly $1-3 million less than other specialties. Earnings' differences across specialties may undermine health reform efforts to control costs and ensure adequate numbers of primary care physicians.


Physician Styles of Patient Management as a Potential Source of Disparities: Cluster Analysis from a Factorial Experiment

Karen Lutfey, Eric Gerstenberger & John McKinlay
Health Services Research, forthcoming

Objective: To identify styles of physician decision making (as opposed to singular clinical actions) and to analyze their association with variations in the management of a vignette presentation of coronary heart disease (CHD).

Data Source: Primary data were collected from primary care physicians in North and South Carolina.

Study Design: In a balanced factorial experimental design, primary care physicians viewed one of 16 (24) video vignette presentations of CHD and provided detailed information about how they would manage the case.

Data Collection Method: 256 MD primary care physicians were interviewed face-to-face in North and South Carolina.

Principal Findings: We identify three clusters depicting unique styles of CHD management that are robust to controls for physician (gender and level of experience) and patient characteristics (age, gender, socioeconomic status, and race) as well as key organizational features of physicians' work settings. Physicians in Cluster 1 "Cardiac" (N = 92) were more likely to focus on cardiac issues compared with their counterparts; physicians in Cluster 2 "Talkers" (N = 93) were more likely to give advice and take additional medical history; whereas physicians in Cluster 3 "Minimalists" (N = 71) were less likely than their counterparts to take action on any of the types of management behavior.

Conclusions: Variations in styles of decision making, which encompass multiple outcome variables and extend beyond individual-level demographic predictors, may add to our understanding of disparities in health quality and outcomes.


Chronic Illness and Patient Satisfaction

Caroline Carlin et al.
Health Services Research, December 2012, Pages 2250-2272

Objective: To examine how the relationship between patient characteristics, patient experience with the health care system, and overall satisfaction with care varies with illness complexity.

Data Sources/Study Setting: Telephone survey in 14 U.S. geographical areas.

Study Design: Structural equation modeling was used to examine how relationships among patient characteristics, three constructs representing patient experience with the health care system, and overall satisfaction with care vary across patients by number of chronic illnesses.

Data Collection/Extraction Methods: Random digital dial telephone survey of adults with one or more chronic illnesses.

Principal Findings: Patients with more chronic illnesses report higher overall satisfaction. The total effects of better patient-provider interaction and support for patient self-management are associated with higher satisfaction for all levels of chronic illness. The latter effect increases with illness burden. Older, female, or insured patients are more satisfied; highly educated patients are less satisfied.

Conclusions: Providers seeking to improve their patient satisfaction scores could do so by considering patient characteristics when accepting new patients or deciding who to refer to other providers for treatment. However, our findings suggest constructive actions that providers can take to improve their patient satisfaction scores without selection on patient characteristics.


Lower Mortality for Abdominal Aortic Aneurysm Repair in High-Volume Hospitals Is Contingent upon Nurse Staffing

Kelly Wiltse Nicely, Douglas Sloane & Linda Aiken
Health Services Research, forthcoming

Objective: To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing.

Data Sources: State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey.

Study Design: Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states.

Data Collection: Secondary data sources.

Principal Findings: Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001).

Conclusions: Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.


Does Widowhood Explain Gender Differences in Out-of-Pocket Medical Spending Among the Elderly?

Gopi Shah Goda, John Shoven & Sita Nataraj Slavov
Journal of Health Economics, forthcoming

Despite the presence of Medicare, out-of-pocket medical spending is a large expenditure risk facing the elderly. While women live longer than men, elderly women incur higher out-of-pocket medical spending than men at each age. In this paper, we examine whether differences in marital status and living arrangements can explain this difference. We find that out-of-pocket medical spending is approximately 29 percent higher when an individual becomes widowed, a large portion of which is spending on nursing homes. Our results suggest a substantial role of living arrangements in out-of-pocket medical spending; however, our estimates combined with differences in rates of widowhood across gender suggest that marital status can explain only one third of the gender difference in total out-of-pocket medical spending, leaving a large portion unexplained. On the other hand, gender differences in widowhood more than explain the observed gender difference in out-of-pocket spending on nursing homes.

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