Between you and your doctor

Kevin Lewis

August 15, 2016

Shock, but no shift: Hospitals' responses to changes in patient insurance mix

Kathryn Wagner

Journal of Health Economics, September 2016, Pages 46-58

Medicaid reimburses healthcare providers for services at a lower rate than any other type of insurance coverage. To account for the burden of treating Medicaid patients, providers claim that they must cost-shift by raising the rates of individuals covered by private insurance. Previous investigations of cost-shifting has produced mixed results. In this paper, I exploit a disabled Medicaid expansion where crowd-out was complete to investigate cost-shifting. I find that hospitals reduce the charge rates of the privately insured. Given that Medicaid is expanding in several states under the Affordable Care Act, these results may alleviate cost-shifting concerns of the reform.


Health Spending For Low-, Middle-, And High-Income Americans, 1963-2012

Samuel Dickman et al.

Health Affairs, July 2016, Pages 1189-1196

US medical spending growth slowed between 2004 and 2013. At the same time, many Americans faced rising copayments and deductibles, which may have particularly affected lower-income people. To explore whether the health spending slowdown affected all income groups equally, we divided the population into income quintiles. We then assessed trends in health expenditures by and on behalf of people in each quintile using twenty-two national surveys carried out between 1963 and 2012. Before the 1965 passage of legislation creating Medicare and Medicaid, the lowest income quintile had the lowest expenditures, despite their worse health compared to other income groups. By 1977 the unadjusted expenditures for the lowest quintile exceeded those for all other income groups. This pattern persisted until 2004. Thereafter, expenditures fell for the lowest quintile, while rising more than 10 percent for the middle three quintiles and close to 20 percent for the highest income quintile, which had the highest expenditures in 2012. The post-2004 divergence of expenditure trends for the wealthy, middle class, and poor occurred only among the nonelderly. We conclude that the new pattern of spending post-2004, with the wealthiest quintile having the highest expenditures for health care, suggests that a redistribution of care toward wealthier Americans accompanied the health spending slowdown.


Selective Regulator Decoupling and Organizations' Strategic Responses

Jonas Heese, Ranjani Krishnan & Frank Moers

Academy of Management Journal, forthcoming

Organizations often respond to institutional pressures by symbolically adopting policies and procedures but decoupling them from actual practice. Literature has examined why organizations decouple from regulatory pressures. In this study, we argue that decoupling occurs within regulatory agencies and results from a combination of conflicting institutional pressures, complex goals, and internal fragmentation. Further, regulatory decoupling is selective, i.e., regulators fail to adequately enforce standards only for one set of organizations. Regulated organizations that benefit from selective regulatory decoupling use nonmarket strategies to maintain their favorable regulatory status and in the process selectively decouple their norms in one organizational activity but not others. As an empirical context, we use the hospital industry where regulators have to balance conflicting pressures to be tough on fraud, while maintaining the community's access to essential but unprofitable services such as charity care and medical education. In response, hospital regulators selectively decouple and exhibit leniency in enforcement of mispricing practices towards beneficent hospitals, defined as hospitals that provide more charity care and medical education. In turn, beneficent hospitals selectively decouple their service and profit goals by providing unprofitable services to uninsured patients, while mispricing insured patients to earn higher reimbursements.


Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans

Simon Haeder, David Weimer & Dana Mukamel

Health Affairs, July 2016, Pages 1160-1166

The adequacy of provider networks for plans sold through insurance Marketplaces established under the Affordable Care Act has received much scrutiny recently. Various studies have established that networks are generally narrow. To learn more about network adequacy and access to care, we investigated two questions. First, no matter the nominal size of a network, can patients gain access to primary care services from providers of their choice in a timely manner? Second, how does access compare to plans sold outside insurance Marketplaces? We conducted a "secret shopper" survey of 743 primary care providers from five of California's nineteen insurance Marketplace pricing regions in the summer of 2015. Our findings indicate that obtaining access to primary care providers was generally equally challenging both inside and outside insurance Marketplaces. In less than 30 percent of cases were consumers able to schedule an appointment with an initially selected physician provider. Information about provider networks was often inaccurate. Problems accessing services for patients with acute conditions were particularly troubling. Effectively addressing issues of network adequacy requires more accurate provider information.


Share Of Specialty Drugs In Commercial Plans Nearly Quadrupled, 2003-14

Stacie Dusetzina

Health Affairs, July 2016, Pages 1241-1246

From 2003 to 2014 the proportion of specialty prescription drugs (defined as those reimbursed at $600 or more per thirty-day fill) nearly quadrupled. Over this time period, fills for specialty drugs increased by 198 percent and spending for the drugs increased by 292 percent, as percentages of total drug fills and spending. Median out-of-pocket spending increased by 46 percent for specialty drugs and decreased by 57 percent for nonspecialty drugs during this time.


Emergency Department Death Rates Dropped By Nearly 50 Percent, 1997-2011

Hemal Kanzaria, Marc Probst & Renee Hsia

Health Affairs, July 2016, Pages 1303-1308

Between 1997 and 2011, there was a nearly 50 percent reduction in US emergency department mortality rates for adults. This trend likely has many causes, related to advances in palliative, prehospital, and emergency care.


The anticipatory effects of Medicare Part D on drug utilization

Abby Alpert

Journal of Health Economics, September 2016, Pages 28-45

While health care policies are frequently signed into law well before they are implemented, such lags are ignored in most empirical work. This paper demonstrates the importance of implementation lags in the context of Medicare Part D, the prescription drug benefit that took effect two years after it was signed into law. Exploiting the differential responses of chronic and acute drugs to anticipated future prices, I show that individuals reduced drug utilization for chronic but not acute drugs in anticipation of Part D's implementation. Accounting for this anticipatory response substantially reduces the estimated total treatment effect of Part D.


Medicaid Expansion In 2014 Did Not Increase Emergency Department Use But Did Change Insurance Payer Mix

Jesse Pines et al.

Health Affairs, August 2016, Pages 1480-1486

In 2014 twenty-eight states and the District of Columbia had expanded Medicaid eligibility while federal and state-based Marketplaces in every state made subsidized private health insurance available to qualified individuals. As a result, about seventeen million previously uninsured Americans gained health insurance in 2014. Many policy makers had predicted that Medicaid expansion would lead to greatly increased use of hospital emergency departments (EDs). We examined the effect of insurance expansion on ED use in 478 hospitals in 36 states during the first year of expansion (2014). In difference-in-differences analyses, Medicaid expansion increased Medicaid-paid ED visits in those states by 27.1 percent, decreased uninsured visits by 31.4 percent, and decreased privately insured visits by 6.7 percent during the first year of expansion compared to nonexpansion states. Overall, however, total ED visits grew by less than 3 percent in 2014 compared to 2012-13, with no significant difference between expansion and nonexpansion states. Thus, the expansion of Medicaid coverage strongly affected payer mix but did not significantly affect overall ED use, even though more people gained insurance coverage in expansion states than in nonexpansion states. This suggests that expanding Medicaid did not significantly increase or decrease overall ED visit volume.


Impact of Massachusetts Health Reform on Enrollment Length and Health Care Utilization in the Unsubsidized Individual Market

Laura Garabedian et al.

Health Services Research, forthcoming

Objective: To evaluate the impact of the 2006 Massachusetts health reform, the model for the Affordable Care Act, on short-term enrollment and utilization in the unsubsidized individual health insurance market.

Data Source: Seven years of administrative and claims data from Harvard Pilgrim Health Care.

Research Design: We employed pre-post survival analysis and an interrupted time series design to examine changes in enrollment length, utilization patterns, and use of elective procedures (discretionary inpatient surgeries and infertility treatment) among nonelderly adult enrollees before (n = 6,912) and after (n = 29,207) the MA reform.

Principal Findings: The probability of short-term enrollment dropped immediately after the reform. Rates of inpatient encounters (HR = 0.83, 95 percent CI: 0.74, 0.93), emergency department encounters (HR = 0.85, 95 percent CI: 0.80, 0.91), and discretionary inpatient surgeries (HR = 0.66 95 percent CI: 0.45, 0.97) were lower in the postreform period, whereas the rate of ambulatory visits was somewhat higher (HR = 1.04, 95 percent CI: 1.00, 1.07). The rate of infertility treatment was higher after the reform (HR = 1.61, 95 percent CI: 1.33, 1.97), driven by women in individual (vs. family) plans. The reform was not associated with increased utilization among short-term enrollees.

Conclusions: MA health reform was associated with a decrease in short-term enrollment and changes in utilization patterns indicative of reduced adverse selection in the unsubsidized individual market. Adverse selection may be a problem for specific, high-cost treatments.


Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays

Laurence Baker et al.

Health Affairs, August 2016, Pages 1444-1451

There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines.


Favorable Risk Selection in Medicare Advantage: Trends in Mortality and Plan Exits Among Nursing Home Beneficiaries

Elizabeth Goldberg et al.

Medical Care Research and Review, forthcoming

The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans' incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates.


Primary Care Appointment Availability for Medicaid Patients: Comparing Traditional and Premium Assistance Plans

Simon Basseyn et al.

Medical Care, September 2016, Pages 878-883

Background: Arkansas and Iowa received waivers from the federal government in 2014 to use federal Medicaid expansion funding to enroll beneficiaries in commercial insurance plans on the Marketplaces. One key hypothesis of these "private option" or "premium assistance" programs was that Medicaid beneficiaries would experience increased access to care. In this study, we compare new patient primary care appointment availability and wait-times for beneficiaries of traditional Medicaid and premium assistance Medicaid.

Methods: Trained field staff posing as patients, randomized to traditional Medicaid or Marketplace plans, called primary care practices seeking new patient appointments in Arkansas and Iowa in May to July 2014. All calls were made to offices that previously indicated being in-network for the plan. Offices were drawn randomly, within insurance type, based on the county proportion of the population with each insurance type. We calculated appointment rates and wait-times for new patients for traditional Medicaid and Marketplace plans.

Results: In Arkansas, Marketplace appointment rates were 27.2 percentage points higher than traditional Medicaid appointment rates (83.2% compared with 55.5%, P<0.001), while in Iowa, Marketplace appointment rates were 12.0 percentage points higher (86.3% compared with 74.3%, P<0.001). Conditional on receiving an appointment, median wait-times were roughly 1 week in each state without significant differences by insurance type.

Conclusions: The experiences of Arkansas and Iowa suggest that enrolling Medicaid beneficiaries into Marketplace plans may lead to higher primary care appointment availability for new patients at participating providers. Further research is needed on whether premium assistance programs affect quality and continuity of care, and at what cost.


The Impact of Nursing Home Pay-for-Performance on Quality and Medicare Spending: Results from the Nursing Home Value-Based Purchasing Demonstration

David Grabowski et al.

Health Services Research, forthcoming

Objective: To evaluate the impact of the Nursing Home Value-Based Purchasing demonstration on quality of care and Medicare spending.

Data Sources/Study Setting: Administrative and qualitative data from Arizona, New York, and Wisconsin nursing homes over the base-year (2008-2009) and 3-year (2009-2012) demonstration period.

Study Design: Nursing homes were randomized to the intervention in New York, while the comparison facilities were constructed via propensity score matching in Arizona and Wisconsin. We used a difference-in-difference analysis to compare outcomes across the base-year relative to outcomes in each of the three demonstration years. To provide context and assist with interpretation of results, we also interviewed staff members at participating facilities.

Principal Findings: Medicare savings were observed in Arizona in the first year only and Wisconsin for the first 2 years; no savings were observed in New York. The demonstration did not systematically impact any of the quality measures. Discussions with nursing home administrators suggested that facilities made few, if any, changes in response to the demonstration, leading us to conclude that the observed savings likely reflected regression to the mean rather than true savings.

Conclusion: The Federal nursing home pay-for-performance demonstration had little impact on quality or Medicare spending.


Search and You Shall Find: Geographic Characteristics Associated With Google Searches During the Affordable Care Act's First Enrollment Period

Sarah Gollust et al.

Medical Care Research and Review, forthcoming

Previous studies indicate that Internet searching was a major source of information for the public during the launch of the Affordable Care Act, but little is known about geographic variation in searching. Our objective was to examine factors associated with health insurance-related Google searches in 199 U.S. metro areas during the first open enrollment period (October 2013 through March 2014), by merging data from Google Trends with metro-area-level and state-level characteristics. Our results indicate substantial geographic variation in the volumes of searching across the United States, and these patterns were related to local uninsurance rates. Specifically, areas with higher uninsurance rates were more likely to search in higher volumes for "Obamacare" and "health insurance," after adjusting for sociodemographic, political, and insurance market characteristics. The enormous political, advocacy, and media attention to the Affordable Care Act's launch may have contributed to heightened Internet search activity, particularly in areas characterized by higher uninsurance.


The Evolution of Physician Practice Styles: Evidence from Cardiologist Migration

David Molitor

NBER Working Paper, August 2016

Physician treatment choices for observably similar patients vary dramatically across regions. This paper exploits cardiologist migration to disentangle the role of physician-specific factors such as preferences and learned behavior versus environment-level factors such as hospital capacity and productivity spillovers on physician behavior. Physicians who start in the same region and subsequently move to dissimilar regions practice similarly before the move, but each percentage point change in practice environment results in an immediate 2/3 percentage point change in physician behavior, with no further changes over time. This suggests environment factors are twice as important as physician-specific factors for explaining regional disparities.


Does It Pay to Penalize Hospitals for Excess Readmissions? Intended and Unintended Consequences of Medicare's Hospital Readmissions Reductions Program

Jennifer Mellor, Michael Daly & Molly Smith

Health Economics, forthcoming

To incentivize hospitals to provide better quality care at a lower cost, the Affordable Care Act of 2010 included the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess 30-day readmissions for Medicare patients treated for certain conditions. We use triple difference estimation to identify the HRRP's effects in Virginia hospitals; this method estimates the difference in changes in readmission over time between patients targeted by the policy and a comparison group of patients and then compares those difference-in-differences estimates in patients treated at hospitals with readmission rates above the national average (i.e., those at risk for penalties) and patients treated at hospitals with readmission rates below or equal to the national average (those not at risk). We find that the HRRP significantly reduced readmission for Medicare patients treated for acute myocardial infarction (AMI). We find no evidence that hospitals delay readmissions, treat patients with greater intensity, or alter discharge status in response to the HRRP, nor do we find changes in the age, race/ethnicity, health status, and socioeconomic status of patients admitted for AMI. Future research on the specific mechanisms behind reduced AMI readmissions should focus on actions by healthcare providers once the patient has left the hospital.


Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety-Net Experience Different Than in the Non-Safety-Net?

Amresh Hanchate et al.

Health Services Research, forthcoming

Objective: Most inpatient care for the uninsured and other vulnerable subpopulations occurs in safety-net hospitals. As insurance expansion increases the choice of hospitals for the previously uninsured, we examined if Massachusetts health reform was associated with shifts in the volume of inpatient care from safety-net to non-safety-net hospitals overall, or among other vulnerable sociodemographic (racial/ethnic minority, low socioeconomic status, high uninsured rate area) and clinical subpopulations (emergent status, diagnosis).

Data Sources/Study Setting: Discharge records for adults discharged from all nonfederal acute care hospitals in Massachusetts, New Jersey, New York, and Pennsylvania 2004-2010.

Study Design: Using a difference-in-differences design, we compared pre-/post-reform changes in safety-net and non-safety-net hospital discharge outcomes in Massachusetts among adults 18-64 with corresponding changes in comparisons states with no reform, overall, and by subpopulations.

Principal Findings: Reform was not associated with changes in inpatient care use at safety-net and non-safety-net hospitals across all discharges or in most subpopulations examined.

Conclusions: Demand for inpatient care at safety-net hospitals may not decrease following insurance expansion. Whether this is due to other access barriers or patient preference needs to be explored.


Combined Regional Investments Could Substantially Enhance Health System Performance And Be Financially Affordable

Jack Homer et al.

Health Affairs, August 2016, Pages 1435-1443

Leaders across the United States face a difficult challenge choosing among possible approaches to transform health system performance in their regions. The ReThink Health Dynamics Model simulates how alternative scenarios could unfold through 2040. This article compares the likely consequences if four interventions were enacted in layered combinations in a prototypical midsize US city. We estimated the effects of efforts to deliver higher-value care; reinvest savings and expand global payment; enable healthier behaviors; and expand socioeconomic opportunities. Results suggest that there may be an effective and affordable way to unlock much greater health and economic potential, ultimately reducing severe illness by 20 percent, lowering health care costs by 14 percent, and improving economic productivity by 9 percent. This would require combined investments in clinical and population-level initiatives, coupled with financial agreements that reduce incentives for costly care and reinvest a share of the savings to ensure adequate long-term financing.


Advertising in Health Insurance Markets

Bradley Shapiro

University of Chicago Working Paper, June 2016

We study the effect of television ads in the market for health insurance for the elderly. Regulators are concerned about firms potentially using ads to "cream skim", or attract an advantageous risk pool as well as the potential for firms to use misinformation to take advantage of the elderly. On the other hand, ads could provide useful information or remind people to reconsider their options, making regulation potentially welfare reducing. Using the discontinuity in advertising exposure created by the borders of television markets, we estimate television advertising to have on average zero lift on the share of seniors who choose private Medicare Advantage (MA) plans over government-provided Traditional Medicare (TM) with enough precision to reject the null of positive ROI from market expansion. Leveraging the unilateral cessation of advertising by United Healthcare for three years, we additionally find that rival advertising provided zero average impact on United's brand share with enough precision to reject positive ROI from business stealing. Additionally, advertising is not more effective in counties with a healthier population, potentially easing the concern over cream skimming. The lack of advertising effect cannot be attributed to the shape of the advertising response curve or to long-run effects.


Accounting For Patients' Socioeconomic Status Does Not Change Hospital Readmission Rates

Susannah Bernheim et al.

Health Affairs, August 2016, Pages 1461-1470

There is an active public debate about whether patients' socioeconomic status should be included in the readmission measures used to determine penalties in Medicare's Hospital Readmissions Reduction Program (HRRP). Using the current Centers for Medicare and Medicaid Services methodology, we compared risk-standardized readmission rates for hospitals caring for high and low proportions of patients of low socioeconomic status (as defined by their Medicaid status or neighborhood income). We then calculated risk-standardized readmission rates after additionally adjusting for patients' socioeconomic status. Our results demonstrate that hospitals caring for large proportions of patients of low socioeconomic status have readmission rates similar to those of other hospitals. Moreover, readmission rates calculated with and without adjustment for patients' socioeconomic status are highly correlated. Readmission rates of hospitals caring for patients of low socioeconomic status changed by approximately 0.1 percent with adjustment for patients' socioeconomic status, and only 3-4 percent fewer such hospitals reached the threshold for payment penalty in Medicare's HRRP. Overall, adjustment for socioeconomic status does not change hospital results in meaningful ways.


The Effect of Occupational Licensing on Consumer Welfare: Early Midwifery Laws and Maternal Mortality

Mark Anderson et al.

NBER Working Paper, July 2016

Occupational licensing is intended to protect consumers. Whether it does so is an important, but unanswered, question. Exploiting variation across states and municipalities in the timing and details of midwifery laws introduced during the period 1900-1940, and using a rich data set that we assembled from primary sources, we find that requiring midwives to be licensed reduced maternal mortality by 6 to 7 percent. In addition, we find that requiring midwives to be licensed may have had led to modest reductions in nonwhite infant mortality and mortality among children under the age of 2 from diarrhea. These estimates provide the first econometric evidence of which we are aware on the relationship between licensure and consumer safety, and are directly relevant to ongoing policy debates both in the United States and in the developing world surrounding the merits of licensing midwives.


Impact of State Reporting Laws on Central Line-Associated Bloodstream Infection Rates in U.S. Adult Intensive Care Units

Hangsheng Liu et al.

Health Services Research, forthcoming

Objective: To examine the effect of mandated state health care-associated infection (HAI) reporting laws on central line-associated bloodstream infection (CLABSI) rates in adult intensive care units (ICUs).

Data Sources: We analyzed 2006-2012 adult ICU CLABSI and hospital annual survey data from the National Healthcare Safety Network. The final analytic sample included 244 hospitals, 947 hospital years, 475 ICUs, 1,902 ICU years, and 16,996 ICU months.

Principal Findings: Controlling for the overall time trend, ICUs in states with laws had lower CLABSI rates beginning approximately 6 months prior to the law's effective date (incidence rate ratio = 0.66; p < .001); this effect persisted for more than 6 1/2 years after the law's effective date. These findings were robust in secondary models and are likely to be attributed to changes in central line usage and/or resources dedicated to infection control.

Conclusions: Our results provide valuable evidence that state reporting requirements for HAIs improved care. Additional studies are needed to further explore why and how mandatory HAI reporting laws decreased CLABSI rates.


Competition, information, and quality: Evidence from nursing homes

Xin Zhao

Journal of Health Economics, September 2016, Pages 136-152

Economic theory suggests that competition and information can both be important for product quality, and yet evidence on how they may interact to affect quality is sparse. This paper estimates the impact of competition between nursing homes on their quality, and how this impact varies when consumers have better access to information. The effect of competition is identified using exogenous variation in the geographical proximity of nursing homes to their potential consumers. The change in information transparency is captured by the launch of the Five-Star Quality Rating System in 2009, which improved access to the quality information of nursing homes. We find that while the effect of competition on nursing home quality is generally rather limited, this effect becomes significantly stronger with increased information transparency. The results suggest that regulations on public quality reporting and on market structure are policy complements, and should be considered jointly to best improve quality.


The Affordable Care Act's Effects On The Formation, Expansion, And Operation Of Physician-Owned Hospitals

Elizabeth Plummer & William Wempe

Health Affairs, August 2016, Pages 1452-1460

The Affordable Care Act (ACA) imposed new restrictions on the formation and expansion of physician-owned hospitals. These restrictions provided incentives for the hospitals and their owners to take preemptive actions before the effective dates of ACA provisions and modify their operations thereafter. We studied 106 physician-owned hospitals in Texas to determine how they responded to ACA restrictions. We found that there were significant pre-ACA increases in the formation, physician ownership, and physical capacity of physician-owned hospitals, which suggests that they reacted quickly to the policy changes. After the ACA's provisions took effect, the hospitals improved the use of their assets to generate increased amounts of services, revenue, and profits. We found no evidence that existing physician-owned hospitals stopped accepting Medicare to avoid the ACA restrictions, although some investors adopted a seemingly unsuccessful strategy of not accepting Medicare at physician-owned hospitals formed after implementation of the ACA. We conclude that the ACA restrictions effectively eliminated the formation of new physician-owned hospitals, thus accomplishing what previous legislative efforts had failed to do.


Electronic Medical Records and Medical Procedure Choice: Evidence from Cesarean Sections

Seth Freedman & Noah Hammarlund

Indiana University Working Paper, July 2016

This paper examines how hospital adoption of Electronic Medical Records (EMRs) impacts medical procedure choice in the context of Cesarean section deliveries. It provides a unique contribution by tying the literature on EMR diffusion to the literature on the utilization of expensive medical technology. We exploit exogenous within-hospital variation in EMR adoption to estimate whether EMRs assists providers in matching patients to the most appropriate procedure, given their medical condition. We find that EMR adoption reduces C-section rates for low-risk mothers. However, we find this effect occurs predominantly in hospitals that were already performing fewer C-sections, and EMRs do not change the behavior of already high-intensity providers. Additional results suggest that our findings are driven by unscheduled C-sections, which are most likely to be impacted by EMRs within the hospital, and that some of the benefits of reduced low-risk C-section rates may be offset by increases in adverse health outcomes.


Variation in Physician Practice Styles within and across Emergency Departments

Jessica Van Parys

PLoS ONE, August 2016

Despite the significant responsibility that physicians have in healthcare delivery, we know surprisingly little about why physician practice styles vary within or across institutions. Estimating variation in physician practice styles is complicated by the fact that patients are rarely randomly assigned to physicians. This paper uses the quasi-random assignment of patients to physicians in emergency departments (EDs) to show how physicians vary in their treatment of patients with minor injuries. The results reveal a considerable degree of variation in practice styles within EDs; physicians at the 75th percentile of the spending distribution spend 20% more than physicians at the 25th percentile. Observable physician characteristics do not explain much of the variation across physicians, but there is a significant degree of sorting between physicians and EDs over time, with high-cost physicians sorting into high-cost EDs as they gain experience. The results may shed light on why some EDs remain persistently higher-cost than others.


Early Efforts By Medicare Accountable Care Organizations Have Limited Effect On Mental Illness Care And Management

Alisa Busch, Haiden Huskamp & Michael McWilliams

Health Affairs, July 2016, Pages 1247-1256

People with mental illness use more health care and have worse outcomes than those without such illnesses. In response to incentives to reduce spending, accountable care organizations (ACOs) may therefore attempt to improve their management of mental illness. We examined changes in mental health spending, utilization, and quality measures associated with ACO contracts in the Medicare Shared Savings Program and Pioneer model for beneficiaries with mental illness, using Medicare claims for the period 2008-13 and difference-in-differences comparisons with local non-ACO providers. Pioneer contracts were associated with lower spending on mental health admissions in the first year of the contract, an effect that was attenuated in the second year. Otherwise, ACO contracts were associated with no changes in mental health spending or readmissions, outpatient follow-up after mental health admissions, rates of depression diagnosis, or mental health status. These results suggest that ACOs have not yet focused on mental illness or have been largely unsuccessful in early efforts to improve their management of it.


Impact of ACA Insurance Coverage Expansion on Perforated Appendix Rates Among Young Adults

John Scott et al.

Medical Care, September 2016, Pages 818-826

Background: The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act allowed young adults to remain on their parents' health insurance plans until age 26 years. Although the provision improved coverage and survey-reported access to care, little is known regarding its impact on timely access for acute conditions. This study aims to assess changes in insurance coverage and perforation rates among young adults with acute appendicitis - an established metric for population-level health care access - after the DCP.

Methods: The National Inpatient Sample and difference-in-differences linear regression were used to assess prepolicy/postpolicy changes for policy-eligible young adults (aged 19-25 y) compared with a slightly older, policy-ineligible comparator group (aged 26-34 y).

Results: After adjustment for covariates, 19-25 year olds experienced a 3.6-percentage point decline in the uninsured rate after the DCP (baseline 22.5%), compared with 26-34 year olds (P<0.001). This coincided with a 1.4-percentage point relative decline in perforated appendix rate for 19-25 year olds (baseline 17.5%), compared with 26-34 year olds (P=0.023). All subgroups showed significant reductions in uninsured rates; however, statistically significant reductions in perforation rates were limited to racial/ethnic minorities, patients from lower-income communities, and patients presenting to urban teaching hospitals.

Conclusions: Reductions in uninsured rates among young adults after the DCP were associated with significant reductions in perforated appendix rates relative to a comparator group, suggesting that insurance expansion could lead to fewer delays in seeking and accessing care for acute conditions. Greater relative declines in perforation rates among the most at-risk subpopulations hold important implications for the use of coverage expansion to mitigate existing disparities in access to care.


Physician Assistant and Nurse Practitioner Malpractice Trends

Douglas Brock, Jeffrey Nicholson & Roderick Hooker

Medical Care Research and Review, forthcoming

Trends in malpractice awards and adverse actions (e.g., revocation of provider license) following an act or omission constituting medical error or negligence were examined. The National Practitioner Data Bank was used to compare rates of malpractice reports and adverse actions for physicians, physician assistants (PAs), and nurse practitioners (NPs). During 2005 through 2014, there ranged from 11.2 to 19.0 malpractice payment reports per 1,000 physicians, 1.4 to 2.4 per 1,000 PAs, and 1.1 to 1.4 per 1,000 NPs. Physician median payments ranged from 1.3 to 2.3 times higher than PAs or NPs. Diagnosis-related malpractice allegations varied by provider type, with physicians having significantly fewer reports (31.9%) than PAs (52.8%) or NPs (40.6%) over the observation period. Trends in malpractice payment reports may reflect policy enactments to decrease liability.

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