Losing patients

Kevin Lewis

October 07, 2019

The Trump Effect: Postinauguration Changes in Marketplace Enrollment
David Anderson & Paul Shafer
Journal of Health Politics, Policy & Law, October 2019, Pages 715-736

Methods: The authors used difference-in-differences and event-study models with weekly county-level Marketplace application data from 1,476 counties in 37 states to estimate the incremental enrollment loss in the postinauguration period.

Findings: Estimates indicate a population-weighted decline of over 700 applications per county-week during the final 2 weeks of the 2017 open enrollment period relative to 2016, corresponding to a nearly 30% decline in applications submitted. A more flexible event-study approach that better accounts for time shifting of enrollment across open enrollment periods found a similar decline of approximately 660 applications per county-week associated with the postinauguration period (−24%).

Does Medicare Coverage Improve Cancer Detection and Mortality Outcomes?
Rebecca Mary Myerson et al.
NBER Working Paper, September 2019

Medicare is the largest government insurance program in the United States, providing coverage for over 60 million people in 2018. This paper analyzes the effects of Medicare insurance on health for a group of people in urgent need of medical care – people with cancer. We used a regression discontinuity design to assess impacts of near-universal Medicare insurance at age 65 on cancer detection and outcomes, using population-based cancer registries and vital statistics data. Our analysis focused on the three tumor sites with recommended screening before and after age 65: breast, colorectal, and lung cancer. At age 65, cancer detection increased by 72 per 100,000 population among women and 33 per 100,000 population among men; cancer mortality also decreased by 9 per 100,000 population for women but did not significantly change for men. In a placebo check, we found no comparable changes at age 65 in Canada. This study provides the first evidence to our knowledge that near-universal access to Medicare at age 65 is associated with improvements in population-level cancer mortality, and provides new evidence on the differences in the impact of health insurance by gender.

The effect of the Affordable Care Act preexisting conditions provision on marriage
Matt Hampton & Otto Lenhart
Health Economics, forthcoming

This paper investigates the effect of the Affordable Care Act preexisting conditions provision on marriage. The policy was implemented to prevent insurers from denying insurance coverage to individuals with preexisting health conditions. We test whether the implementation of the provision led to decreases in marriage among affected adults. We add to earlier work on how marital behavior is influenced by spousal health insurance and examine for the presence of “marriage lock,” a situation in which individuals remain married primarily for insurance. Using longitudinal data from the Panel Study of Income Dynamics from 2009 to 2017 and estimating difference‐in‐differences models, we find that male household heads with preexisting conditions are 7.12 percentage points (8.9 percent) less likely to be married after the policy. Using information on insurance status prior to the policy change, we find significant reductions in marriage among individuals with preexisting conditions who were previously insured by spousal health insurance plans. The findings suggest that the inability to attain individual coverage and reliance on spousal insurance provided incentives to remain married before 2014.

Primary Care Physician Practice Styles and Patient Care: Evidence from Physician Exits in Medicare
Itzik Fadlon & Jessica Van Parys
NBER Working Paper, September 2019

Primary care physicians (PCPs) provide frontline health care to patients in the U.S.; however, it is unclear how their practice styles affect patient care. In this paper, we estimate the long-lasting effects of PCP practice styles on patient health care utilization by focusing on Medicare patients affected by PCP relocations or retirements, which we refer to as "exits." Observing where patients receive care after these exits, we estimate event studies to compare patients who switch to PCPs with different practice style intensities. We find that PCPs have large effects on a range of aggregate utilization measures, including physician and outpatient spending and the number of diagnosed conditions. Moreover, we find that PCPs have large effects on the quality of care that patients receive, and that all of these effects persist for several years. Our results suggest that switching to higher-quality PCPs could significantly affect patients' longer-run health outcomes.

Debt and Bargaining Outcomes: Evidence from U.S. Hospitals
Mitch Towner
Management Science, forthcoming

Using the healthcare industry as a novel laboratory, I study whether a firm’s use of debt enhances its bargaining power during negotiations with nonfinancial stakeholders. I find that reimbursement rates negotiated between a hospital and insurers for two homogeneous procedures are higher when the hospital has more debt. This relation is stronger among hospitals with less bargaining power relative to insurers ex ante. The evidence is consistent with the idea that debt improves a firm’s bargaining power.

Self-Regulation in the Pharmaceutical Industry: The Exposure of Children and Adolescents to Erectile Dysfunction Commercials
Denis Arnold & James Oakley
Journal of Health Politics, Policy & Law, October 2019, Pages 765-787

Methods: The authors measured recent industry spending on DTCA and used regression models of Nielsen Monitor-Plus data to assess pharmaceutical firm self-regulation after the public disclosure of noncompliance with industry self-regulatory principles, specifically regarding the exposure of children and adolescents to broadcast advertisements for erectile dysfunction drugs.

Findings: Public disclosure of noncompliance with self-regulatory DTCA standards did not bring advertising into compliance. Results demonstrate that firms failed to meet the industry standard during every quarter of the six-year period of this study.

Conclusions: Results support previous research findings that pharmaceutical self-regulation is a deceptive blocking strategy rather than a means for the industry to police itself. Policy recommendations include broadcast restrictions on adult content and deincentivizing DTCA via tax reform.

The Two Margin Problem in Insurance Markets
Michael Geruso et al.
NBER Working Paper, September 2019

Insurance markets often feature consumer sorting along both an extensive margin (whether to buy) and an intensive margin (which plan to buy). We present a new graphical theoretical framework that extends the workhorse model to incorporate both selection margins simultaneously. A key insight from our framework is that policies aimed at addressing one margin of selection often involve an economically meaningful trade-off on the other margin in terms of prices, enrollment, and welfare. For example, while a larger penalty for opting to remain uninsured reduces the uninsurance rate, it also tends to lead to unraveling of generous coverage because the newly insured are healthier and sort into less generous plans, driving down the relative prices of those plans. While risk adjustment transfers shift enrollment from lower- to higher-generosity plans, they also sometimes increase the uninsurance rate by raising the prices of less generous plans, which are the entry points into the market. We illustrate these trade-offs in an empirical sufficient statistics approach that is tightly linked to the graphical framework. Using data from Massachusetts, we show that in many policy environments these trade-offs can be empirically meaningful and can cause these policies to have unexpected consequences for overall social welfare.

Polypill for Cardiovascular Disease Prevention in an Underserved Population
Daniel Muñoz et al.
New England Journal of Medicine, 19 September 2019, Pages 1114-1123

Background: Persons with low socioeconomic status and nonwhite persons in the United States have high rates of cardiovascular disease. The use of combination pills (also called “polypills”) containing low doses of medications with proven benefits for the prevention of cardiovascular disease may be beneficial in such persons. However, few data are available regarding the use of polypill therapy in underserved communities in the United States, in which adherence to guideline-based care is generally low.

Methods: We conducted a randomized, controlled trial involving adults without cardiovascular disease. Participants were assigned to the polypill group or the usual-care group at a federally qualified community health center in Alabama. Components of the polypill were atorvastatin (at a dose of 10 mg), amlodipine (2.5 mg), losartan (25 mg), and hydrochlorothiazide (12.5 mg). The two primary outcomes were the changes from baseline in systolic blood pressure and low-density lipoprotein (LDL) cholesterol level at 12 months.

Results: The trial enrolled 303 adults, of whom 96% were black. Three quarters of the participants had an annual income below $15,000. The mean estimated 10-year cardiovascular risk was 12.7%, the baseline blood pressure was 140/83 mm Hg, and the baseline LDL cholesterol level was 113 mg per deciliter. The monthly cost of the polypill was $26. At 12 months, adherence to the polypill regimen, as assessed on the basis of pill counts, was 86%. The mean systolic blood pressure decreased by 9 mm Hg in the polypill group, as compared with 2 mm Hg in the usual-care group (difference, −7 mm Hg; 95% confidence interval [CI], −12 to −2; P=0.003). The mean LDL cholesterol level decreased by 15 mg per deciliter in the polypill group, as compared with 4 mg per deciliter in the usual-care group (difference, −11 mg per deciliter; 95% CI, −18 to −5; P<0.001).

Data breach remediation efforts and their implications for hospital quality
Sung Choi, Eric Johnson & Christoph Lehmann
Health Services Research, October 2019, Pages 971-980

Data Sources: Department of Health and Human Services’ (HHS) public database on hospital data breaches and Medicare Compare's public data on hospital quality measures for 2012‐2016.

Materials and Methods: Data breach data were merged with the Medicare Compare data for years 2012‐2016, yielding a panel of 3025 hospitals with 14 297 unique hospital‐year observations.

Study Design: The relationship between breach remediation and hospital quality was estimated using a difference‐in‐differences regression. Hospital quality was measured by 30‐day acute myocardial infarction mortality rate and time from door to electrocardiogram.

Principal Findings: Hospital time‐to‐electrocardiogram increased as much as 2.7 minutes and 30‐day acute myocardial infarction mortality increased as much as 0.36 percentage points during the 3‐year window following a breach.

Emergency Physician Practice Changes After Being Named in a Malpractice Claim
Jestin Carlson et al.
Annals of Emergency Medicine, forthcoming

Methods: We performed a retrospective difference-in-differences study comparing practice patterns of emergency physicians named in a malpractice claim and unnamed matched controls working contemporaneously in the same emergency departments (EDs), using data from a national emergency medicine management group (59 EDs in 11 US states from 2010 to 2015). We studied aggregate measures of care intensity (hospital admission rate and relative value units/visit), studied care speed (relative value units/hour and discharged patients’ length of stay), and assessed patient experience (monthly physician Press Ganey percentile rank).

Results: A total of 65 emergency physicians named in at least 1 malpractice claim and 140 matched controls met inclusion criteria. After the malpractice claim filing date, there were no significant changes in measures of care intensity or speed. However, named emergency physicians’ patient experience scores improved immediately after the malpractice claim filing date and showed sustained improvements by 6.52 Press Ganey percentile ranks (95% confidence interval 0.67 to 12.38), with the increase most prominent among those involved in the 46 failure-to-diagnose claims (10.52; 95% confidence interval 3.72 to 17.32).

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