Professor, Health Research & Policy
Senior Fellow, Stanford Institute for Economic Policy Research
Department Chair, Department of Health Research and Policy (2015 - Present)
Catherine R. Kennedy and Daniel L. Grossman Fellow in Human Biology, Human Biology Program (2016 - Present)
Senior Fellow, Stanford Institute for Economic Policy Research (2015 - Present)
Fellow, Stanford Center for Health Policy (2000 - Present)
Research Associate, National Bureau of Economic Research (2002 - Present)
Director of the Scholarly Concentration Program, Stanford University (2007 - Present)
Chief of Health Services Research, Department of Health Research and Policy (2001 - 2015)
Honors & Awards
NIHCM Research Award, National Institute for Health Care Management (1999)
Alice S. Hersh Young Investigator Award, Academy for Health Services Research and Health Policy (2000)
ASHE Medal, American Society of Health Economists (2008)
PhD, Princeton University, Economics (1994)
MA, Princeton University, Economics (1994)
Current Research and Scholarly Interests
Much of my current research examines the impacts of changing financial incentives, regulations, and organizational structures on health care provision and costs. One aspect of work in this area involves studying impacts of managed care and related insurance arrangements on things like health care costs, the pricing of physician services, prices for health insurance, and the availability and utilization of medical technologies. Other work examines factors influencing the adoption and use of medical technologies more generally, including particular work on imaging equipment. I am also interested in a range of other questions about health care systems, physicians organizations, provider compensation, health care cost growth, and health care quality.
- Environmental and Health Policy Analysis
HUMBIO 4B (Spr)
Independent Studies (8)
- Directed Reading in Health Research and Policy
HRP 299 (Aut, Win, Spr, Sum)
- Graduate Research
HRP 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
HRP 370 (Aut, Win, Spr, Sum)
- Medical Scholars Research (Away)
MED 370W (Sum)
- Medical Scholars Research (Away)
OBGYN 370W (Sum)
- Medical Scholars Research (Away)
OTOHNS 370W (Sum)
- Second Year Health Policy PHD Tutorial
HRP 800 (Aut, Win, Spr)
- Undergraduate Research
HRP 199 (Aut, Win, Spr, Sum)
- Directed Reading in Health Research and Policy
Prior Year Courses
- Environmental and Health Policy Analysis
HUMBIO 4B (Spr)
- Environmental and Health Policy Analysis
HUMBIO 4B (Spr)
- Innovation in Healthcare Venture Capital Investing
STRAMGT 307 (Aut)
- Environmental and Health Policy Analysis
Under-Utilization of Routine Ultrasound Surveillance after Endovascular Aortic Aneurysm Repair.
Annals of vascular surgery
Since 2009, the Society for Vascular Surgery has advocated annual surveillance imaging with ultrasound (US) after the first postoperative year for uncomplicated endovascular aneurysm repairs (EVARs). We sought to describe diffusion of US into long-term routine surveillance and to estimate potential cost savings among Medicare beneficiaries after EVAR.Using Medicare claims data, we identified patients receiving EVAR from 2002 to 2010 and included only those who did not subsequently have reinterventions, late aneurysm-related complications, or death. We collected all relevant postoperative imaging (computed tomography [CT] and US) through 2011. Patients with follow-up less than 1 year were excluded. We estimated cost savings with increased use of US after the first postoperative year.The cohort comprised 24,615 patients with a mean follow-up of 3.9 ± 2.3 years. Mean number of images decreased from 2.23 in the first postoperative year to 0.31 in the 10th year. Utilization of US at the first postoperative year remained low but increased from 15.2% in 2003 to 28.8% in 2011 (P < 0.001). By the 10th postoperative year, the proportion of patients receiving US increased from 8.2% to 37.8%, while use of CT only remained high but decreased from 60.8% to 42.1%. Mean cost of surveillance imaging was $2,132/CT and $234/US. Performing US in 50-75% of patients beginning 1 year after EVAR would decrease costs by 14-48%/year. This translates to a mean cost savings of $338-$1135 per imaged patient per year, with an estimated savings to Medicare of $155 million to $305 million over 10 years.CT remains the primary modality of surveillance for up to 10 years after EVAR for patients without reinterventions or aneurysm-related complications. Increasing the use of US and decreasing the use of CT would save cost without compromising outcomes.
View details for DOI 10.1016/j.avsg.2017.03.203
View details for PubMedID 28501663
Lack of Association Between the Use of Nerve Blockade and the Risk of Postoperative Chronic Opioid Use Among Patients Undergoing Total Knee Arthroplasty: Evidence from the Marketscan Database.
Anesthesia and analgesia
Total knee arthroplasty (TKA) is associated with high rates of prolonged opioid use after surgery (10%-34%). By decreasing opioid use in the immediate postoperative period, perioperative nerve blockade has been hypothesized to decrease the risk of persistent opioid use.Using health care utilization data, we constructed a sample of 120,080 patients undergoing TKA between 2002 and 2012 and used billing data to identify the utilization of peripheral or neuraxial blockade. We then used a multivariable logistic regression to estimate the association between nerve blockade and the risk of chronic opioid use, defined as having filled ≥10 prescriptions or ≥120 days' supply for an opioid in the first postsurgical year. Our analyses were adjusted for an extensive set of potential confounding variables, including -medical comorbidities, previous opioid use, and previous use of other medications.We did not find an association between nerve blockade and the risk of postsurgical chronic opioid use across any of these 3 groups: adjusted relative risk (ARR) 0.984 for patients opioid-naïve in the year before surgery (98.3% confidence interval [CI], 0.870-1.12, P = .794), ARR 1.02 for intermittent opioid users (98.3% CI, 0.948-1.09, P = .617), and ARR 0.986 (98.3% CI, 0.963-1.01, P = .257) for chronic opioid users. Similar results held for alternative measures of postsurgical opioid use.Although the use of perioperative nerve blockade for TKA may improve short-term outcomes, the analyzed types of blocks do not appear to decrease the risk of persistent opioid use in the longer term.
View details for DOI 10.1213/ANE.0000000000001943
View details for PubMedID 28430692
Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis
BMJ-BRITISH MEDICAL JOURNAL
Objectives To identify trends in concurrent use of a benzodiazepine and an opioid and to identify the impact of these trends on admissions to hospital and emergency room visits for opioid overdose.Design Retrospective analysis of claims data, 2001-13.Setting Administrative health claims database.Participants 315 428 privately insured people aged 18-64 who were continuously enrolled in a health plan with medical and pharmacy benefits during the study period and who also filled at least one prescription for an opioid.Interventions Concurrent benzodiazepine/opioid use, defined as an overlap of at least one day in the time periods covered by prescriptions for each drug. Main outcome measures Annual percentage of opioid users with concurrent benzodiazepine use; annual incidence of visits to emergency room and inpatient admissions for opioid overdose.Results 9% of opioid users also used a benzodiazepine in 2001, increasing to 17% in 2013 (80% relative increase). This increase was driven mainly by increases among intermittent, as opposed to chronic, opioid users. Compared with opioid users who did not use benzodiazepines, concurrent use of both drugs was associated with an increased risk of an emergency room visit or inpatient admission for opioid overdose (adjusted odds ratio 2.14, 95% confidence interval 2.05 to 2.24; P<0.001) among all opioid users. The adjusted odds ratio for an emergency room visit or inpatient admission for opioid overdose was 1.42 (1.33 to 1.51; P<0.001) for intermittent opioid users and 1.81 (1.67 to 1.96; P<0.001) chronic opioid users. If this association is causal, elimination of concurrent benzodiazepine/opioid use could reduce the risk of emergency room visits related to opioid use and inpatient admissions for opioid overdose by an estimated 15% (95% confidence interval 14 to 16).Conclusions From 2001 to 2013, concurrent benzodiazepine/opioid use sharply increased in a large sample of privately insured patients in the US and significantly contributed to the overall population risk of opioid overdose.
View details for DOI 10.1136/bmj.j760
View details for Web of Science ID 000397014900002
View details for PubMedID 28292769
"Opt Out" and Access to Anesthesia Care for Elective and Urgent Surgeries among U.S. Medicare Beneficiaries.
2017; 126 (3): 461-471
In 2001, the Centers for Medicare and Medicaid Services issued a rule allowing U.S. states to "opt out" of the regulations requiring physician supervision of nurse anesthetists in an effort to increase access to anesthesia care. Whether "opt out" has successfully achieved this goal remains unknown.Using Medicare administrative claims data, we examined whether "opt out" reduced the distance traveled by patients, a common measure of access, for patients undergoing total knee arthroplasty, total hip arthroplasty, cataract surgery, colonoscopy/sigmoidoscopy, esophagogastroduodenoscopy, appendectomy, or hip fracture repair. In addition, we examined whether "opt out" was associated with an increase in the use of anesthesia care for cataract surgery, colonoscopy/sigmoidoscopy, or esophagogastroduodenoscopy. Our analysis used a difference-in-differences approach with a robust set of controls to minimize confounding."Opt out" did not reduce the percentage of patients who traveled outside of their home zip code except in the case of total hip arthroplasty (2.2% point reduction; P = 0.007). For patients travelling outside of their zip code, "opt out" had no significant effect on the distance traveled among any of the procedures we examined, with point estimates ranging from a 7.9-km decrease for appendectomy (95% CI, -19 to 3.4; P = 0.173) to a 1.6-km increase (95% CI, -5.1 to 8.2; P = 0.641) for total hip arthroplasty. There was also no significant effect on the use of anesthesia for esophagogastroduodenoscopy, appendectomy, or cataract surgery."Opt out" was associated with little or no increased access to anesthesia care for several common procedures.
View details for DOI 10.1097/ALN.0000000000001504
View details for PubMedID 28106610
Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release.
journal of bone and joint surgery. American volume
2016; 98 (23): 1970-1977
Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost.We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test.Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001).Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique.Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.
View details for PubMedID 27926678
The effect of hospital/physician integration on hospital choice
JOURNAL OF HEALTH ECONOMICS
2016; 50: 1-8
In this paper, we estimate how hospital ownership of physicians' practices affects their patients' hospital choices. We match data on the hospital admissions of Medicare beneficiaries, including the identity of their physician, with data on the identity of the owner of their physician's practice. We find that a hospital's ownership of a physician dramatically increases the probability that the physician's patients will choose the owning hospital. We also find that patients are more likely to choose a high-cost, low-quality hospital when their physician is owned by that hospital.
View details for DOI 10.1016/j.jhealeco.2016.08.006
View details for Web of Science ID 000390500800001
View details for PubMedID 27639202
Hospital Ownership of Physicians: Hospital Versus Physician Perspectives.
Medical care research and review
Although there has been significant interest from health services researchers and policy makers about recent trends in hospitals' ownership of physician practices, few studies have investigated the strengths and weaknesses of available data sources. In this article, we compare results from two national surveys that have been used to assess ownership patterns, one of hospitals (the American Hospital Association survey) and one of physicians (the SK&A survey). We find some areas of agreement, but also some disagreement, between the two surveys. We conclude that full understanding of the causes and consequences of hospital ownership of physicians requires data collected at the both the hospital and the physician level. The appropriate measure of integration depends on the research question being investigated.
View details for PubMedID 27811140
Public Reporting of Hospital-Level Cancer Surgical Volumes in California: An Opportunity to Inform Decision Making and Improve Quality.
Journal of oncology practice
Most patients, providers, and payers make decisions about cancer hospitals without any objective data regarding quality or outcomes. We developed two online resources allowing users to search and compare timely data regarding hospital cancer surgery volumes.Hospital cancer surgery volumes for all California hospitals were calculated using ICD-9 coded hospital discharge summary data. Cancer surgeries included (bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach) were selected on the basis of a rigorous literature review to confirm sufficient evidence of a positive association between volume and mortality. The literature could not identify threshold numbers of surgeries associated with better or worse outcomes. A multidisciplinary working group oversaw the project and ensured sound methodology.In California in 2014, about 60% of surgeries were performed at top-quintile-volume hospitals, but the per-hospital median numbers of surgeries for esophageal, pancreatic, stomach, liver, or bladder cancer surgeries were four or fewer. At least 670 patients received cancer surgery at hospitals that performed only one or two surgeries for a particular cancer type; 72% of those patients lived within 50 miles of a top-quintile-volume hospital.There is clear potential for more readily available information about hospital volumes to help patient, providers, and payers choose cancer surgery hospitals. Our successful public reporting of hospital volumes in California represents an important first step toward making publicly available even more provider-specific data regarding cancer care quality, costs, and outcomes, so those data can inform decision-making and encourage quality improvement.
View details for PubMedID 27601510
Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period.
JAMA internal medicine
2016; 176 (9): 1286-1293
Chronic opioid use imposes a substantial burden in terms of morbidity and economic costs. Whether opioid-naive patients undergoing surgery are at increased risk for chronic opioid use is unknown, as are the potential risk factors for chronic opioid use following surgery.To characterize the risk of chronic opioid use among opioid-naive patients following 1 of 11 surgical procedures compared with nonsurgical patients.Retrospective analysis of administrative health claims to determine the association between chronic opioid use and surgery among privately insured patients between January 1, 2001, and December 31, 2013. The data concluded 11 surgical procedures (total knee arthroplasty [TKA], total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery [FESS], cataract surgery, transurethral prostate resection [TURP], and simple mastectomy). Multivariable logistic regression analysis was performed to control for possible confounders, including sex, age, preoperative history of depression, psychosis, drug or alcohol abuse, and preoperatice use of benzodiazepines, antipsychotics, and antidepressants.One of the 11 study surgical procedures.Chronic opioid use, defined as having filled 10 or more prescriptions or more than 120 days' supply of an opioid in the first year after surgery, excluding the first 90 postoperative days. For nonsurgical patients, chronic opioid use was defined as having filled 10 or more prescriptions or more than 120 days' supply following a randomly assigned "surgery date."The study included 641 941 opioid-naive surgical patients (169 666 men; mean [SD] age, 44.0 [12.8] years), and 18 011 137 opioid-naive nonsurgical patients (8 849 107 men; mean [SD] age, 42.4 [12.6] years). Among the surgical patients, the incidence of chronic opioid in the first preoperative year ranged from 0.119% for Cesarean delivery (95% CI, 0.104%-0.134%) to 1.41% for TKA (95% CI, 1.29%-1.53%) The baseline incidence of chronic opioid use among the nonsurgical patients was 0.136% (95% CI, 0.134%-0.137%). Except for cataract surgery, laparoscopic appendectomy, FESS, and TURP, all of the surgical procedures were associated with an increased risk of chronic opioid use, with odds ratios ranging from 1.28 (95% CI, 1.12-1.46) for cesarean delivery to 5.10 (95% CI, 4.67-5.58) for TKA. Male sex, age older than 50 years, and preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use were associated with chronic opioid use among surgical patients.In opioid-naive patients, many surgical procedures are associated with an increased risk of chronic opioid use in the postoperative period. A certain subset of patients (eg, men, elderly patients) may be particularly vulnerable.
View details for DOI 10.1001/jamainternmed.2016.3298
View details for PubMedID 27400458
Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays.
2016; 35 (8): 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.
View details for DOI 10.1377/hlthaff.2015.1553
View details for PubMedID 27503970
Increased risk of incident chronic medical conditions in infertile men: analysis of United States claims data
FERTILITY AND STERILITY
2016; 105 (3): 629-636
To determine the incidence of chronic medical conditions of men with infertility.Retrospective cohort study.Not applicable.Subjects contained within the Truven Health MarketScan claims database from 2001 to 2009.Not applicable.The development of chronic medical conditions including hypertension, diabetes, hyperlipidemia, renal disease, pulmonary disease, liver disease, depression, peripheral vascular disease, cerebrovascular disease, heart disease, injury, alcohol abuse, drug abuse, anxiety disorders, and bipolar disorder.In all, 13,027 men diagnosed with male factor infertility were identified with an additional 23,860 receiving only fertility testing. The average age was 33.1 years for men diagnosed with infertility and 32.8 years for men receiving testing alone. After adjusting for confounding factors, men diagnosed with male factor infertility had a higher risk of developing diabetes (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.10-1.53), ischemic heart disease (HR 1.48, 95% CI 1.19-1.84), alcohol abuse (HR 1.48, 95% CI 1.07-2.05), and drug abuse (1.67, 95% CI 1.06-2.63) compared with men who only received infertility testing. Similar patterns were identified when comparing those with male factor infertility to vasectomized men. The association between male factor infertility and later health outcomes were strongest for men with longer follow-up.In this cohort of patients in a national insurance database, men diagnosed with male factor infertility had a significantly higher risk of adverse health outcomes in the years after an infertility evaluation. These findings suggest the overall importance of men's reproductive health and warrant additional investigation to understand the association and identify interventions to improve outcomes for these patients.
View details for DOI 10.1016/j.fertnstert.2015.11.011
View details for Web of Science ID 000373406300015
View details for PubMedID 26674559
- Does health plan generosity enhance hospital market power? JOURNAL OF HEALTH ECONOMICS 2015; 44: 54-62
Postoperative Surveillance and Long-term Outcomes After Endovascular Aneurysm Repair Among Medicare Beneficiaries
2015; 150 (10): 957-963
The Society for Vascular Surgery recommends annual surveillance with computed tomography (CT) or ultrasonography after endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysms. However, such lifelong surveillance may be unnecessary for most patients, thereby contributing to overuse of imaging services.To investigate whether nonadherence to Society for Vascular Surgery-recommended surveillance guidelines worsens long-term outcomes after EVAR among Medicare beneficiaries.We collected data from Medicare claims from January 1, 2002, through December 31, 2011. A total of 9503 patients covered by fee-for-service Medicare who underwent EVAR from January 1, 2002, through December 31, 2005, were categorized as receiving complete or incomplete surveillance. We performed logistic regressions controlling for patient demographic and hospital characteristics. Patients were then matched by propensity score with adjusting for all demographic variables, including age, sex, race, Medicaid eligibility, residential status, hospital volume, ruptured abdominal aortic aneurysms, and all preexisting comorbidities. We then calculated differences in long-term outcomes after EVAR between adjusted groups. Data analysis was performed from January 1, 2002, through December 31, 2011.Post-EVAR imaging modality, aneurysm-related mortality, late rupture, and complications.Median follow-up duration was 6.1 years. Incomplete surveillance was observed in 5526 of 9695 patients (57.0%) who survived the initial hospital stay at a mean (SD) of 5.2 (2.9) years after EVAR. After propensity matching, our cohort consisted of 7888 patients, among whom 3944 (50.0%) had incomplete surveillance. For those in the matched cohort, patients with incomplete surveillance had a lower incidence of late ruptures (26 of 3944 [0.7%] vs 57 of 3944 [1.4%]; P = .001) and major or minor reinterventions (46 of 3944 [1.2%] vs 246 of 3944 [6.2%]; P < .001) in unadjusted analysis. Aneurysm-related mortality was not statistically different between groups (13 of 3944 [0.3%] vs 24 of 3944 [0.6%]; P = .07). In adjusted analysis of postoperative outcomes controlling for all patient and hospital factors by the tenth postoperative year, patients in the incomplete surveillance group experienced lower rates of total complications (2.1% vs 14.0%; P < .001), late rupture (1.1% vs 5.3%; P < .001), major or minor reinterventions (1.4% vs 10.0%; P < .001), aneurysm-related mortality (0.4% vs 1.3%; P < .001), and all-cause mortality (30.9% vs 68.8%, P < .001).Nonadherence to the Society for Vascular Surgery guidelines for post-EVAR imaging was not associated with poor outcomes, suggesting that, in many patients, less frequent surveillance is not associated with worse outcomes. Improved criteria for defining optimal surveillance will achieve higher value in aneurysm care.
View details for DOI 10.1001/jamasurg.2015.1320
View details for Web of Science ID 000367585200008
- Less Physician Practice Competition Is Associated With Higher Prices Paid For Common Procedures. Health affairs 2015; 34 (10): 1753-1760
- No Significant Association between Anesthesia Group Concentration and Private Insurer Payments in the United States ANESTHESIOLOGY 2015; 123 (3): 507-514
- ANTITRUST FOR ACCOUNTABLE CARE ORGANIZATIONS JOURNAL OF COMPETITION LAW & ECONOMICS 2015; 11 (2): 317-329
Concentration In Orthopedic Markets Was Associated With A 7 Percent Increase In Physician Fees For Total Knee Replacements
2015; 34 (6): 916-921
Physician groups are growing larger in size and fewer in number. Although this consolidation could result in improved patient care, the resulting increase in market concentration also could allow larger groups to negotiate higher physician fees from private insurers. We examined the association between market concentration and physician fees in the case of total knee arthroplasty by calculating market concentration for orthopedic groups practicing in a given market and by analyzing administrative claims data from Marketscan. In the period 2001-10 the average professional fee for total knee arthroplasty was $2,537. During this time, in markets that moved from the bottom quartile of concentration to the top quartile, physician fees paid by private payers increased by $168 per procedure. The increase nearly offset the $261 decline in fees that we observed, absent changes in market concentration. These findings suggest that caution should be used in implementing policies designed to encourage further group concentration, which could produce similar effects.
View details for DOI 10.1377/hlthaff.2014.1325
View details for Web of Science ID 000358453800004
Increased Risk of Cancer in Infertile Men: Analysis of US Claims Data
JOURNAL OF UROLOGY
2015; 193 (5): 1596-1601
Aberrations in reproductive fitness may be a harbinger of medical diseases in men. Data suggest a higher risk of testicular cancer in infertile men. However, the relationship between infertility and other cancers remains uncertain.We analyzed subjects from the Truven Health MarketScan® claims database from 2001 to 2009. Infertile men were identified through diagnosis and treatment codes. Comparison groups were created of men who underwent vasectomy and a control cohort of men who were not infertile and had not undergone vasectomy. The incidence of cancer was compared to national U.S. estimates. Infertile men were also compared to men who underwent vasectomy and the control cohort using a Cox regression model.A total of 76,083 infertile men were identified with an average age of 35.1 years. Overall 112,655 men who underwent vasectomy and 760,830 control men were assembled. Compared to age adjusted national averages, infertile, vasectomy and control subjects in the study cohorts had higher rates of all cancers and many individual cancers. In time to event analysis, infertile men had a higher risk of cancer than those who underwent vasectomy or controls. Infertile men had a higher risk of testis cancer, nonHodgkin lymphoma and all cancers than the vasectomy and control groups.Consistent with prior reports, we identified an increased risk of testicular cancer in infertile men. The current data also suggest that infertile men are at a mildly increased risk of all cancers in the years after infertility evaluation. Future research should focus on confirming these associations and elucidating pathways between infertility and cancer.
View details for DOI 10.1016/j.juro.2014.11.080
View details for Web of Science ID 000353113200052
View details for PubMedID 25463997
California Emergency Department Visit Rates For Medical Conditions Increased While Visit Rates For Injuries Fell, 2005-11
2015; 34 (4): 621-626
The emergency department (ED) is the source of most hospital admissions; provides care for patients with no other point of access to the health care system; receives advanced care referrals from primary care physicians; and provides surveillance data on injuries, infectious diseases, violence, and adverse drug events. Understanding the changes in the profile of disease in the ED can inform emergency services administration and planning and can provide insight into the public's health. We analyzed the trends in the diagnoses seen in California EDs from 2005 to 2011, finding that while the ED visit rate for injuries decreased by 0.7 percent, the rate of ED visits for noninjury diagnoses rose 13.4 percent. We also found a rise in symptom-related diagnoses, such as abdominal pain, along with nervous system disorders, gastrointestinal disease, and mental illness. These trends point out the increasing importance of EDs in providing care for complex medical cases, as well as the changing nature of illness in the population needing immediate medical attention.
View details for DOI 10.1377/hlthaff.2014.0471
View details for Web of Science ID 000354792900012
View details for PubMedID 25847645
Impact of including readmissions for qualifying events in the patient safety indicators.
American journal of medical quality
2015; 30 (2): 114-118
The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) do not capture complications arising after discharge. This study sought to quantify the bias related to omission of readmissions for PSI-qualifying conditions. Using 2000-2009 California Office of Statewide Health Planning and Development Patient Discharge Data, the study team examined the change in PSI rates when including readmissions in the numerator, hospitals performing in the extreme deciles, and longitudinal performance. Including 7-day readmissions resulted in a 0.3% to 8.9% increase in average hospital PSI rates. Hospital PSI rates with and without PSI-qualifying 30-day readmissions were highly correlated for point estimates and within-hospital longitudinal change. Most hospitals remained in the same relative performance decile. Longer length of stay, public payer, and discharge to skilled nursing facilities were associated with a higher risk of readmission for a PSI-qualifying event. Failure to include readmissions in calculating PSIs is unlikely to lead to erroneous conclusions.
View details for DOI 10.1177/1062860613518341
View details for PubMedID 24463327
Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations.
2015; 34 (2): 229-238
While new biologics have revolutionized the treatment of age-related macular degeneration-the leading cause of severe vision loss among older adults-these new drugs have also raised concerns over the economic impact of medical innovation. The two leading agents are similar in effectiveness but vary greatly in price-up to $2,000 per injection for ranibizumab compared to $50 for bevacizumab. We examined the diffusion of these drugs in fee-for-service Medicare and Veterans Affairs (VA) systems during 2005-11, in part to assess the impact that differing financial incentives had on prescribing. Physicians treating Medicare patients have a direct financial incentive to prescribe the more expensive agent (ranibizumab), while VA physicians do not. Medicare injections of the more expensive ranibizumab peaked in 2007 at 47 percent. Beginning in 2009 the less expensive bevacizumab became the predominant therapy for Medicare patients, accounting for more than 60 percent of injections. For VA patients, the distribution of injections across the two drugs was relatively equal, particularly from 2009 to 2011. Our analysis indicates that there are opportunities in both the VA and Medicare to adopt more value-conscious treatment patterns and that multiple mechanisms exist to influence utilization.
View details for DOI 10.1377/hlthaff.2014.1032
View details for PubMedID 25646102
- Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs 2015; 34 (2): 229-238
- EXPANDING PATIENTS' PROPERTY RIGHTS IN THEIR MEDICAL RECORDS AMERICAN JOURNAL OF HEALTH ECONOMICS 2015; 1 (1): 82-100
Adherence to postoperative surveillance guidelines after endovascular aortic aneurysm repair among Medicare beneficiaries
JOURNAL OF VASCULAR SURGERY
2015; 61 (1): 23-27
After endovascular aortic aneurysm repair (EVAR), the Society for Vascular Surgery recommends a computed tomography (CT) scan ≤30 days, followed by annual imaging. We sought to describe long-term adherence to surveillance guidelines among United States Medicare beneficiaries and determine patient and hospital factors associated with incomplete surveillance.We analyzed fee-for-service Medicare claims for patients receiving EVAR from 2002 to 2005 and collected all relevant postoperative imaging through 2011. Additional data included patient comorbidities and demographics, yearly hospital volume of abdominal aortic aneurysm repair, and Medicaid eligibility. Allowing a grace period of 3 months, complete surveillance was defined as at least one CT or ultrasound assessment every 15 months after EVAR. Incomplete surveillance was categorized as gaps for intervals >15 months between consecutive images as or lost to follow-up if >15 months elapsed after the last imaging.Our cohort comprised 9695 patients. Median follow-up duration was 6.1 years. A CT scan ≤30 days of EVAR was performed in 3085 (31.8%) patients and ≤60 days in 60.8%. The median time to the postoperative CT was 38 days (interquartile range, 25-98 days). Complete surveillance was observed in 4169 patients (43.0%). For this group, the mean follow-up time was shorter than for those with incomplete surveillance (3.4 ± 2.74 vs 6.5 ± 2.1 years; P < .001). Among those with incomplete surveillance, follow-up became incomplete at 3.3 ± 1.9 years, with 57.6% lost to follow-up, 64.1% with gaps in follow-up (mean gap length, 760 ± 325 days), and 37.6% with both. A multivariable analysis showed incomplete surveillance was independently associated with Medicaid eligibility (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.29-1.55; P < .001), low-volume hospitals (HR, 1.12; 95% CI, 1.05-1.20; P < .001), and ruptured abdominal aortic aneurysm (HR, 1.51; 95% CI, 1.24-1.84; P < .001).Postoperative imaging after EVAR is highly variable, and less than half of patients meet current surveillance guidelines. Additional studies are necessary to determine if variability in postoperative surveillance affects long-term outcomes.
View details for DOI 10.1016/j.jvs.2014.07.003
View details for Web of Science ID 000346637600004
View details for PubMedID 25088738
Impact of drug-eluting stents on the comparative effectiveness of coronary artery bypass surgery and percutaneous coronary intervention
AMERICAN HEART JOURNAL
2015; 169 (1): 149-154
Drug-eluting stents (DES) have largely replaced bare-metal stents (BMS) for percutaneous coronary intervention (PCI). It is uncertain, however, whether introduction of DES had a significant impact on the comparative effectiveness of PCI versus coronary artery bypass graft surgery (CABG) for death and myocardial infarction (MI).We identified Medicare beneficiaries aged ≥66 years who underwent multivessel CABG or multivessel PCI and matched PCI and CABG patients on propensity score. We defined the BMS era as January 1999 to April 2003 and the DES era as May 2003 to December 2006. We compared 5-year outcomes of CABG and PCI using Cox proportional hazards models, adjusting for baseline characteristics and year of procedure and tested for a statistically significant interaction (P(int)) of DES era with treatment (CABG or PCI).Five-year survival improved from the BMS era to the DES era by 1.2% for PCI and by 1.1% for CABG, and the CABG:PCI hazard ratio was unchanged (0.90 vs 0.90; P(int) = .96). Five-year MI-free survival improved by 1.4% for PCI and 1.1% for CABG, with no change in the CABG:PCI hazard ratio (0.81 vs 0.82; P(int) = .63). By contrast, survival-free of MI or repeat coronary revascularization improved from the BMS era to the DES era by 5.7% for PCI and 0.9% for CABG, and the CABG:PCI hazard ratio changed significantly (0.50 vs 0.57, P(int) ≤ .0001).The introduction of DES did not alter the comparative effectiveness of CABG and PCI with respect to hard cardiac outcomes.
View details for DOI 10.1016/j.ahj.2014.10.004
View details for Web of Science ID 000346124400022
View details for PubMedID 25497260
- Physician Practice Competition and Prices Paid by Private Insurers for Office Visits JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2014; 312 (16): 1653-1662
- Emergency department visits by children, adolescents, and young adults in California by insurance status, 2005-2010. JAMA 2014; 312 (15): 1587-1588
- The Affordable Care Act Reduces Emergency Department Use By Young Adults: Evidence From Three States HEALTH AFFAIRS 2014; 33 (9): 1648-1654
Payer Status, Preoperative Surveillance, and Rupture of Abdominal Aortic Aneurysms in the US Medicare Population.
Annals of vascular surgery
2014; 28 (6): 1378-1383
To determine the factors contributing to increased rate of ruptured abdominal aortic aneurysms (AAAs) for elderly poor patients.Medicare claims were analyzed for patients who underwent AAA repair from 2006 to 2009 with preoperative abdominal imaging. Repair for ruptured versus intact AAAs was our primary outcome measure. We used logistic regression to determine the relationship between Medicaid eligibility and the risk of rupture, sequentially adding variables related to patient characteristics, socioeconomic status, receipt of preoperative AAA surveillance, and hospital AAA volume. We then estimated the proportional effect of each factor.No differences in rupture were observed in women based on payer status. Medicaid-eligible men were more likely to present with ruptured AAA (odds ratio [OR] 2.42, 95% confidence interval [CI] 1.65-3.52). After adjusting for patient and hospital factors, the poor remained at higher risk for rupture (OR 1.5, 95% CI 1.10-2.26). This disparate risk of rupture was more commonly observed in hospitals treating a higher proportion of Medicaid-eligible patients. We estimate that 36% of the observed disparity in rupture for the elderly poor is explained by patient factors, 27% by gaps in surveillance, 9% by hospital factors, and <1% by socioeconomic factors.Incomplete preoperative surveillance is a key contributor to increased rupture of AAA in the elderly poor. Efforts aimed at improving disparities must include consistent access to medical care.
View details for DOI 10.1016/j.avsg.2014.02.008
View details for PubMedID 24530712
Outcomes after coronary artery calcium and other cardiovascular biomarker testing among asymptomatic medicare beneficiaries.
Circulation. Cardiovascular imaging
2014; 7 (4): 655-662
Biomarkers improve cardiovascular disease (CVD) risk prediction, but their comparative effectiveness in clinical practice is not known. We sought to compare the use, spending, and clinical outcomes in asymptomatic Medicare beneficiaries evaluated for CVD with coronary artery calcium (CAC) or other cardiovascular risk markers.We used a 20% sample of 2005 to 2011 Medicare claims to identify fee-for-service beneficiaries aged ≥65.5 years with no CVD claims in the previous 6 months. We matched patients with CAC with patients who received high-sensitivity C-reactive protein (hs-CRP; n=8358) or lipid screening (n=6250) using propensity-score methods. CAC was associated with increased noninvasive cardiac testing within 180 days (hazard ratio, 2.22, 95% confidence interval, 1.68-2.93, P<0.001, versus hs-CRP; hazard ratio, 4.30, 95% confidence interval, 3.04-6.06, P<0.001, versus lipid screening) and increased coronary angiography and revascularization. During 3-year follow-up, CAC was associated with higher CVD-related spending ($6525 versus $4432 for hs-CRP, P<0.001; and $6500 versus $3073 for lipid screening, P<0.001) and fewer CVD-related events when compared with hs-CRP (hazard ratio, 0.74, 95% confidence interval, 0.58-0.94, P=0.017) but not compared with lipid screening (hazard ratio, 0.84, 95% confidence interval, 0.64-1.11, P=0.23).CAC testing among asymptomatic Medicare beneficiaries was associated with increased use of cardiac tests and procedures, higher spending, and slightly improved clinical outcomes when compared with hs-CRP testing.
View details for DOI 10.1161/CIRCIMAGING.113.001869
View details for PubMedID 24777939
- Outcomes after coronary artery calcium and other cardiovascular biomarker testing among asymptomatic medicare beneficiaries. Circulation. Cardiovascular imaging 2014; 7 (4): 655-662
Patients' Preferences Explain A Small But Significant Share Of Regional Variation In Medicare Spending
2014; 33 (6): 957-963
This study assessed the extent to which differences in patients' preferences across geographic areas explained differences in traditional fee-for-service Medicare spending across Dartmouth Atlas of Health Care Hospital Referral Regions (HRRs). Preference measures were based on results of a survey that asked patients questions about their physicians, their own health status, and the care they would want in their last six months of life. We found that patients' preferences explained 5 percent of the variation across HRRs in total Medicare spending. In comparison, supply factors, such as the number of physicians, specialists, and hospital beds, explained 23 percent, and patients' health and income explained 12 percent. We also explored the relative importance of preferences in determining three components of total spending: spending at the end of life, inpatient spending, and spending on physician services. Relative to supply factors, health, and income, patients' preferences explained the largest share of variation in end-of-life spending and the smallest share of variation in spending on physician services. We conclude that variation in preferences contributes to differences across areas in Medicare spending. Medicare policy must consider both supply factors and patients' preferences in deciding how much to accommodate area variation in spending and the extent to which that variation should be subsidized by taxpayers.
View details for DOI 10.1377/hlthaff.2013.1184
View details for Web of Science ID 000338187200006
The Association Between Community-level Insurance Coverage and Emergency Department Use
2014; 52 (6): 535-540
Emergency departments (EDs) nationwide are key entry points into the health care system, and their use may reflect changes in access and need in their communities. However, no studies to date have empirically and longitudinally studied how changes in a community's level of insurance coverage, a key determinant of access, affect ED utilization.To determine the effects of changes in a community's rate of insurance coverage on its population's ED use.We conducted a longitudinal analysis of all California counties between 2005 and 2010 using comprehensive ED visit data from the California Office of Statewide Health Planning and Development. Using Poisson regression with county and year fixed effects, we determined how changes in the rate of insurance coverage within a given county affect ED visits per 1000 residents.We found that changes in the rate of insurance coverage within a county had a slight but significant inverse relationship with ED visits per 1000 residents for both adults and children. For example, if a county's rate of insurance coverage among adults jumped from the 10th (73.22%) to the 90th percentile (84.93%), an estimated 2 fewer ED visits would occur per 1000 adult residents.As the rate of insurance coverage increased within California counties, overall ED utilization declined only slightly. Thus, expanding insurance coverage may not lead to significant decreases in overall ED use.
View details for DOI 10.1097/MLR.0000000000000136
View details for Web of Science ID 000337723900011
View details for PubMedID 24824537
- Vertical Integration: Hospital Ownership Of Physician Practices Is Associated With Higher Prices And Spending HEALTH AFFAIRS 2014; 33 (5): 756-763
Vertical integration: hospital ownership of physician practices is associated with higher prices and spending.
2014; 33 (5): 756-763
We examined the consequences of contractual or ownership relationships between hospitals and physician practices, often described as vertical integration. Such integration can reduce health spending and increase the quality of care by improving communication across care settings, but it can also increase providers' market power and facilitate the payment of what are effectively kickbacks for inappropriate referrals. We investigated the impact of vertical integration on hospital prices, volumes (admissions), and spending for privately insured patients. Using hospital claims from Truven Analytics MarketScan for the nonelderly privately insured in the period 2001-07, we constructed county-level indices of prices, volumes, and spending and adjusted them for enrollees' age and sex. We measured hospital-physician integration using information from the American Hospital Association on the types of relationships hospitals have with physicians. We found that an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians--ownership of physician practices--was associated with higher hospital prices and spending. We found that an increase in contractual integration reduced the frequency of hospital admissions, but this effect was relatively small. Taken together, our results provide a mixed, although somewhat negative, picture of vertical integration from the perspective of the privately insured.
View details for DOI 10.1377/hlthaff.2013.1279
View details for PubMedID 24799571
Gaps in preoperative surveillance and rupture of abdominal aortic aneurysms among Medicare beneficiaries.
Journal of vascular surgery
2014; 59 (3): 583-588
Screening and surveillance are recommended in the management of small abdominal aortic aneurysms (AAAs). Gaps in surveillance after early diagnosis may lead to unrecognized AAA growth, rupture, and death. This study investigates the frequency and predictors of rupture of previously diagnosed AAAs.Data were extracted from Medicare claims for patients who underwent AAA repair between 2006 and 2009. Relevant preoperative abdominal imaging exams were tabulated up to 5 years prior to AAA repair. Repair for ruptured AAAs was compared with repair for intact AAAs for those with an early diagnosis of an AAA, defined as having received imaging at least 6 months prior to surgery. Gaps in surveillance were defined as no image within 1 year of surgery or no imaging for more than a 2-year time span after the initial image. Logistic regression was used to examine independent predictors of rupture despite early diagnosis.A total of 9298 patients had repair after early diagnosis, with rupture occurring in 441 (4.7%). Those with ruptured AAAs were older (80.2 ± 6.9 vs 77.6 ± 6.2 years; P < .001), received fewer images prior to repair (5.7 ± 4.1 vs 6.5 ± 3.5; P = .001), were less likely to be treated in a high-volume hospital (45.4% vs 59.5%; P < .001), and were more likely to have had gaps in surveillance (47.4% vs 11.8%; P < .001) compared with those receiving repair for intact AAAs. After adjusting for medical comorbidities, gaps in surveillance remained the largest predictor of rupture in a multivariate analysis (odds ratio, 5.82; 95% confidence interval, 4.64-7.31; P < .001).Despite previous diagnosis of AAA, many patients experience rupture prior to repair. Improved mechanisms for surveillance are needed to prevent rupture and ensure timely repair for patients with AAAs.
View details for DOI 10.1016/j.jvs.2013.09.032
View details for PubMedID 24246537
Adoption and Effectiveness of Internal Mammary Artery Grafting in Coronary Artery Bypass Surgery Among Medicare Beneficiaries
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2014; 63 (1): 33-39
The aim of this study was to assess the pattern of the adoption of internal mammary artery (IMA) grafting in the United States, test its association with clinical outcomes, and assess whether its effectiveness differs in key clinical subgroups.The effect of IMA grafting on major clinical outcomes has never been tested in a large randomized trial, yet it is now a quality standard for coronary artery bypass graft (CABG) surgery.We identified Medicare beneficiaries ≥66 years of age who underwent isolated multivessel CABG between 1988 and 2008, and we documented patterns of IMA use over time. We used a multivariable propensity score to match patients with and without an IMA and compared rates of death, myocardial infarction (MI), and repeat revascularization. We tested for variations in IMA effectiveness with treatment × covariate interaction tests.The IMA use in CABG rose slowly from 31% in 1988 to 91% in 2008, with persistent wide geographic variations. Among 60,896 propensity score-matched patients over a median 6.8-year follow-up, IMA use was associated with lower all-cause mortality (adjusted hazard ratio: 0.77, p < 0.001), lower death or MI (adjusted hazard ratio: 0.77, p < 0.001), and fewer repeat revascularizations over 5 years (8% vs. 9%, p < 0.001). The association between IMA use and lower mortality was significantly weaker (p ≤ 0.008) for older patients, women, and patients with diabetes or peripheral arterial disease.Internal mammary artery grafting was adopted slowly and still shows substantial geographic variation. IMA use is associated with lower rates of death, MI, and repeat coronary revascularization.
View details for DOI 10.1016/j.jacc.2013.08.1632
View details for Web of Science ID 000329838300007
View details for PubMedID 24080110
Why Are Medicare and Commercial Insurance Spending Weakly Correlated?
AMERICAN JOURNAL OF MANAGED CARE
2014; 20 (1): E8-E14
View details for Web of Science ID 000330599000009
Why Are Medicare and commercial insurance spending weakly correlated?
American journal of managed care
2014; 20 (1): e8-14
To investigate the source of the weak correlation across geographic areas between Medicare and private insurance spending.Retrospective, descriptive analysis.We obtained Medicare spending data at the hospital referral region (HRR) level for 2007 from the Dartmouth Atlas, and commercial claims from large employers for 2007 from the Truven MarketScan Database. We constructed county-level data on hospital market structure from Medicare patient flows and obtained county-level data on the Medicare wage index from the Centers for Medicare & Medicaid Services website. We aggregated these sources to the HRR level. We decomposed Medicare and private spending into 2 components: price and volume. We also decomposed Medicare and private prices into 2 components: a common measure of cost and a sector-specific markup. We computed correlations between Medicare and private prices and volumes, and the correlation of each sector’s price and volume with cost and markup.We found that Medicare and private prices are strongly positively correlated, largely because both are keyed off of common costs. Consistent with previous work, we found that Medicare and private volumes are strongly positively correlated as well.The weak correlation between Medicare and private spending is consistent with these 2 empirical regularities. It is mathematically due to negative correlations between each sector’s price and the other sector’s volume. In particular, we found that private prices have important spillover effects on Medicare volume. Future research on the effects of competition should take account of this phenomenon.
View details for PubMedID 24669412
Implications of Metric Choice for Common Applications of Readmission Metrics
HEALTH SERVICES RESEARCH
2013; 48 (6): 1978-1995
OBJECTIVE: To quantify the differential impact on hospital performance of three readmission metrics: all-cause readmission (ACR), 3M Potential Preventable Readmission (PPR), and Centers for Medicare and Medicaid 30-day readmission (CMS). DATA SOURCES: 2000-2009 California Office of Statewide Health Planning and Development Patient Discharge Data Nonpublic file. STUDY DESIGN: We calculated 30-day readmission rates using three metrics, for three disease groups: heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Using each metric, we calculated the absolute change and correlation between performance; the percent of hospitals remaining in extreme deciles and level of agreement; and differences in longitudinal performance. PRINCIPAL FINDINGS: Average hospital rates for HF patients and the CMS metric were generally higher than for other conditions and metrics. Correlations between the ACR and CMS metrics were highest (r = 0.67-0.84). Rates calculated using the PPR and either ACR or CMS metrics were moderately correlated (r = 0.50-0.67). Between 47 and 75 percent of hospitals in an extreme decile according to one metric remained when using a different metric. Correlations among metrics were modest when measuring hospital longitudinal change. CONCLUSIONS: Different approaches to computing readmissions can produce different hospital rankings and impact pay-for-performance. Careful consideration should be placed on readmission metric choice for these applications.
View details for DOI 10.1111/1475-6773.12075
View details for Web of Science ID 000327392300011
View details for PubMedID 23742056
Limitations of using same-hospital readmission metrics
INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE
2013; 25 (6): 633-639
To quantify the limitations associated with restricting readmission metrics to same-hospital only readmission.Using 2000-2009 California Office of Statewide Health Planning and Development Patient Discharge Data Nonpublic file, we identified the proportion of 7-, 15- and 30-day readmissions occurring to the same hospital as the initial admission using All-cause Readmission (ACR) and 3M Corporation Potentially Preventable Readmissions (PPR) Metric. We examined the correlation between performance using same and different hospital readmission, the percent of hospitals remaining in the extreme deciles when utilizing different metrics, agreement in identifying outliers and differences in longitudinal performance. Using logistic regression, we examined the factors associated with admission to the same hospital.68% of 30-day ACR and 70% of 30-day PPR occurred to the same hospital. Abdominopelvic procedures had higher proportions of same-hospital readmissions (87.4-88.9%), cardiac surgery had lower (72.5-74.9%) and medical DRGs were lower than surgical DRGs (67.1 vs. 71.1%). Correlation and agreement in identifying high- and low-performing hospitals was weak to moderate, except for 7-day metrics where agreement was stronger (r = 0.23-0.80, Kappa = 0.38-0.76). Agreement for within-hospital significant (P < 0.05) longitudinal change was weak (Kappa = 0.05-0.11). Beyond all patient refined-diagnostic related groups, payer was the most predictive factor with Medicare and MediCal patients having a higher likelihood of same-hospital readmission (OR 1.62, 1.73).Same-hospital readmission metrics are limited for all tested applications. Caution should be used when conducting research, quality improvement or comparative applications that do not account for readmissions to other hospitals.
View details for DOI 10.1093/intqhc/mzt068
View details for Web of Science ID 000327791600003
View details for PubMedID 24167061
Private insurers' payments for routine physician office visits vary substantially across the United States.
2013; 32 (9): 1583-1590
Anecdotal reports suggest that substantial variation exists in private insurers' payments for physician services, but systematic evidence is lacking. Using a retrospective analysis of insurance claims for routine office visits, consultations, and preventive visits from more than forty million physician claims in 2007, we examined variations in private payments to physicians and the extent to which variation is explained by patients' and physicians' characteristics and by geographic region. We found much variation in payments for these routine evaluation and management services. Physicians at the high end of the payment distribution were generally paid more than twice what physicians at the low end were paid for the same service. Little variation was explained by patients' age or sex, physicians' specialty, place of service, whether the physician was a "network provider," or type of plan, although about one-third of the variation was associated with the geographic area of the practice. Interventions that promote more price-consciousness on the part of patients could help reduce health care spending, but more data on the specific causes of price variation are needed to determine appropriate policy responses.
View details for DOI 10.1377/hlthaff.2013.0309
View details for PubMedID 24019363
- Effects of Care Management and Telehealth: A Longitudinal Analysis Using Medicare Data JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 2013; 61 (9): 1560-1567
Effects of care management and telehealth: a longitudinal analysis using medicare data.
Journal of the American Geriatrics Society
2013; 61 (9): 1560-1567
To evaluate mortality and healthcare utilization effects of an intervention that combined care management and telehealth, targeting individuals with congestive heart failure, chronic obstructive pulmonary disease, or diabetes mellitus.Retrospective matched cohort study.Northwest United States.High-cost Medicare fee-for-service beneficiaries (N = 1,767) enrolled in two Centers for Medicare and Medicaid Services demonstration participating clinics and a propensity-score matched control group.The Health Buddy Program, which integrates a content-driven telehealth system with care management.Mortality, inpatient admissions, hospital days, and emergency department (ED) visits during the 2-year study period were measured. Cox-proportional hazard models and negative binomial regression models were used to assess the relationship between the intervention and survival and utilization, controlling for demographic and health characteristics that were statistically different between groups after matching.At 2 years, participants offered the Health Buddy Program had 15% lower risk-adjusted all-cause mortality (hazard ratio (HR) = 0.85, 95% confidence interval (CI) = 0.74-0.98; P = .03) and had reductions in the number of quarterly inpatient admissions from baseline to the study period that were 18% greater than those of matched controls during this same time period (-0.035 vs -0.003; difference-in-differences = -0.032, 95% CI = -0.054 to -0.010, P = .005). No relationship was found between the Health Buddy Program and ED use or number of hospital days for participants who were hospitalized. The Health Buddy Program was most strongly associated with fewer admissions for individuals with chronic obstructive pulmonary disease and mortality for those with congestive heart failure.Care management coupled with content-driven telehealth technology has potential to improve health outcomes in high-cost Medicare beneficiaries.
View details for DOI 10.1111/jgs.12407
View details for PubMedID 24028359
Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries.
Journal of vascular surgery
2013; 57 (6): 1519-1523 e1
Abdominal aortic aneurysm (AAA) screening remains largely underutilized in the U.S., and it is likely that the proportion of patients with aneurysms requiring prompt treatment is much higher compared with well-screened populations. The goals of this study were to determine the proportion of AAAs that required prompt repair after diagnostic abdominal imaging for U.S. Medicare beneficiaries and to identify patient and hospital factors contributing to early vs late diagnosis of AAA.Data were extracted from Medicare claims records for patients at least 65 years old with complete coverage for 2 years who underwent intact AAA repair from 2006 to 2009. Preoperative ultrasound and computed tomography was tabulated from 2002 to repair. We defined early diagnosis of AAA as a patient with a time interval of greater than 6 months between the first imaging examination and the index procedure, and late diagnosis as patients who underwent the index procedure within 6 months of the first imaging examination.Of 17,626 patients who underwent AAA repair, 14,948 met inclusion criteria. Mean age was 77.5 ± 6.1 years. Early diagnosis was identified for 60.6% of patients receiving AAA repair, whereas 39.4% were repaired after a late diagnosis. Early diagnosis rates increased from 2006 to 2009 (59.8% to 63.4%; P < .0001) and were more common for intact repair compared with repair after rupture (62.9% vs 35.1%; P < .0001) and for women compared with men (66.3% vs 59.0%; P < .0001). On multivariate analysis, repair of intact vs ruptured AAAs (odds ratio, 3.1; 95% confidence interval, 2.7-3.6) and female sex (odds ratio, 1.4; 95% confidence interval, 1.3-1.5) remained the strongest predictors of surveillance. Although intact repairs were more likely to be diagnosed early, over one-third of patients undergoing repair for ruptured AAAs received diagnostic abdominal imaging greater than 6 months prior to surgery.Despite advances in screening practices, significant missed opportunities remain in the U.S. Medicare population for improving AAA care. It remains common for AAAs to be diagnosed when they are already at risk for rupture. In addition, a significant proportion of patients with early imaging rupture prior to repair. Our findings suggest that improved mechanisms for observational management are needed to ensure optimal preoperative care for patients with AAAs.
View details for DOI 10.1016/j.jvs.2012.12.034
View details for PubMedID 23414696
Comparative effectiveness of multivessel coronary bypass surgery and multivessel percutaneous coronary intervention: a cohort study.
Annals of internal medicine
2013; 158 (10): 727-734
Chinese translationRandomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality.To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population.Observational treatment comparison using propensity score matching and Cox proportional hazards models.United States, 1992 to 2008.Medicare beneficiaries aged 66 years or older.Multivessel CABG or multivessel PCI.The CABG-PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up.Among 105 156 propensity score-matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, -0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.Treatments were chosen by patients and physicians rather than being randomly assigned.Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease.National Heart, Lung, and Blood Institute.
View details for DOI 10.7326/0003-4819-158-10-201305210-00639
View details for PubMedID 23609014
Impact of the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act on Abdominal Ultrasonography Use Among Medicare Beneficiaries
ARCHIVES OF INTERNAL MEDICINE
2012; 172 (19): 1456-1462
Since January 1, 2007, Medicare has covered abdominal aortic aneurysm (AAA) screening for new male enrollees with a history of smoking under the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act. We examined the association between this program and abdominal ultrasonography for AAA screening, elective AAA repair, hospitalization for AAA rupture, and all-cause mortality.We used a 20% sample of traditional Medicare enrollees from 2004 to 2008 to identify 65-year-old men eligible for screening and 3 control groups not eligible for screening (70-year-old men, 76-year-old men, and 65-year-old women). We used logistic regression to examine the change in outcomes at 365 days for eligible vs ineligible beneficiaries before and after SAAAVE Act implementation, adjusting for comorbidities, state-level smoking prevalence, geographic variation, and time trends.Fewer than 3% of abdominal ultrasonography claims after 2007 were for SAAAVE-specific AAA screening. There was a significantly greater increase in abdominal ultrasonography use among SAAAVE-eligible beneficiaries (2.0 percentage points among 65-year-old men, from 7.6% in 2004 to 9.6% in 2008; 0.7 points [8.9% to 9.6%] among 70-year-old men; 0.7 points [10.8% to 11.5%] among 76-year-old men; and 0.9 points [7.5% to 8.4%] among 65-year-old women) (P < .001 for all comparisons with 65-year-old men). The SAAAVE Act was associated with increased use of abdominal ultrasonography in 65-year-old men compared with 70-year-old men (adjusted odds ratio [AOR], 1.15; 95% CI, 1.11-1.19) (P < .001), and this increased use remained even when SAAAVE-specific AAA screening was excluded (AOR, 1.12; 95% CI, 1.08-1.16) (P < .001). Implementation of the SAAAVE Act was not associated with changes in rates of AAA repair, AAA rupture, or all-cause mortality.The impact of the SAAAVE Act on AAA screening was modest and was based on abdominal ultrasonography use that it did not directly reimburse. The SAAAVE Act had no discernable effect on AAA rupture or all-cause morality.
View details for DOI 10.1001/archinternmed.2012.4268
View details for Web of Science ID 000310070200005
View details for PubMedID 22987204
Exposure to Ionizing Radiation and Estimate of Secondary Cancers in the Era of High-Speed CT Scanning: Projections From the Medicare Population
JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY
2012; 9 (4): 245-250
The aims of this study were to analyze the distribution and amount of ionizing radiation delivered by CT scans in the modern era of high-speed CT and to estimate cancer risk in the elderly, the patient group most frequently imaged using CT scanning.A retrospective cohort study was conducted using Medicare claims spanning 8 years (1998-2005) to assess CT use. The data were analyzed in two 4-year cohorts, 1998 to 2001 (n = 5,267,230) and 2002 to 2005 (n = 5,555,345). The number and types of CT scans each patient received over the 4-year periods were analyzed to determine the percentage of patients exposed to threshold radiation of 50 to 100 mSv (defined as low) and >100 mSv (defined as high). The National Research Council's Biological Effects of Ionizing Radiation VII models were used to estimate the number of radiation-induced cancers.CT scans of the head were the most common examinations in both Medicare cohorts, but abdominal imaging delivered the greatest proportion (43% in the first cohort and 40% in the second cohort) of radiation. In the 1998 to 2001 cohort, 42% of Medicare patients underwent CT scans, with 2.2% and 0.5% receiving radiation doses in the low and high ranges, respectively. In the 2002 to 2005 cohort, 50% of Medicare patients received CT scans, with 4.2% and 1.2% receiving doses in the low and high ranges. In the two populations, 1,659 (0.03%) and 2,185 (0.04%) cancers related to ionizing radiation were estimated, respectively.Although radiation doses have been increasing along with the increasing reliance on CT scans for diagnosis and therapy, using conservative estimates with worst-case scenario methodology, the authors found that the risk for secondary cancers is low in older adults, the group subjected to the most frequent CT scanning. Trends showing increasing use, however, underscore the importance of monitoring CT utilization and its consequences.
View details for DOI 10.1016/j.jacr.2011.12.007
View details for Web of Science ID 000305449600010
View details for PubMedID 22469374
Association of Coronary CT Angiography or Stress Testing With Subsequent Utilization and Spending Among Medicare Beneficiaries
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2011; 306 (19): 2128-2136
Coronary computed tomography angiography (CCTA) is a new noninvasive diagnostic test for coronary artery disease (CAD), but its association with subsequent clinical management has not been established.To compare utilization and spending associated with functional (stress testing) and anatomical (CCTA) noninvasive cardiac testing in a Medicare population.Retrospective, observational cohort study using claims data from a 20% random sample of 2005-2008 Medicare fee-for-service beneficiaries 66 years or older with no claims for CAD in the preceding year, who received nonemergent, noninvasive testing for CAD (n = 282,830).Cardiac catheterization, coronary revascularization, acute myocardial infarction, all-cause mortality, and total and CAD-related Medicare spending over 180 days of follow-up.Compared with stress myocardial perfusion scintigraphy (MPS), CCTA was associated with an increased likelihood of subsequent cardiac catheterization (22.9% vs 12.1%; adjusted odds ratio [AOR], 2.19 [95% CI, 2.08 to 2.32]; P < .001), percutaneous coronary intervention (7.8% vs 3.4%; AOR, 2.49 [2.28 to 2.72]; P < .001), and coronary artery bypass graft surgery (3.7% vs 1.3%; AOR, 3.00 [2.63 to 3.41]; P < .001). CCTA was also associated with higher total health care spending ($4200 [$3193 to $5267]; P < .001), which was almost entirely attributable to payments for any claims for CAD ($4007 [$3256 to $4835]; P < .001). Compared with MPS, there was lower associated spending with stress echocardiography (-$4981 [-$4991 to -$4969]; P < .001) and exercise electrocardiography (-$7449 [-$7452 to -$7444]; P < .001). At 180 days, CCTA was associated with a similar likelihood of all-cause mortality (1.05% vs 1.28%; AOR, 1.11 [0.88 to 1.38]; P = .32) and a slightly lower likelihood of hospitalization for acute myocardial infarction (0.19% vs 0.43%; AOR, 0.60 [0.37 to 0.98]; P = .04).Medicare beneficiaries who underwent CCTA in a nonacute setting were more likely to undergo subsequent invasive cardiac procedures and have higher CAD-related spending than patients who underwent stress testing.
View details for Web of Science ID 000297013000019
View details for PubMedID 22089720
The Relationship between Low Back Magnetic Resonance Imaging, Surgery, and Spending: Impact of Physician Self-Referral Status
HEALTH SERVICES RESEARCH
2011; 46 (5): 1362-1381
To examine the relationship between use of magnetic resonance imaging (MRI) and receipt of surgery for patients with low back pain.Medicare claims for a 20 percent sample of beneficiaries from 1998 to 2005.We identify nonradiologist physicians who appear to begin self-referral arrangements for MRI between 1999 and 2005, as well as their patients who have a new episode of low back pain care during this time. We focus on regression models that identify the relationship between receipt of MRI and subsequent use of back surgery and health care spending. Receipt of MRI may be endogenous, so we use physician acquisition of MRI as an instrument for receipt of MRI. The models adjust for demographic and socioeconomic covariates as well as month, year, and physician fixed effects.We include traditional, fee-for-service Medicare beneficiaries with a visit to an orthopedist or primary care physician for nonspecific low back pain, and no claims for low back pain in the year prior.In the first stage, acquisition of MRI equipment is a strongly correlated with patients receiving MRI scans. Among patients of orthopedists, receipt of an MRI scan increases the probability of having surgery by 34 percentage points. Among patients of primary care physicians, receiving a low back MRI is not statistically significantly associated with subsequent surgery receipt.Orthopedists and primary care physicians who begin billing for the performance of MRI procedures, rather than referring patients outside of their practice for MRI, appear to change their practice patterns such that they use more MRI for their patients with low back pain. These increases in MRI use appear to lead to increases in low back surgery receipt and health care spending among patients of orthopedic surgeons, but not of primary care physicians.
View details for DOI 10.1111/j.1475-6773.2011.01265.x
View details for Web of Science ID 000294739800002
View details for PubMedID 21517834
Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic Disease Linked To Savings
2011; 30 (9): 1689-1697
Treatment of chronically ill people constitutes nearly four-fifths of US health care spending, but it is hampered by a fragmented delivery system and discontinuities of care. We examined the impact of a care coordination approach called the Health Buddy Program, which integrates a telehealth tool with care management for chronically ill Medicare beneficiaries. We evaluated the program's impact on spending for patients of two clinics in the US Northwest who were exposed to the intervention, and we compared their experience with that of matched controls. We found significant savings among patients who used the Health Buddy telehealth program, which was associated with spending reductions of approximately 7.7-13.3 percent ($312-$542) per person per quarter. These results suggest that carefully designed and implemented care management and telehealth programs can help reduce health care spending and that such programs merit continued attention by Medicare. Meanwhile, mortality differences in the treatment and control groups suggest that the intervention may have produced noticeable changes in health outcomes, but we leave it to future research to explore these effects fully.
View details for DOI 10.1377/hlthaff.2011.0216
View details for Web of Science ID 000294670400011
View details for PubMedID 21900660
Assessing Cost-Effectiveness And Value As Imaging Grows: The Case Of Carotid Artery CT
2010; 29 (12): 2260-2267
Computed tomographic (CT) angiography is an imaging test that is safer and less expensive than an older test in diagnosing narrowing of the carotid arteries-the most common cause of stroke in US adults. Our examination of Medicare data between 2001 and 2005 found that about 20 percent of the time this test was used, it substituted for the older test. The majority of new use, however, constituted "incremental" use, in cases where patients previously would not have received any test. We found no evidence that the growth in CT angiography led to more patients' being treated for carotid artery disease. The value of the test as a substitute for the older procedure may be enough to still justify expanding use. Tracking the uses of emerging technologies to encourage efficient use is essential, but it can be challenging in cases where new tools have multiple uses and information is incomplete.
View details for DOI 10.1377/hlthaff.2010.0046
View details for Web of Science ID 000285016000017
View details for PubMedID 21134928
Acquisition Of MRI Equipment By Doctors Drives Up Imaging Use And Spending
2010; 29 (12): 2252-2259
Some orthopedists and neurologists acquired their own magnetic resonance imaging (MRI) equipment during the early 2000s. This paper examines changes in imaging use and in overall spending by patients of orthopedists and neurologists who began billing for MRI scans between 1999 and 2005. Results show that physicians ordered substantially more scans once they began billing for MRI. For example, after orthopedists began billing for MRI, the number of MRI procedures used within thirty days of a first visit increased by about 38 percent. Not only did MRI spending increase for their patients, but spending for other aspects of care rose as well. Attention should be paid to ensuring that advanced medical equipment acquired in physician practices is used appropriately.
View details for DOI 10.1377/hlthaff.2009.1099
View details for Web of Science ID 000285016000016
View details for PubMedID 21134927
- Payment Reform HEALTH SERVICES RESEARCH 2010; 45 (6): 1847-1853
HMO Coverage Reduces Variations In The Use Of Health Care Among Patients Under Age Sixty-Five
2010; 29 (11): 2068-2074
Variation in the use of hospital and physician services among Medicare beneficiaries is well documented. However, less is known about the younger, commercially insured population. Using data from the Community Tracking Study to investigate this issue, we found significant variation in the use of both inpatient and outpatient services across twelve metropolitan areas. HMO insurance reduces, but does not eliminate, the extent of this variation. Our results suggest that health plan spending to better organize delivery systems and manage care may be efficient, and regulations that arbitrarily cap plans' spending on administration, such as minimum medical loss ratios, could undermine efforts to achieve better value in health care.
View details for DOI 10.1377/hlthaff.2009.0810
View details for Web of Science ID 000283668700016
View details for PubMedID 21041750
The contribution of health plans and provider organizations to variations in measured plan quality
INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE
2010; 22 (3): 210-218
Some argue that health plans have minimal impacts on quality of care and that quality data collection should focus only on physician organizations. We investigate the relative impact of physician organizations and health plans on quality measures.Statistical analysis of data on 9 Healthcare Effectiveness Data and Information Set (HEDIS) measures from 6 health plans and 159 provider organizations. We use regression analyses to examine the amount of variation in HEDIS measures accounted for by variation across provider organizations, and whether accounting for health plans explains additional variation. We also examine whether accounting for provider organizations explains away variation in HEDIS scores across health plans.Six health plans and 159 contracted provider groups in California.Nine HEDIS scores.For all nine measures studied, variation across provider organizations explains much of the HEDIS score variation. But, after accounting for variation across providers, variation across plans statistically significantly explains additional variation. We also find statistically significant differences across health plans in HEDIS rates that are not substantially affected when we control for the provider organization that cared for the patient.On their face, these results suggest that plans can influence quality independent of the selection of physician organizations with which they contract, in contrast to hypotheses that plans are 'too far' from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in plan administrative databases.
View details for DOI 10.1093/intqhc/mzq011
View details for Web of Science ID 000277734100008
View details for PubMedID 20299493
Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients
2009; 28 (6): W1133-W1140
Magnetic resonance imaging (MRI) is a technology frequently used to evaluate low back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions it may trigger. We analyze the relationship between MRI supply and care for fee-for-service Medicare patients with low back pain. We find that increases in MRI supply are related to higher use of both low back MRI and surgery. This is worrisome, and careful attention should be paid to assessing the outcomes for patients.
View details for DOI 10.1377/hlthaff.28.6.w1133
View details for Web of Science ID 000271622300059
View details for PubMedID 19828486
Identifying organizational cultures that promote patient safety
HEALTH CARE MANAGEMENT REVIEW
2009; 34 (4): 300-311
Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate.This study explored how aspects of general organizational culture relate to hospital patient safety climate.In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures.Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate.Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and reduced hierarchy, including use of multidisciplinary team training, continuous quality improvement tools, and human resource practices and policies.
View details for Web of Science ID 000270852700002
View details for PubMedID 19858915
Health Care Cost Growth Among The Privately Insured
2009; 28 (5): 1294-1304
Controlling health care cost growth remains a high priority for policymakers and private decisionmakers, yet little is known about sources of this growth. We examined spending growth among the privately insured between 2001 and 2006, separating the contributions of price changes from those driven by consumption. Most spending growth was driven by outpatient services and pharmaceuticals, with growth in quantities explaining the entire growth in outpatient spending and about three-quarters of growth in spending on prescription drugs. Rising prices played a greater role in growth in spending for brand-name than for generic drugs. These findings can inform efforts to control private- sector spending.
View details for DOI 10.1377/hlthaff.28.5.1294
View details for Web of Science ID 000269646100008
View details for PubMedID 19738244
Relationship of Safety Climate and Safety Performance in Hospitals
HEALTH SERVICES RESEARCH
2009; 44 (2): 399-421
To examine the relationship between measures of hospital safety climate and hospital performance on selected Patient Safety Indicators (PSIs).Primary data from a 2004 survey of hospital personnel. Secondary data from the 2005 Medicare Provider Analysis and Review File and 2004 American Hospital Association's Annual Survey of Hospitals.A cross-sectional study of 91 hospitals.Negative binomial regressions used an unweighted, risk-adjusted PSI composite as dependent variable and safety climate scores and controls as independent variables. Some specifications included interpersonal, work unit, and organizational safety climate dimensions. Others included separate measures for senior managers and frontline personnel's safety climate perceptions.Hospitals with better safety climate overall had lower relative incidence of PSIs, as did hospitals with better scores on safety climate dimensions measuring interpersonal beliefs regarding shame and blame. Frontline personnel's perceptions of better safety climate predicted lower risk of experiencing PSIs, but senior manager perceptions did not.The results link hospital safety climate to indicators of potential safety events. Some aspects of safety climate are more closely related to safety events than others. Perceptions about safety climate among some groups, such as frontline staff, are more closely related than perceptions in other groups.
View details for DOI 10.1111/j.1475-6773.2008.00918.x
View details for Web of Science ID 000264164400006
View details for PubMedID 19178583
View details for PubMedCentralID PMC2677046
Are American Physicians more Satisfied? - Results from an International Study of Physicians in University Hospitals
2009; 71 (4): 210-217
Understanding the factors that affect physicians' job satisfaction is important not only to physicians themselves, but also to patients, health system managers, and policy makers. Physicians represent the crucial resource in health-care delivery. In order to enhance efficiency and quality in health care, it is indispensable to analyse and consider the motivators of physicians. Physician job satisfaction has significant effects on productivity, the quality of care, and the supply of physicians. The purpose of our study was to assess the associations between work-related monetary and non-monetary factors and physicians' work satisfaction as perceived by similar groups of physicians practicing at academic medical centres in Germany and the U.S.A., two countries that, in spite of differing health-care systems, simultaneously experience problems in maintaining their physician workforce. We used descriptive statistics, factor and correlation analyses to evaluate physicians' responses to a self-administered questionnaire. Our study revealed that overall German physicians were less satisfied than U.S. physicians. With respect to particular work-related predictors of job satisfaction we found that similar factors contributed to job satisfaction in both countries. To improve physicians' satisfaction with working conditions, our results call for the implementation of policies that reduce the time burden on physicians to allow more time for interaction with patients and colleagues, increase monetary incentives, and enhance physicians' participation in the development of care management processes and in managerial decisions that affect patient care.
View details for DOI 10.1055/s-0028-1119367
View details for Web of Science ID 000265711300003
View details for PubMedID 19288428
Patient Safety Climate in 92 US Hospitals Differences by Work Area and Discipline
2009; 47 (1): 23-31
Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in hospitals would facilitate the design and implementation of interventions.To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline.We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals.We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response).The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines.Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area.Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.
View details for Web of Science ID 000262186500004
View details for PubMedID 19106727
Job Satisfaction and Motivation among Physicians in Academic Medical Centers: Insights from a Cross-National Study
JOURNAL OF HEALTH POLITICS POLICY AND LAW
2008; 33 (6): 1133-1167
Our study assesses how work-related monetary and nonmonetary factors affect physicians' job satisfaction at three academic medical centers in Germany and the United States, two countries whose differing health care systems experience similar problems in maintaining their physician workforce. We used descriptive statistics and factor and correlation analyses to evaluate physicians' responses to a self-administered questionnaire. Our study revealed that German physician respondents were less satisfied overall than their U.S. counterparts. In both countries, participation in decision making that may affect physicians' work was an important correlate of satisfaction. In Germany other important factors were opportunities for continuing education, job security, extent of administrative work, collegial relationships, and access to specialized technology. In the U.S. sample, job security, financial incentives, interaction with colleagues, and cooperative working relationships with colleagues and management were important predictors of overall job satisfaction. The implications of these findings for the development of policies and management tactics to increase physician job satisfaction in German and U.S. academic medical centers are discussed.
View details for DOI 10.1215/03616878-2008-035
View details for Web of Science ID 000261647400007
View details for PubMedID 19038874
Expanded Use Of Imaging Technology And The Challenge of Measuring Value
2008; 27 (6): 1467-1478
The availability of computed tomography (CT) and magnetic resonance imaging (MRI) scanning has grown rapidly, but the value of increased availability is not clear. We document the relationship between CT and MRI availability and use, and we consider potentially important sources of benefits. We discuss key questions that need to be addressed if value is to be well understood. In an example we study, expanded imaging may be valuable because it provides quicker access to more precise diagnostic information, although evidence for improved health outcomes is limited. This may be a common situation; thus, a particularly important question is how non-health-outcome benefits of imaging can be quantified.
View details for DOI 10.1377/hlthaff.27.6.1467
View details for Web of Science ID 000260769300003
View details for PubMedID 18997202
Patient Safety Climate in US Hospitals Variation by Management Level
2008; 46 (11): 1149-1156
Strengthening hospital safety culture offers promise for reducing adverse events, but efforts to improve culture may not succeed if hospital managers perceive safety differently from frontline workers.To determine whether frontline workers and supervisors perceive a more negative patient safety climate (ie, surface features, reflective of the underlying safety culture) than senior managers in their institutions. To ascertain patterns of variation within management levels by professional discipline.A safety climate survey was administered from March 2004 to May 2005 in 92 US hospitals. Individual-level cross sectional comparisons related safety climate to management level. Hierarchical and hospital-fixed effects modeling tested differences in perceptions.Random sample of hospital personnel (18,361 respondents).Frequency of responses indicating absence of safety climate (percent problematic response) overall and for 8 survey dimensions.Frontline workers' safety climate perceptions were 4.8 percentage points (1.4 times) more problematic than were senior managers', and supervisors' perceptions were 3.1 percentage points (1.25 times) more problematic than were senior managers'. Differences were consistent among 7 safety climate dimensions. Differences by management level depended on discipline: senior manager versus frontline worker discrepancies were less pronounced for physicians and more pronounced for nurses, than they were for other disciplines.Senior managers perceived patient safety climate more positively than nonsenior managers overall and across 7 discrete safety climate domains. Patterns of variation by management level differed by professional discipline. Continuing efforts to improve patient safety should address perceptual differences, both among and within groups by management level.
View details for Web of Science ID 000260745900004
View details for PubMedID 18953225
Health plan performance measurement: Does it affect quality of care for medicare managed care enrollees?
INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING
2008; 45 (2): 168-183
Although the objective of provider performance measurement is to improve quality of care, little evidence exists on whether it has this effect. This study examines the implementation of mandatory quality reporting for Medicare managed care (MMC) plans. We compare utilization rates of performance-measured services for Medicare beneficiaries who were and were not enrolled in these plans before and after the program's introduction. We find that the use of measured services increased among both MMC and fee-for-service beneficiaries after the adoption of performance measurement. Our results provide no evidence that performance measurement increased quality of care among MMC enrollees.
View details for Web of Science ID 000258739800004
View details for PubMedID 18767382
Trends in charges and payments for nonhospitalized emergency department pediatric visits, 1996-2003.
Academic emergency medicine
2008; 15 (4): 347-354
To compare charges and payments for outpatient pediatric emergency visits across payer groups to provide information on reimbursement trends.Total charges and payments for emergency department (ED) visits Medicaid/State Children's Health Insurance Program (SCHIP), privately insured, and uninsured pediatric patients from 1996 to 2003 using data from the Medical Expenditure Panel Survey. Average charges per visit and average payments per visit were also tracked, using regression analysis to adjust for changes in patient characteristics.While charges for pediatric ED visits rose over time, payments did not keep pace. This led to a decrease in reimbursement rates from 63% in 1996 to 48% in 2003. For all years, Medicaid/SCHIP visits had the lowest reimbursement rates, reaching 35% in 2003. The proportion of visits from children insured by Medicaid/SCHIP also increased over the period examined. In 2003, after adjustment, charges were $792 per visit from children covered by Medicaid/SCHIP, $913 for visits from uninsured children, and $952 for visits from privately insured children.Reimbursements for outpatient ED visits in the pediatric population have decreased from the period of 1996 to 2003 in all payer groups: public (Medicaid/SCHIP), private, and the uninsured. Medicaid/SCHIP has consistently paid less per visit than the privately insured and the uninsured. Further research on the effects of these declining reimbursements on the financial viability of ED services for children is warranted.
View details for DOI 10.1111/j.1553-2712.2008.00075.x
View details for PubMedID 18370988
Variations in hospital resource use for medicare and privately insured populations in California
2008; 27 (2): W123-W134
The amount of resources used in the care of chronically ill Medicare fee-for-service (FFS) patients varies widely across hospitals. We studied variations across California hospitals in hospital resource use for chronically ill patients covered by Medicare health maintenance organizations (HMOs) and private insurers and found substantial variation in all of the coverage groups studied. Resource-use measures based on Medicare FFS data often reflect patterns evident for other payers. Previous estimates of savings if the most resource-intensive hospitals more closely resembled less resource-intensive hospitals, based on just Medicare FFS spending, could underestimate possible savings when other payers are taken into account.
View details for DOI 10.1377/hlthaff.27.2.w123
View details for Web of Science ID 000257188500060
View details for PubMedID 18270221
Decreasing reimbursements for outpatient emergency department visits across payer groups from 1996 to 2004
Annual Meeting of the American-College-of-Emergency-Physicians
MOSBY-ELSEVIER. 2008: 265–74
There is increasing concern that decreasing reimbursements to emergency departments (EDs) will negatively affect their functioning, but little evidence has been published identifying trends in reimbursement rates. We seek to examine and document the trends in reimbursement for outpatient ED visits throughout the past decade.We use Medical Expenditure Panel Survey data covering a 9-year span from 1996 to 2004, using outpatient ED visits as the unit of analysis. Our primary outcome variables were total and per-visit charges and payments across insurance. Using regression analyses with a generalized linear models approach, we also derived the adjusted mean payment and mean charge for each ED visit, as well as the average payment ratio.Overall, adjusted mean charges for an outpatient ED visit increased from $713 (95% confidence interval [CI] $665 to $771) in 1996 to $1,390 (95% CI $1,317 to $1,462) in 2004. The adjusted mean payment also increased from $410 (95% CI $366 to $453) in 1996 to $592 (95% CI $551 to $634) in 2004. Because payments increased at a slower rate in all payer groups compared with charges, the overall share of charges that were paid decreased over time from 57% in 1996 (n=3,433) to 42% in 2004 (n=5,763; P<.001). The proportion of total charges paid in 2004 was highest for privately insured visits (56%; n=2,005) and lowest for Medicaid visits (33%; n=1,618). For visits by uninsured patients (n=996), 35% of charges were paid in 2004.The proportion of charges paid for outpatient ED visits from Medicaid, Medicare, and privately insured and uninsured patients persistently decreased from 1996 to 2004. These concerning decreases may threaten the survival of EDs and their ability to continue to provide care as safety nets in the US health care system.
View details for DOI 10.1016/j.annemergmed.2007.08.009
View details for Web of Science ID 000253739300008
View details for PubMedID 17997503
Ongoing physical activity advice by humans versus computers: The community health advice by telephone (CHAT) trial
2007; 26 (6): 718-727
Given the prevalence of physical inactivity among American adults, convenient, low-cost interventions are strongly indicated. This study determined the 6- and 12-month effectiveness of telephone interventions delivered by health educators or by an automated computer system in promoting physical activity.Initially inactive men and women age 55 years and older (N = 218) in stable health participated. Participants were randomly assigned to human advice, automated advice, or health education control.The validated 7-day physical activity recall interview was used to estimate minutes of moderate to vigorous physical activity. Physical activity differences by experimental arm were verified on a random subsample via accelerometry.Using intention-to-treat analysis, at 6 months, participants in both interventions, although not differing from one another, showed significant improvements in weekly physical activity compared with controls. These differences were generally maintained at 12 months, with both intervention arms remaining above the target of 150 min per week of moderate to vigorous physical activity on average.Automated telephone-linked delivery systems represent an effective alternative for delivering physical activity advice to inactive older adults.
View details for DOI 10.1037/0278-6184.108.40.2068
View details for Web of Science ID 000250861700011
View details for PubMedID 18020844
Workforce perceptions of hospital safety culture: Development and validation of the patient safety climate in healthcare organizations survey
HEALTH SERVICES RESEARCH
2007; 42 (5): 1999-2021
To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity.Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate.Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers.We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA).We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's alpha coefficients ranged from 0.50 to 0.89.It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.
View details for DOI 10.1111/j.1475-6773.2007.00706.x
View details for Web of Science ID 000249429000012
View details for PubMedID 17850530
View details for PubMedCentralID PMC2254575
Laws requiring health plans to provide direct access to obstetricians and gynecologists, and use of cancer screening by women
HEALTH SERVICES RESEARCH
2007; 42 (3): 990-1007
Many states have passed legislation mandating that health plans provide direct access to obstetricians/gynecologists (hereinafter "ob/gyns") for women, limiting the ability of plans to require referrals or otherwise restrict access. One benefit of these laws may be improved preventive screening rates, but no literature has examined the relationship between ob/gyn direct access laws and use of breast cancer and cervical cancer screening.We use repeated cross-sections of privately insured women age 18-64 (Pap test) and 40-64 (mammography) from the Behavioral Risk Factor Surveillance System for 1996-2000, linked to data on the presence of ob/gyn direct access laws by state. Outcome measures are receipt of mammography and receipt of a Pap test within the past 2 years. Regression analyses are used to assess the relationship between the presence of ob/gyn direct access laws and screening, adjusting for a range of individual characteristics, fixed state characteristics, and time trends.We find no statistically significant relationships between the presence of an ob/gyn direct access law and receipt of either mammography or Pap test screening. We explore a range of alternate specifications and find none that yield clear evidence of a relationship.Laws requiring direct access to ob/gyns are not associated with large or consistent measurable impacts on use of cancer screening.
View details for DOI 10.1111/j.1475-6773.2006.00646.x
View details for Web of Science ID 000246201400006
View details for PubMedID 17489900
Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants
NEW ENGLAND JOURNAL OF MEDICINE
2007; 356 (21): 2165-2175
There has been a large increase in both the number of neonatal intensive care units (NICUs) in community hospitals and the complexity of the cases treated in these units. We examined differences in neonatal mortality among infants with very low birth weight (below 1500 g) among NICUs with various levels of care and different volumes of very-low-birth-weight infants.We linked birth certificates, hospital discharge abstracts (including interhospital transfers), and fetal and infant death certificates to assess neonatal mortality rates among 48,237 very-low-birth-weight infants who were born in California hospitals between 1991 and 2000.Mortality rates among very-low-birth-weight infants varied according to both the volume of patients and the level of care at the delivery hospital. The effect of volume also varied according to the level of care. As compared with a high level of care and a high volume of very-low-birth-weight infants (more than 100 per year), lower levels of care and lower volumes (except for those of two small groups of hospitals) were associated with significantly higher odds ratios for death, ranging from 1.19 (95% confidence interval [CI], 1.04 to 1.37) to 2.72 (95% CI, 2.37 to 3.12). Less than one quarter of very-low-birth-weight deliveries occurred in facilities with NICUs that offered a high level of care and had a high volume, but 92% of very-low-birth-weight deliveries occurred in urban areas with more than 100 such deliveries.Mortality among very-low-birth-weight infants was lowest for deliveries that occurred in hospitals with NICUs that had both a high level of care and a high volume of such patients. Our results suggest that increased use of such facilities might reduce mortality among very-low-birth-weight infants.
View details for Web of Science ID 000246673100006
View details for PubMedID 17522400
Proposition 71 and CIRM - assessing the return on investment
2007; 25 (5): 513-521
Given that Californian voters authorized state coffers to sell $3 billion in bonds to fund the California Institute for Regenerative Medicine (CIRM) with the expectation of health and financial benefits, what benchmarks should be used to measure the initiative's success?
View details for Web of Science ID 000246369400014
View details for PubMedID 17483831
Does quality improvement implementation affect hospital quality of care?
2007; 85 (2): 3-12
The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.
View details for PubMedID 17650463
Differences in neonatal mortality among whites and Asian American subgroups - Evidence from California
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE
2007; 161 (1): 69-76
To obtain information about health outcomes in neonates in 9 subgroups of the Asian population in the United States.Cross-sectional comparison of outcomes for births to mothers of Cambodian, Chinese, Filipino, Indian, Japanese, Korean, Laotian, Thai, and Vietnamese origin and for births to non-Hispanic white mothers. Regression models were used to compare neonatal mortality across groups before and after controlling for various risk factors.All California births between January 1,1991, and December 31, 2001.More than 2.3 million newborn infants.Racial and ethnic groups.Neonatal mortality (death within 28 days of birth).The unadjusted mortality rate for births to non-Hispanic white mothers was 2.0 per 1000. The unadjusted mortality rate for births to Chinese and Japanese mothers was significantly lower (Chinese: 1.2 per 1000, P<.001; Japanese: 1.2 per 1000, P=.004), and for births to Korean mothers the rate was significantly higher (2.7 per 1000, P=.003). For infants of Chinese mothers, observed risk factors explain the differences observed in unadjusted data. For infants of Cambodian, Japanese, Korean, and Thai mothers, differences persist or widen after risk factors are considered. After risk adjustment, infants of Cambodian, Japanese, and Korean mothers have significantly lower neonatal mortality rates compared with infants born to non-Hispanic white mothers (adjusted odds ratios, 0.58 for infants of Cambodian mothers, 0.67 for infants of Japanese mothers, and 0.69 for infants of Korean mothers; all P<.05); infants of Thai mothers have higher neonatal mortality rates (adjusted odds ratio, 1.89; P<.05).There are significant variations in neonatal mortality between subgroups of the Asian American population that are not entirely explained by differences in observable risk factors. Efforts to improve clinical care that treat Asian Americans as a homogeneous group may miss important opportunities for improving infant health in specific subgroups.
View details for Web of Science ID 000243273800010
View details for PubMedID 17199070
Physician practice size and variations in treatments and outcomes: Evidence from medicare patients with AMI
2007; 26 (1): 195-205
Little is known about the relationships between physician practice size and patient treatments or outcomes. We examined whether the practice size of attending physicians was related to within-hospital differences in care for Medicare patients with acute myocardial infarction (AMI). We found that patients treated by solo physicians were less likely to receive cardiac catheterization and angioplasty within a day of admission and more likely to die than other patients in the same hospital, even after a number of patient and physician characteristics were taken into account. These differences suggest that solo practitioners are less likely to follow guidelines calling for quick use of angioplasty.
View details for DOI 10.1377/hlthaff.26.1.195
View details for Web of Science ID 000244223200022
View details for PubMedID 17211029
Effect of opening midlevel neonatal intensive care units on the location of low birth weight births in California
2006; 118 (6): E1667-E1679
Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born.We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level).The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (-15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (-2 points). Similar patterns were observed in 1500- to 2499-g newborns.The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.
View details for DOI 10.1542/peds.2006-0612
View details for Web of Science ID 000242478900060
View details for PubMedID 17116699
Declining reimbursements for ED visits across payor groups from 1996-2003
Annual Meeting of the American-College-of-Emergency-Physicians
MOSBY-ELSEVIER. 2006: S117–S117
View details for Web of Science ID 000240958400392
Do mandates requiring insurers to pay for emergency care influence the use of the emergency department?
2006; 25 (4): 1086-1094
Many states have "prudent layperson" mandates that require health plans to reimburse hospitals for emergency department (ED) care delivered to patients who believe that they have symptoms warranting emergency treatment. Increased, and possibly unnecessary, ED use has often been attributed to these policies. We use data from thirty-five states to study relationships between passage of prudent layperson policies in the late 1990s and ED use among the privately insured. None of the analyses show evidence that the mandates are associated with increased use. We conclude that prudent layperson mandates are not associated with increases in ED visits among privately insured patients.
View details for DOI 10.1377/hlthaff.25.4.1086
View details for Web of Science ID 000239629900026
View details for PubMedID 16835190
Who searches the internet for health information?
4th World Conference of the International-Health-Economics-Association (iHEA)
WILEY-BLACKWELL PUBLISHING, INC. 2006: 819–36
To determine what types of consumers use the Internet as a source of health information.A survey of consumer use of the Internet for health information conducted during December 2001 and January 2002.We estimated multivariate regression models to test hypotheses regarding the characteristics of consumers that affect information seeking behavior.Respondents were randomly sampled from an Internet-enabled panel of over 60,000 households. Our survey was sent to 12,878 panel members, and 69.4 percent of surveyed panel members responded. We collected information about respondents' use of the Internet to search for health information and to communicate about health care with others using the Internet or e-mail within the last year.Individuals with reported chronic conditions were more likely than those without to search for health information on the Internet. The uninsured, particularly those with a reported chronic condition, were more likely than the privately insured to search. Individuals with longer travel times for their usual source of care were more likely to use the Internet for health-related communication than those with shorter travel times.Populations with serious health needs and those facing significant barriers in accessing health care in traditional settings turn to the Internet for health information.
View details for DOI 10.1111/j.1475-6773.2006.00510.x
View details for Web of Science ID 000237464400013
View details for PubMedID 16704514
View details for PubMedCentralID PMC1713205
Quality improvement implementation and hospital performance on quality indicators
HEALTH SERVICES RESEARCH
2006; 41 (2): 307-334
To examine the association between the scope of quality improvement (QI) implementation in hospitals and hospital performance on selected indicators of clinical quality.Secondary data from 1997 mailed survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets compiled by Solucient Inc. containing data on managed care penetration and hospital financial performance.Cross-sectional study of 1,784 community hospitals to assess relationship between QI implementation approach and six hospital-level quality indicators. DATA COLLECTION/ABSTRACTION METHODS: Two-stage instrumental variables estimation in which predicted values (instruments) of four QI scope variables and control (exogenous) variables used to estimate hospital-level quality indicators.Involvement by multiple hospital units in QI effort is associated with worse values on hospital-level quality indicators. Percentage of hospital staff and percentage of senior managers participating in formally organized QI teams are associated with better values on quality indicators. Percentage of physicians participating in QI teams is not associated with better values on the hospital-level quality indicators studied.Results supported the proposition that the scope of QI implementation in hospitals is significantly associated with hospital-level quality indicators. However, the direction of the association varied across different measures of QI implementation scope.
View details for DOI 10.1111/j.1475-6773.2005.00483.x
View details for Web of Science ID 000235892500003
View details for PubMedID 16584451
Quality improvement implementation and hospital performance on patient safety indicators
MEDICAL CARE RESEARCH AND REVIEW
2006; 63 (1): 29-57
This study examines the association between scope of Quality Improvement (QI) implementation in hospitals and hospital performance on patient safety indicators. Secondary data sources included a 1997 survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets. Using a sample of 1,784 community hospitals, the study employed two-stage instrumental variables estimation in which predicted values of four QI scope variables and control variables were used to estimate four patient safety indicators. Involvement by multiple hospital units in the QI effort is associated with worse values on all four patient safety indicators. Percentages of hospital staff and of senior managers participating in QI teams exhibited no statistically significant association with any patient safety indicator. Percentage of physicians participating in QI teams is associated with better values on two patient safety indicators.
View details for DOI 10.1177/1077558705283122
View details for Web of Science ID 000235711000002
View details for PubMedID 16686072
Impact of instructional practices on student satisfaction with attendings' teaching in the inpatient component of internal medicine clerkships
JOURNAL OF GENERAL INTERNAL MEDICINE
2006; 21 (1): 7-12
To determine the prevalence and influence of specific attending teaching practices on student evaluations of the quality of attendings' teaching in the inpatient component of Internal Medicine clerkships.Nationwide survey using a simple random sample. Setting: One hundred and twenty-one allopathic 4-year medical schools in the United States.A total of 2,250 fourth-year medical students.In the spring of 2002, student satisfaction with the overall quality of teaching by attendings in the inpatient component of Internal Medicine clerkships was measured on a 5-point scale from very satisfied to very dissatisfied (survey response rate, 68.3%). Logistic regression was used to determine the association of specific teaching practices with student evaluations of the quality of their attendings' teaching. Attending physicians' teaching practices such as engaging students in substantive discussions (odds ratio (OR)=3.0), giving spontaneous talks and prepared presentations (OR=1.6 and 1.8), and seeing new patients with the team (OR=1.2) were strongly associated with higher student satisfaction, whereas seeming rushed and eager to finish rounds was associated with lower satisfaction (OR=0.6).Findings suggest that student satisfaction with attendings' teaching is high overall but there is room for improvement. Specific teaching behaviors used by attendings affect student satisfaction. These specific behaviors could be taught and modified for use by attendings and clerkship directors to enhance student experiences during clerkships.
View details for DOI 10.1111/j.1525-1497.2005.0253.x
View details for Web of Science ID 000235163600002
View details for PubMedID 16423117
- Evaluating the efficiency of California providers in caring for patients with chronic illnesses HEALTH AFFAIRS 2006; 25 (1): W5526-W5543
The role of organizational infrastructure in implementation of hospitals' quality improvement.
2006; 84 (1): 11-20
Quality improvement (QI) is an organized approach to planning and implementing continuous improvement in performance. Although QI holds promise for improving quality of care and patient safety, hospitals that adopt QI often struggle with its implementation. This article examines the role of organizational infrastructure in implementation of quality improvement practices and structures in hospitals. The authors focus specifically on four elements of hospital support and infrastructure for QI-integrated data systems, financial support for QI, clinical integration, and information system capability. These macrolevel factors provide consistent, ongoing support for the QI efforts of clinical teams engaging in direct patient care, thus promoting institutionalization of QI. Results from the multivariate analysis of 1997 survey data on 2350 hospitals provide strong support for the hypotheses. Results signal that organizations intent upon improving quality must attend to the context in which QI efforts are practiced, and that such efforts are unlikely to be effective unless appropriate support systems are in place to ensure full implementation.
View details for PubMedID 16573012
Medicaid managed care and health care for children
HEALTH SERVICES RESEARCH
2005; 40 (5): 1466-1488
Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children. DATA SOURCES AND MEASURES: Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys (n=2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit).Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors.Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care.Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.
View details for DOI 10.1111/j.1475-6773.2005.00427.x
View details for Web of Science ID 000231708000012
View details for PubMedID 16174143
Internet use and stigmatized illness
SOCIAL SCIENCE & MEDICINE
2005; 61 (8): 1821-1827
People with stigmatized illnesses often avoid seeking health care and education. The internet may be a useful health education and outreach tool for this group. This study examined patterns of internet use for health information among those with and without stigmatized illnesses. A national survey of internet users in the USA was conducted. Respondents who self-reported a stigmatized condition-defined as anxiety, depression, herpes, or urinary incontinence-were compared to respondents who reported having at least one other chronic illness, such as cancer, heart problems, diabetes, and back pain. The analytical sample consisted of 7014 respondents. Cross-sectional associations between stigmatized illness and frequency of internet use for information about health care, use of the internet for communication about health, changes in health care utilization after internet use, and satisfaction with the internet were determined. After controlling for a number of potential confounders, those with stigmatized illnesses were significantly more likely to have used the internet for health information, to have communicated with clinicians about their condition using the internet, and to have increased utilization of health care based on information found on the internet, than those with non-stigmatized conditions. Length of time spent online, frequency of internet use, satisfaction with health information found on the internet, and discussion of internet findings with health care providers did not significantly differ between the two groups. Results from this survey suggest that the internet may be a valuable health communication and education tool for populations who are affected by stigmatized illnesses.
View details for DOI 10.1016/j.socsimed.2005.03.025
View details for Web of Science ID 000231462700020
View details for PubMedID 16029778
Effect of an Internet-based system for doctor-patient communication on health care spending
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION
2005; 12 (5): 530-536
We studied the effect of a structured electronic communication service on health care spending, comparing doctor office and laboratory spending for a group of patients before and after the service became available to them relative to changes in a control group. In the treatment group, doctor office spending and laboratory spending fell in the period after the service became available, relative to the control group (p < 0.05). A rough estimate is that average doctor office spending per treatment group member per month fell $1.71 after availability of the service, and laboratory spending fell roughly $0.12. Spending associated with use of the electronic service was $0.29 per member per month. We conclude that use of structured electronic visits can reduce health care spending.
View details for DOI 10.1197/jamia.M1778
View details for Web of Science ID 000232419100004
View details for PubMedID 15905484
Has prudent layperson legislation achieved its goals of increasing access for emergency care?
Scientific Assembly of the American-College-of-Emergency-Physicians
MOSBY-ELSEVIER. 2005: S119–S119
View details for Web of Science ID 000231741000424
Evaluating the efficiency of california providers in caring for patients with chronic illnesses.
2005: W5-526 43
In this paper we compare the relative efficiency of health care providers in managing patients with severe chronic illnesses over fixed periods of time. To minimize the contribution of differences in severity of illness to differences in care management, we evaluate performance over fixed intervals prior to death for patients who died during a five-year period, 1999-2003. Medicare spending, hospital bed and full-time equivalent (FTE) physician inputs, and utilization varied extensively between regions, among hospitals located within a given region, and among hospitals belonging to a given hospital system. The data point to important opportunities to improve efficiency.
View details for PubMedID 16291779
Free Internet access, the digital divide, and health information
2005; 43 (4): 415-420
The Internet has emerged as a valuable tool for health information. Half of the U.S. population lacked Internet access in 2001, creating concerns about those without access. Starting in 1999, a survey firm randomly invited individuals to join their research panel in return for free Internet access. This provides a unique setting to study the ways that people who had not previously obtained Internet access use the Internet when it becomes available to them.In 2001-2002, we surveyed 12,878 individuals 21 years of age and older on the research panel regarding use of the Internet for health; 8935 (69%) responded. We analyzed respondents who had no prior Internet access, and then compared this group to those who had prior Internet access.Among those newly provided free Internet access, 24% had used the Internet for health information in the past year, and users reported notable benefits, such as improved knowledge and self-care abilities. Not surprisingly, the no-prior-Internet group reported lower rates of using the Internet (24%) than the group that had obtained Internet access prior to joining the research panel (40%), but the 2 groups reported similar perceptions of the Internet and self-reported effects.Those who obtained Internet access for the first time by joining the panel used the Internet for health and appeared to benefit from it. Access helps explain the digital divide, although most people given free access do not use the Internet for health information.
View details for Web of Science ID 000227914000013
View details for PubMedID 15778645
Predictors of surgery resident satisfaction with teaching by attendings - A national survey
ANNALS OF SURGERY
2005; 241 (2): 373-380
To identify factors that predict fourth- and fifth-year surgical resident satisfaction of attending teaching quality.With the training of surgical residents undergoing major changes, a key issue facing surgical educators is whether high-quality surgeons can still be produced. Innovative techniques (eg, computer simulation surgery) are being developed to substitute partially for conventional teaching methods. However, an aspect of training that cannot be so easily replaced is the faculty-resident interaction. This study investigates resident perceptions of attending teaching quality and the factors associated with this faculty-resident interaction to identify predictors of resident educational satisfaction.A national survey of clinical fourth- and fifth-year surgery residents in 125 academically affiliated general surgery training programs was performed. The survey contained 67 questions and addressed demographics, hospital, and service characteristics, as well as surgery, education, and clinical care-related factors. Univariate analyses were performed to describe the characteristics of the sample; multivariate analyses were performed to evaluate the factors associated with resident educational satisfaction.The response rate was 61.5% (n = 756). Average age was 32 years; most were male (79%), white (72%), and married (69%); 42% had children. Ninety-five percent of respondents graduated from U.S. medical schools, and the average debt was $80,307. Of 20 potentially mutable factors, 6 variables had positive associations with resident education satisfaction and 7 had negative associations. Positive factors included the resident being the operating surgeon in major surgeries, substantial citing of evidence-based literature by the attending, attending physicians giving spontaneous or unplanned presentations, increasing the continuity of care, clinical teaching aimed at the chief resident level, and having clinical decisions made together by both the attending and resident. There were 7 negative factors such as overly supervising in surgery, being interrupted so much that teaching was ineffective, and attending physicians being rushed and/or eager to finish rounds.This study identifies several factors that were associated with resident educational satisfaction. It offers the perspective of the learners (ie, residents) and, importantly, highlights mutable factors that surgery faculty (and departments) may consider changing to improve surgery resident education and satisfaction. Improving such satisfaction may help to produce a better product.
View details for DOI 10.1097/01.sla.0000150257.04889.70
View details for Web of Science ID 000226567200025
View details for PubMedID 15650650
The relationship between SCHIP enrollment and hospitalizations for ambulatory care sensitive conditions in California
JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED
2005; 16 (1): 96-110
The State Children's Health Insurance Program (SCHIP) was implemented in 1998, providing new funds for states to cover uninsured children. This study examines the relationship between SCHIP implementation in California and hospitalizations for ambulatory care sensitive conditions (ACSCs), an indicator of primary care access and quality. We use administrative SCHIP enrollment records for urban California counties, linked with corresponding rates of hospitalization for seven ACSCs among children ages 1-18 for 1996-2000. Results from multivariate regression models indicate that increases of 1 percentage point in SCHIP enrollment are associated with reductions of 0.42 ACSC admissions per 100,000 children age 1-18 (p = 0.009). Models that use lagged effects of SCHIP enrollment indicate an even stronger relationship. These are population-level relationships, and translate to much larger effects on the specific population subset that enrolled in SCHIP. These results suggest a strong beneficial effect of SCHIP on primary care among the children covered.
View details for Web of Science ID 000227618500011
View details for PubMedID 15741712
Benefits of interoperability: a closer look at the estimates.
2005: W5-22 W5 25
The paper by Jan Walker and colleagues provides an estimate of savings to be gained by increased health care information exchange and interoperability (HIEI). However, the assumptions on which their analysis was based seem very optimistic and could produce estimates that are not achievable. This commentary outlines some questions about their assumptions and suggests that less-aggressive assumptions could lead to more realistic expectations about the financial implications of achieving interoperability.
View details for PubMedID 15659455
The effect of area HMO market share on cancer screening
HEALTH SERVICES RESEARCH
2004; 39 (6): 1751-1772
Managed care may have widespread impacts on health care delivery for all patients in the areas where they operate. We examine the relationship between area managed care activity and screening for breast, cervical, and prostate cancer among patients enrolled in more managed care plans and patients who are enrolled in less managed plans.Data on cancer screening from the 1996 Medical Expenditure Panel Survey (MEPS) were linked to data on health maintenance organization (HMO) and preferred provider organization (PPO) market share and HMO competition at the metropolitan statistical area (MSA) level. Logistic regression analysis was used to examine the relationship between area managed care prevalence and the use of mammography, clinical breast examination, Pap smear, and prostate cancer screening in the past two years, controlling for important covariates.Among all patients, increases in area-level HMO market share are associated with increases in the appropriate use of mammography, clinical breast exam, and Pap smear (OR for high relative to low managed care areas are 1.75, p < .01, for mammography, 1.58, p < .05, for clinical breast exam, and 1.71, p < .01, for Pap smear). In analyses of subgroups, the relationship is significant only for individuals who are enrolled in the nonmanaged plans; there is no relationship for individuals in more managed plans. No relationship is observed between area HMO market share and prostate cancer screening in any analysis. Neither the level of competition between area HMOs nor area PPO market share is associated with screening rates.Area-level managed care activity can influence preventive care treatment patterns.
View details for Web of Science ID 000226743200008
View details for PubMedID 15533185
Use of the Internet for health information by the chronically ill.
Preventing chronic disease
2004; 1 (4): A13-?
Chronic conditions are among the leading causes of death and disability in the United States. The Internet is a source of health information and advice for individuals with chronic conditions and shows promise for helping individuals manage their conditions and improve their quality of life.We assessed Internet use for health information by people who had one or more of five common chronic conditions. We conducted a national survey of adults aged 21 and older, then analyzed data from 1980 respondents who had Internet access and who reported that they had hypertension, diabetes, cancer, heart problems, and/or depression.Adjusted rates for any Internet use for health information ranged from 33.8% (heart problems only) to 52.0% (diabetes only). A sizable minority of respondents - particularly individuals with diabetes - reported that the Internet helped them to manage their condition themselves, and 7.9% said information on the Internet led them to seek care from a different doctor.Use of the Internet for health information by chronically ill patients is moderate. Self-reported effects on choice of treatment or provider are small but noteworthy.
View details for PubMedID 15670445
Consumers' use of the Internet for health insurance
AMERICAN JOURNAL OF MANAGED CARE
2004; 10 (9): 609-616
We examined consumers' search for information about health insurance choices and their use of the Internet for that search and to manage health benefits.We surveyed a random sample of more than 4500 individuals aged 21 years and older who were members of a survey research panel during December 2001 and January 2002.The survey included questions about searching for health insurance information in 3 health insurance markets: Medicare, individual or nongroup, and employer-sponsored group. We also asked questions about use of the Internet to manage health benefits. We tabulated means of responses to each question by market and tested for independence across demographic groups using the Pearson chi-square test.We identified important differences across and within markets in the extent to which people look for information about health insurance alternatives and the role of the Internet in their search. Although many individuals were unaware of whether their employer or health plan provided a website to manage health benefits, those who used the sites generally evaluated them favorably.Our results suggest that the Internet is an important source of health insurance information, particularly for individuals purchasing coverage individually in the nongroup and Medicare markets relative to those obtaining coverage from an employer. In the case of Medicare coverage, studies focusing on beneficiaries' use of Internet resources may underestimate the Internet's importance by neglecting caregivers who use the Internet. Many individuals may be unaware of the valuable resources available through employers or health plans.
View details for Web of Science ID 000223835600005
View details for PubMedID 15515993
Predictors for medical students entering a general surgery residency: National survey results
65th Annual Meeting of the Society-of-University-Surgeons
MOSBY-ELSEVIER. 2004: 567–72
The number of general surgery (GS) residency applicants had been decreasing before 2003. This national survey of fourth-year medical students elucidates factors related to the basic surgery clerkship that are associated with the decision to enter a GS residency.A national sample of 2250 fourth-year medical students from all 4-year allopathic US medical schools was surveyed in spring 2002. Multivariate analyses were performed to identify mutable predictors for students entering GS.Data from 1531 fourth-year medical students from 121 different medical schools (response rate=68%) showed that 5.6% planned to enter GS. In multivariate analyses, the strongest predictor of entering GS was satisfaction with the quality of attending teaching (odds ratio 2.14, P <.01) in surgery clerkships. Several clerkship factors, such as frequency of call nights and total hours worked., were not as strongly associated with entering GS residency, Subsequent analyses showed that predictors of satisfaction with the quality of attending teaching included intraoperative activities (ie, suturing, cutting, and stapling), having attending-led rounds, and performing a history and physical with an attending. Significant negative predictors of satisfaction included observing or retracting only in surgery.In this national survey, factors are identified that are significantly associated with students entering a GS residency. Some of these mutable factors may increase the pool of GS residency applicants.
View details for DOI 10.1016/j.surg.2004.05.021
View details for Web of Science ID 000223844300011
View details for PubMedID 15349103
Relationship between HMO market share and the diffusion and use of advanced MRI technologies.
Journal of the American College of Radiology
2004; 1 (7): 478-487
Financial incentives associated with managed care may shift incentives associated with the adoption of new medical technologies. This study examined whether managed-care activity was associated with the adoption rate of magnetic resonance imaging (MRI) equipment during the 1990s.Data from three nationwide "censuses" of MRI sites conducted in 1993, 1997, and 1999 were used. The number of MRI sites and magnets; magnet field strength; MRI procedures; the use of contrast media; and the presence of power injectors, echoplanar imaging, cardiac MRI, and interventional MRI were measured in each of 322 metropolitan statistical areas each year. Regression analysis was used to assess the relationship between area MRI availability and overall area health maintenance organization (HMO) market share, controlling for potential confounders.Areas with higher HMO activity had markedly lower adoption and use of MRI. By 1999, high-HMO areas had about 40% fewer MRI scanners per 100,000 people than low-HMO areas (1.02 vs. 1.73, P < .01). High-HMO areas had fewer 1.5-T scanners than low areas in all 3 years and tended to use contrast media less often in 1993 and 1997 (all P < .01). There were statistically insignificant trends toward less availability of echoplanar imaging, cardiac MRI, and interventional MRI in high-HMO areas.The fact that managed care is associated with the slower adoption of MRI and less availability of some of the most advanced MRI equipment suggests the need for attention to the potential for managed care to have important effects on the quality of care and health care spending by influencing technology growth.
View details for PubMedID 17411636
Variation in access to health care for different racial/ethnic groups by the racial/ethnic composition of an individual's county of residence
2004; 42 (7): 707-714
Although the majority of studies examining racial/ethnic disparities in health care have focused on the characteristics of the individual, more recently there has been growing attention to the notion that an individual's health practices could be influenced by the characteristics of the place where they reside.The objective of this study was to examine whether access to care for individuals of different racial/ethnic groups varies by the prevalence of blacks and the prevalence of Latinos in their county of residence.We conducted a cross-sectional cohort.Individuals from the 1996 Medical Expenditure Panel Survey, a nationally representative sample of U.S. households, who described their race/ethnicity as white, black, or Latino, and who resided in 1 of 677 counties (n = 14740) were studied.Counties were assigned to 6 groups based on the prevalence of blacks and Latinos who resided there (<6% referred to as "low prevalence," 6-39% referred to as "midprevalence," >or=40% referred to as "high prevalence" separately for both blacks and Latinos). Outcomes included whether during the past year any family members: 1). experienced difficulty obtaining any type of health care, delayed obtaining care, or did not receive health care they thought they needed (referred to as "difficulty obtaining care"); or (2). did not receive a doctor's care or a prescription medication because the family needed money to buy food, clothing, or pay for housing (referred to as "financial barriers").After controlling for other individual and area-level covariates, blacks reported lower rates of both outcome variables when they lived in a county with a high prevalence of blacks compared with blacks who lived in a county with a low prevalence of blacks (difficulty obtaining care: 4.3% vs. 18.8%, P <0.005; financial barriers: 1.6% vs. 10.5%, P <0.005). There was a similar association for Latinos by the prevalence of Latinos in the county for difficulty obtaining care (high: 5.0% vs. low: 13.4%, P <0.05), but not the financial barriers outcome (high: 2.2% vs. low: 2.4%, P = 0.90). Whites who lived in an area with a high prevalence of Latinos were more likely to report both outcomes compared with whites who lived in a county with a low prevalence of Latinos (difficulty obtaining care: 17.7% vs. 9.4%, P <0.05; financial barriers: 8.5% vs. 3.2%, P <0.005) .Blacks and Latinos may perceive fewer barriers to care when they live in a county with a high prevalence of people of similar race/ethnicity. Conversely, whites may perceive more difficulty receiving care when they live in an area with a high prevalence of Latinos. Diminishing disparities in access to health care may require interventions that extend beyond the individual.
View details for DOI 10.1097/01.mlr.0000129906.95881.83
View details for Web of Science ID 000222440300012
View details for PubMedID 15213496
Managed care, information, and diffusion: The case of treatment for heart-attack patients
Joint Meeting of the Society-of-Government-Economists/116th Annual Meeting of the American-Economic-Association
AMER ECONOMIC ASSOC. 2004: 347–51
View details for Web of Science ID 000222423100063
Impact of new mid-level neonatal intensive care units on the level of care received by low-birthweight infants
Annual Meeting of the Pediatric-Academic-Societies
NATURE PUBLISHING GROUP. 2004: 517A–517A
View details for Web of Science ID 000220591103012
Are gatekeeper requirements associated with cancer screening utilization?
HEALTH SERVICES RESEARCH
2004; 39 (1): 153-178
There is widespread debate over whether health plans should require enrollees to use "gatekeepers," which are primary care providers that coordinate care and control access to specialists. However, little is known about whether health plan gatekeeper requirements improve or reduce quality-of-care. Our objective was to examine whether gatekeeper requirements are associated with the utilization of cancer screening for breast, cervical, and prostate cancer.Three linked sources (N = 13,534): (1) 1996 Medical Expenditure Panel Survey (MEPS) Household Survey, a nationally representative, ongoing survey sponsored by the Agency for Healthcare Research and Quality; (2) 1996 MEPS Health Insurance Plan Abstraction, which codes data from health plan booklets obtained from privately insured respondents, and (3) 1995 National Health Interview Survey.Cross-sectional, multivariate logistic regression analysis using secondary data.We found in multivariate analyses that women in gatekeeper plans were significantly more likely to obtain mammography screening (Odds Ratio [OR] = 1.22, 95 percent Confidence Interval [CI] 1.07-1.40), clinical breast examinations (OR = 1.39, 95 percent CI 1.23-1.57), and Pap smears (OR = 1.33, 95 percent CI 1.16-1.52) than women not in gatekeeper plans. In contrast, gatekeeper requirements were not associated with prostate cancer screening (OR = 1.11, 95 percent CI 0.93-1.33). We found no association between screening utilization and aggregate plan types (HMO, POS, PPO, FFS).Gatekeeper requirements are associated with higher utilization of widely recommended cancer screening procedures, but not with utilization of a less uniformly recommended cancer screening procedure. Researchers should consider the analysis of specific plan characteristics rather than aggregate plan types in conducting future research, and insurers and policymakers should consider the potential benefits of gatekeepers with respect to preventive care when designing health plans and legislation.
View details for Web of Science ID 000188758000011
View details for PubMedID 14965082
Do health plans influence quality of care?
INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE
2004; 16 (1): 19-30
To investigate the relative impact of physician groups and health plans on quality of care measures.Secondary data analysis of receipt of preventive care services included in the Health Plan Employer Data and Information Set (HEDIS) among 10 758 patients representing 21 health maintenance organizations and 22 large provider groups in the San Francisco and Los Angeles, California, areas in 1997. Each patient was eligible for (at least) one of six HEDIS-measured services. Data identify whether or not the service was provided, the patient's health plan, and the provider group responsible for the care. We used logistic regression to examine variations across plans in HEDIS rates, and whether variations persist after controls for provider groups are included.Patients from 21 health maintenance organizations serving San Francisco and Los Angeles, California, in 1997.Breast cancer screening, childhood immunizations, cervical cancer screening, diabetic retinal exam, prenatal care in the first trimester, and check-ups after delivery among patients for whom these services are appropriate.There are statistically significant differences across health plans in utilization rates for the six services examined. These differences are not substantially affected when we control for the provider group that cared for the patient. That is, controlling for provider group does not explain variations across plans, consistent with the view that health plans have an impact on HEDIS quality measures independent of the providers that they contract with.There are activities that plans can undertake which influence their HEDIS scores. On the face of it, these results suggest that plans can independently improve quality, in contrast to hypotheses that plans would be "too far" from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in the quality of plan administrative databases.
View details for DOI 10.1093/intqhc/mzh003
View details for Web of Science ID 000188796200004
View details for PubMedID 15020557
Within-year variation in hospital utilization and its implications for hospital costs
JOURNAL OF HEALTH ECONOMICS
2004; 23 (1): 191-211
Variability in demand for hospital services may have important effects on hospital costs, but this has been difficult to examine because data on within-year variations in hospital use have not been available for large samples of hospitals. We measure daily occupancy in California hospitals and examine variation in hospital utilization at the daily level. We find substantial day-to-day variation in hospital utilization, and noticeable differences between hospitals in the amount of day-to-day variation in utilization. We examine the impact of variation on hospital costs, showing that increases in variance are associated with increases in hospital expenditures, but that the effects are qualitatively modest.
View details for DOI 10.1016/j.jhealeco.2003.09.005
View details for Web of Science ID 000189210600009
View details for PubMedID 15154694
The relationship between technology availability and health care spending
2003; 22 (6): W537-W551
View details for Web of Science ID 000186632200055
The relationship between technology availability and health care spending.
2003: W3-537 51
We analyze the relationship between the supply of new technologies and health care utilization and spending, focusing on diagnostic imaging, cardiac, cancer, and newborn care technologies. As anticipated by previous research, increases in the supply of technology tend to be related to higher utilization and spending on the service in question. In some cases, notably diagnostic imaging, increases in availability appear associated with incremental utilization rather than substitution for other services. Policy efforts to assess and manage the availability of new technologies could benefit society where the additional spending produced by new services is not associated with strong quality improvements.
View details for PubMedID 15506158
Use of the Internet and e-mail for health care information - Results from a national survey
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2003; 289 (18): 2400-2406
The Internet has attracted considerable attention as a means to improve health and health care delivery, but it is not clear how prevalent Internet use for health care really is or what impact it has on health care utilization. Available estimates of use and impact vary widely. Without accurate estimates of use and effects, it is difficult to focus policy discussions or design appropriate policy activities.To measure the extent of Internet use for health care among a representative sample of the US population, to examine the prevalence of e-mail use for health care, and to examine the effects that Internet and e-mail use has on users' knowledge about health care matters and their use of the health care system.Survey conducted in December 2001 and January 2002 among a sample drawn from a research panel of more than 60 000 US households developed and maintained by Knowledge Networks. Responses were analyzed from 4764 individuals aged 21 years or older who were self-reported Internet users.Self-reported rates in the past year of Internet and e-mail use to obtain information related to health, contact health care professionals, and obtain prescriptions; perceived effects of Internet and e-mail use on health care use.Approximately 40% of respondents with Internet access reported using the Internet to look for advice or information about health or health care in 2001. Six percent reported using e-mail to contact a physician or other health care professional. About one third of those using the Internet for health reported that using the Internet affected a decision about health or their health care, but very few reported impacts on measurable health care utilization; 94% said that Internet use had no effect on the number of physician visits they had and 93% said it had no effect on the number of telephone contacts. Five percent or less reported use of the Internet to obtain prescriptions or purchase pharmaceutical products.Although many people use the Internet for health information, use is not as common as is sometimes reported. Effects on actual health care utilization are also less substantial than some have claimed. Discussions of the role of the Internet in health care and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Internet strongly influences health care utilization.
View details for Web of Science ID 000182831200030
View details for PubMedID 12746364
Is the prevalence of gatekeeping in a community associated with individual trust in medical care?
2003; 41 (5): 660-668
Consumer concerns about the restrictions of managed care may lead to distrust.To examine whether a community's level of gatekeeping activity is associated with an individual's trust in medical care.Cross-sectional cohort (N = 49,929).Participants in a nationally representative sample derived from the Community Tracking Survey who had health insurance, had a usual source of care, made at least 1 physician visit, and resided in one of the sampled metropolitan areas with corresponding community-level data, including the prevalence of gatekeeping activity.Four questions measuring trust in physician.Individuals from communities with a higher prevalence of gatekeeping activity report less trust than individuals from areas with a lower prevalence of gatekeeping activity, after adjusting for whether that individual had a health plan with a gatekeeper requirement. For example, in communities with the highest prevalence of gatekeeping activity relative to the lowest, the odds ratio for individuals to agree strongly that they trusted their doctor to put their medical needs above all other considerations was 0.77 (95% confidence interval, 0.71-0.84). Also, a higher prevalence of gatekeeping in the community was positively associated with the perception that a physician was strongly influenced by insurance company rules when making decisions about medical care. Conversely, a higher prevalence of gatekeeping in the community was negatively associated with the perception that a doctor might perform an unnecessary test or procedure and with concern about restricted referral for specialty care.Individuals' trust in their physicians may be influenced by wider contextual variables, like the prevalence of gatekeeping in the community.
View details for Web of Science ID 000182695900014
View details for PubMedID 12719690
The effects of NICU patient volume and NICU level at the hospital of birth on neonatal mortality over time for infants with a birth weight < 2000 g: California 1991-1999
Annual Meeting of the Pediatric-Academic-Societies/Society-for-Pediatric-Research
NATURE PUBLISHING GROUP. 2003: 442A–442A
View details for Web of Science ID 000181897902497
Variation in access to care by the ethnic composition of an individual's county of residence.
26th Annual Meeting of the Society-of-General-Internal-Medicine
SPRINGER. 2003: 174–175
View details for Web of Science ID 000182564300665
The effects of NICU patient volume and NICU level at the hospital of birth on neonatal mortality overtime for infants with a birth weight < 2000g ; California 1991-1999.
Western Regional Meeting of the American-Federation-for-Medical-Research
LIPPINCOTT WILLIAMS & WILKINS. 2003: S120–S120
View details for Web of Science ID 000180569600173
Managed care spillover effects
ANNUAL REVIEW OF PUBLIC HEALTH
2003; 24: 435-456
In addition to influencing care for patients enrolled in managed care plans, growth in managed care could lead to broad changes in the structure and functioning of the health care system that could ultimately influence care for all patients, even those not covered by managed care plans. This paper summarizes the mechanisms by which these effects could arise, including shifts in the types of services available in markets and changes in physician practice patterns. The paper summarizes available empirical evidence on broad-level effects of managed care, concluding that the literature supports the view that managed care can have generalized effects on health care spending, utilization patterns, and infrastructure, although existing literature has not clearly identified effects on health outcomes.
View details for DOI 10.1146/annurev.publhealth.24.100901.141000
View details for Web of Science ID 000185094600022
View details for PubMedID 12471276
Managed care, technology adoption, and health care: the adoption of neonatal intensive care
Conference on the Industrial-Organization-of-Medical-Care
BLACKWELL PUBLISHING. 2002: 524–48
Managed care may influence technology diffusion in health care. This article empirically examines the relationship between HMO market share and the diffusion of neonatal intensive care units. Higher HMO market share is associated with slower adoption of mid-level units, but not with adoption of the most advanced high-level units. Opposite the common supposition that slowing technology growth will harm patients, results suggest that health outcomes for seriously ill newborns are better in higher-level units and that reduced availability of mid-level units may increase their chance of receiving care in a high-level center, so that slower mid-level growth could have benefitted patients.
View details for Web of Science ID 000179256800010
View details for PubMedID 12585306
Management of ventricular arrhythmias in diverse populations in California
AMERICAN HEART JOURNAL
2002; 144 (3): 431-439
The use of coronary angiography and revascularization is lower than expected among black patients. It is uncertain whether use of other cardiac procedures also varies according to race and ethnicity and whether outcomes are affected.We analyzed discharge abstracts from all nonfederal hospitals in California of patients hospitalized for a primary diagnosis of ventricular tachycardia or ventricular fibrillation between 1992 and 1994. We compared mortality rates and use of electrophysiologic study (EPS) and implantable cardioverter-defibrillator (ICD) procedures according to the race and ethnicity of the patient.Among 8713 patients admitted with ventricular tachycardia or ventricular fibrillation, 29% (n = 2508) had a subsequent EPS procedure, and 9% (n = 818) had an ICD implanted. After controlling for potential confounding factors, we found that black patients were significantly less likely than white patients to undergo EPS (odds ratio 0.72, CI 0.56-0.92) or ICD implantation (odds ratio 0.39, CI 0.25-0.60). Blacks discharged alive from the initial hospital admission had higher mortality rates over the next year than white patients, even after controlling for multiple confounding risk factors (risk ratio 1.18, CI 1.03-1.36). The use of EPS and ICD procedures was also significantly affected by several other factors, most notably by on-site procedure availability but also by age, sex, and insurance status.In a large population of patients hospitalized for ventricular arrhythmia, blacks had significantly lower rates of utilization for EPS and ICD procedures and higher subsequent mortality rates.
View details for DOI 10.1067/mhj.2002.125500
View details for Web of Science ID 000178086800010
View details for PubMedID 12228779
Effect of managed care on preventable hospitalization rates in California
2002; 40 (4): 315-324
Hospitalization rates for ambulatory care-sensitive (ACS) conditions have emerged as a potential indicator of health care access and quality. The effect of managed care on reducing these potentially preventable hospitalizations is unknown.To ascertain whether increases in managed care penetration were associated with changes in hospitalization rates for ACS conditions.Longitudinal analysis between 1990 and 1997 of all California hospitalizations for ACS conditions aggregated to 394 small areas.Association of change in ACS hospitalization rate with change in managed care penetration.In unadjusted analysis there was no association between the change in managed care penetration and the change in hospitalization rates for ACS conditions over time. However, in a multivariate model that controlled for changes in area demographics and hospitalization rates for marker conditions that were assumed to be stable over time, the change in managed care penetration was negatively associated with a small but statistically significant change in the ACS hospitalization rate. Each 10-point increase in percentage private managed care penetration was associated with a 3.1% decrease in the ACS hospitalization rate (95% CI, -5.4% to -0.8%)Overall, in California, an increase in the penetration of private managed care in a community was associated with a decrease in ACS admission rates. Additional research is needed to determine if the observed association is causal, the mechanism of the effect and whether it represents an improvement in patients' health outcomes.
View details for Web of Science ID 000174712000007
View details for PubMedID 12021687
Managed care, medical technology, and the well-being of society.
Topics in magnetic resonance imaging
2002; 13 (2): 107-113
The growth of managed care could have widespread effects on the structure and functioning of the health care delivery system, potentially influencing all patients, even those not enrolled in managed care plans. One important mechanism by which managed care could have such broad effects is by influencing technology development and adoption. This article examines available literature on the effects of managed care activity on technology adoption and the implications of any effects on patient care, outcomes, and health care costs. Existing literature supports the view that managed care has contributed to slowing the adoption of new technologies, particularly the high-cost, high-profile technologies that have been the focus of the most attention. The literature outlining the effects of managed-care-induced changes in technology adoption on patient care and outcomes is not large, but what literature there is tends not to find negative effects on patient care and outcomes. Specific evidence about costs also is somewhat sparse, but it suggests that managed care has contributed to some reduction in health care spending, although the extent to which savings will persist over time is unclear. Although evidence thus far does not suggest important detrimental effects of managed care on care or outcomes and even indicates some benefit through savings, it should be noted that existing literature has only explored a small number of the many technologies and services that might have been influenced, and there remain issues for the future that deserve vigilance.
View details for PubMedID 12055455
The burden of out-of-pocket payments for health care in Tbilisi, Republic of Georgia
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2002; 287 (8): 1043-1049
In the 1990s, the Republic of Georgia instituted health care reforms to convert the centralized, state-operated health care system inherited from the Soviet Union to a decentralized, market-driven system of health care delivery. Under the new system, 87% of health care expenditures are financed through out-of-pocket payments at the point of service.To describe the effects of health care reforms on access to care and health care financing among ill residents of Tbilisi, Georgia.A probability-proportionate-to-size cluster survey conducted in 1999 of 248 households containing 306 household members who had been ill in the past 6 months in Tbilisi, Georgia.Reported health care utilization, out-of-pocket expenditures, and financing practices.Of sick household members, 51% used official health care services at hospitals and clinics; 49% did not use official services and sought advice from relatives or friends, used traditional medicines, or did nothing. Those with serious illness were more likely to seek care through official services (82%) than those with nonserious illness (27%). Ninety-three percent of respondents said costs were the major deterrent to obtaining health care. Ten percent of ill household members reported that they were unable to obtain health care because of high costs; 16% reported being unable to afford all the medications necessary to treat their illness. Sixty-one percent of ill household members used savings to pay for health care expenditures and 19% of those able to obtain care had to use strategies such as borrowing money or selling personal items to pay for health care. Total out-of-pocket health care expenditures (53%) were paid for by borrowing money or selling personal items. A significant portion of households with ill members (87%) reported an interest in purchasing health care insurance.Economic disruption and health care reforms have led to access problems and out-of-pocket financing strategies that include reliance on personal savings, selling personal items, and borrowing money. Future reforms should consider an appropriate system for health care insurance risk pooling for the population of Tbilisi, Georgia.
View details for Web of Science ID 000174052100036
View details for PubMedID 11866656
The relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction
AMERICAN JOURNAL OF MEDICINE
2002; 112 (3): 176-182
To determine if greater managed care market share is associated with greater use of recommended therapies for fee-for-service patients with acute myocardial infarction.We examined the care of 112,900 fee-for-service Medicare beneficiaries aged > or = 65 years who resided in one of 320 metropolitan statistical areas and who were admitted with an acute myocardial infarction between February 1994 through July 1995. Use of recommended medical treatments and 30-day survival were determined for areas with low (<10%), medium (10% to 30%), and high (>30%) managed care market share.After adjustment for severity of illness, teaching status of the admission hospital, and area characteristics, areas with high levels of managed care had greater use of beta-blockers (relative risk [RR] for greater use = 1.18; 95% confidence interval [CI]: 1.06 to 1.29) and aspirin at discharge (RR = 1.05; 95% CI: 1.02 to 1.07), but less appropriate coronary angiography (RR = 0.93; 95% CI: 0.86 to 1.01) and reperfusion (RR = 0.95; 95% CI: 0.85 to 1.03) when compared with areas with low levels of managed care.Medicare beneficiaries with fee-for-service insurance who resided in areas with high managed care activity were more likely to have received appropriate treatment with beta-blockers and aspirin, and less likely to have undergone coronary angiography following admission for myocardial infarction. Thus, the effects of managed care may not be limited to managed care enrollees.
View details for Web of Science ID 000174602100002
View details for PubMedID 11893343
Managed care, health care quality, and regulation
Conference on the Regulation of Managed Care Organizations and the Doctor-Patient Relationship
UNIV CHICAGO PRESS. 2001: 715–41
View details for Web of Science ID 000177714700014
Managed care and technology adoption in health care: evidence from magnetic resonance imaging
JOURNAL OF HEALTH ECONOMICS
2001; 20 (3): 395-421
This paper empirically examines the relationship between HMO market share and the diffusion of magnetic resonance imaging (MRI) equipment. Across markets, increases in HMO market share are associated with slower diffusion of MRI into hospitals between 1983 and 1993, and with substantially lower overall MRI availability in the mid- and later 1990s. High managed care areas also had markedly lower rates of MRI procedure use. These results suggest that technology adoption in health care can respond to changes in financial and other incentives associated with managed care, which may have implications for health care costs and patient welfare.
View details for Web of Science ID 000168292500006
View details for PubMedID 11373838
Measuring competition in health care markets
Conference on Data Needs for Studies of Competition in Market Ares
WILEY-BLACKWELL PUBLISHING, INC. 2001: 223–51
Measuring competition is increasingly important for analysis of health care markets and policies. Measurement of competition in health care is made complex by the breadth of potential issues under study, by the lack of necessary data, and by rapid changes in health care financing and delivery. This study reviews key issues in the measurement of competition and is designed to familiarize researchers and policymakers interested in competition measurement, but not steeped in its practice, with key concepts, data sources, and ways of adapting measures to fit ongoing changes in health care markets.Attention to several key issues will strengthen measurement. Important components of successful measurement are: careful identification of the products and market areas for study; selection of Herfindahl-Hirschman or other indices to fit the issues being considered; consideration of econometric problems, like endogeneity, with common measures; and attention to the ways that current marketplace changes, like growth in managed care, affect the performance of classic measures. Data needed for constructing measures are also frequently scarce, insufficient, or both. Measurement could be improved with access to better data.
View details for Web of Science ID 000168024100004
View details for PubMedID 11327175
The impact of practice setting on physician perceptions of the quality of practice and patient care in the managed care era
ARCHIVES OF INTERNAL MEDICINE
2001; 161 (2): 202-211
Managed care is practiced in both traditional institutional health maintenance organization (HMO) settings and in a variety of complex and decentralized office-based arrangements. This study examines how practice setting affects physician perceptions of the quality of professional practice and patient care in a managed care environment.A survey was conducted in 1998 of 1081 physicians in San Mateo County, California, who practice in either a traditional staff group model HMO (SGM-HMO) (n = 113) or office-based independent practice (OBIP) (n = 250). Respondents were surveyed about current and past practice characteristics, income changes, current satisfaction with professional and patient care matters, utility of treatment guidelines and formularies, and general perceptions of managed care. Responses were compared between practice settings using bivariate comparisons and logistic regression analyses.Physicians in the SGM-HMO and those in OBIP reported similar hours worked per week, time spent with patients during office visits, and total patient encounters per week. Declining income was more frequent in OBIP (61% vs 47%) and relatively more substantial (27% with income declines >25% vs 4% in SGM-HMO). Adjusting for income changes, practice setting, years in practice, and sex, SGM-HMO physicians were significantly more satisfied with a variety of professional and quality of care issues (P<.001), viewed more favorably the utility of treatment guidelines and drug formularies (P<.001), and held more positive general perceptions of managed care (P<.001) than OBIP physicians.In a managed care environment, SGM-HMO physicians are significantly more satisfied with the quality of practice and patient care than physicians in OBIP. This study suggests that the myriad managed care contracts, formularies, and guidelines received by physicians in OBIPs may lead to more negative perceptions of the quality of professional practice and patient care.
View details for Web of Science ID 000166480500008
View details for PubMedID 11176733
- Managed Care, Health Care Quality, and Regulation Journal of Legal Studies 2001; 30 (2, part 2): 715-742
The effect of passing an "anti-immigrant" ballot proposition on the use of prenatal care by foreign-born mothers in California.
Journal of immigrant health
2000; 2 (4): 203-212
This study examines whether the passage of California's Proposition 187, a proposition designed to restrict undocumented immigrants from using public services, had a negative effect on the use of prenatal care and birth outcomes. Comparisons of prenatal care use and birth outcomes before and after the passage of the proposition are made between low-education foreign-born and U.S.-born mothers using California's Birth Public Use files. Multivariate linear and logistic regressions were used to control for regional and maternal characteristics. We find a significant but small decline in the use of prenatal care by low-education foreign-born women after Proposition 187 passed; however, there was no detectable deterioration of birth outcomes. Whether future reductions in the availability of prenatal care would damage the health of children is unclear.
View details for PubMedID 16228741
HMO market penetration and costs of employer-sponsored health plans
2000; 19 (5): 121-128
Using two employer surveys, we evaluate the role of increased health maintenance organization (HMO) market share in containing costs of employer-sponsored coverage. Total costs for employer health plans are about 10 percent lower in markets in which HMOs' market share is above 45 percent than they are in markets with HMO enrollments of below 25 percent. This is the result of lower premiums for HMOs than for non-HMO plans, as well as the competitive effect of HMOs that leads to lower non-HMO premiums for employers that continue to offer these benefits. Slower growth in premiums in areas with high HMO enrollments suggests that expanded HMO market share may also lower the long-run growth in costs.
View details for Web of Science ID 000089288200014
View details for PubMedID 10992659
Medicaid policy, physician behavior, and health care for the low-income population
JOURNAL OF HUMAN RESOURCES
2000; 35 (3): 480-502
View details for Web of Science ID 000088449200004
'Competition' among employers offering health insurance
JOURNAL OF HEALTH ECONOMICS
2000; 19 (1): 121-140
Most employees contribute towards the cost of employer-sponsored insurance, despite tax laws that favor zero contributions. Contribution levels vary markedly across firms, and the average contribution (as a percentage of the premium) has increased over time. We offer a novel explanation for these facts: employers raise contribution levels to encourage their employees to obtain coverage from their spouses' employer. We develop a model to show how the employee contribution required by a given firm depends on characteristics of the firm and its work force, and find empirical support for many of the model's predictions.
View details for Web of Science ID 000084635300005
View details for PubMedID 10947570
- Medicaid Policy, Physician Behavior, and Health Care for the Low-Income Population Journal of Human Resources 2000; 35 (3): 480-502
Physicians' perceptions of autonomy and satisfaction in California
1999; 18 (4): 134-145
This study compares levels of satisfaction and autonomy among California physicians using data from a 1991 survey of physicians and a 1996 survey of California physicians. The surveys measured physicians' perceived freedom to undertake eight common activities that may be threatened by marketplace changes, satisfaction with current practice, and inclination to attend medical school again. Young physicians in 1996 were significantly less likely to report that they were able to spend enough time on the eight identified patient-care activities. They also were significantly less satisfied with their current practice and less likely to say that they would go to medical school again. Satisfaction also declined for older physicians between 1991 and 1996.
View details for Web of Science ID 000081518400015
View details for PubMedID 10425851
Managed care, consolidation among health care providers, and health care: evidence from mammography
RAND JOURNAL OF ECONOMICS
1999; 30 (2): 351-U2
We discuss the effects of managed care on the structure of the health care delivery system, focusing on managed-care-induced consolidation among health care providers. We empirically investigate the relationship between HMO market share and mammography providers. We find evidence of consolidation: increases in HMO activity are associated with reductions in the number of mammography providers and with increases in the number of services produced by remaining providers. We also find that increases in HMO market share are associated with reductions in costs for mammography and with increases in waiting times for appointments, but not with worse health outcomes.
View details for Web of Science ID 000080841000009
View details for PubMedID 10558503
Association of managed care market share and health expenditures for fee-for-service Medicare patients
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1999; 281 (5): 432-437
Managed care has the potential to transform fundamentally the structure and functioning of the entire health care system, including the care provided to patients who are not enrolled in managed care plans.To determine whether increasing health maintenance organization (HMO) market share is associated with decreased expenditures for the care of patients covered by Medicare's traditional fee-for-service plan, a group cared for well outside the boundaries of managed care.Data from the Health Care Financing Administration were used to compare expenditures for the care of Medicare fee-for-service beneficiaries for 802 market areas, representing the entire United States, for 1990 to 1994. These data were matched with data on system-wide (Medicare and non-Medicare) HMO market share in these areas.All fee-for-service Medicare beneficiaries (1990-1994) except for those with end-stage renal disease.Average fee-for-service expenditure per fee-for-service Medicare beneficiary by market area.In a regression model, increases in system-wide HMO market share were associated with declines in both Part A and Part B fee-for-service expenditures per Medicare beneficiary (P<.001). Increases from 10% market share to 20% market share were associated with 2.0% decreases in Part A fee-for-service expenditures and 1.5% decreases in Part B fee-for-service expenditures.Managed care can have widespread effects on the health care system. Health care for individuals who are not covered by managed care organizations can be influenced by the presence of managed care. Lower expenditures in areas with high HMO market shares may indicate that traditional Medicare beneficiaries in areas with high market shares received fewer or less intensive services than traditional Medicare beneficiaries in other areas.
View details for Web of Science ID 000078318500031
View details for PubMedID 9952203
Effect of an intensive educational program for minority college students and recent graduates on the probability of acceptance to medical school
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1998; 280 (9): 772-776
Increasing the number of minority physicians is a long-standing goal of professional associations and government.To determine the effectiveness of an intensive summer educational program for minority college students and recent graduates on the probability of acceptance to medical school.Nonconcurrent prospective cohort study based on data from medical school applications, Medical College Admission Tests, and the Association of American Medical Colleges Student and Applicant Information Management System.Eight US medical schools or consortia of medical schools.Underrepresented minority (black, Mexican American, mainland Puerto Rican, and American Indian) applicants to US allopathic medical schools in 1997 (N =3830), 1996 (N = 4654), and 1992 (N =3447).The Minority Medical Education Program (MMEP), a 6-week, residential summer educational program focused on training in the sciences and improvement of writing, verbal reasoning, studying, test taking, and presentation skills.Probability of acceptance to at least 1 medical school.In the 1997 medical school application cohort, 223 (49.3%) of 452 MMEP participants were accepted compared with 1406 (41.6%) of 3378 minority nonparticipants (P= .002). Positive and significant program effects were also found in the 1996 (P=.01) and 1992 (P=.005) cohorts and in multivariate analysis after adjusting for nonprogrammatic factors likely to influence acceptance (P<.001). Program effects were also observed in students who participated in the MMEP early in college as well as those who participated later and among those with relatively high as well as low grades and test scores.The MMEP enhanced the probability of medical school acceptance among its participants. Intensive summer education is a strategy that may help improve diversity in the physician workforce.
View details for Web of Science ID 000075609900004
View details for PubMedID 9729987
Managed care and technology diffusion: The case of MRI
1998; 17 (5): 195-207
A growing body of evidence suggests that managed care can reduce overall health care costs but provides little insight into how this could happen. One possibility is that managed care influences the adoption of new medical technologies. In examining the relationship between health maintenance organization (HMO) activity and market-level availability and use of magnetic resonance imaging (MRI), we find that high HMO market share is associated with low levels of MRI availability and use. This suggests that managed care may be able to reduce health care costs by influencing the adoption and use of new medical equipment and technologies.
View details for Web of Science ID 000075974700016
View details for PubMedID 9769583
Factors associated with women's adherence to mammography screening guidelines
HEALTH SERVICES RESEARCH
1998; 33 (1): 29-53
To examine individual and environmental factors associated with adherence to mammography screening guidelines.A unique data set that combines a national probability sample (1992 National Health Interview Survey); a national probability sample of mammography facility characteristics (1992 National Survey of Mammography Facilities); county-level data on 1990 HMO market share; and county-level data on the supply of primary care providers (1991 Area Resource File).The design was cross-sectional. DATA EXTRACTION/ANALYSIS: Data sets were linked to create an individual-level sample of women ages 50-74 (weighted n = 2,026). We used multipart, sequential logistic regression models to examine the predictors of having ever had mammography, having had recent mammography, and adherence to guidelines. We categorized women as adherent if they reported a lifetime number of exams appropriate for their age (based on screening every two years) and they reported having had an exam in the past two years.Only 27 percent of women had the age-appropriate number of screening exams (range 16 percent-37 percent), while 59 percent of women had been screened within two years. Women were significantly more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened; were younger; had smaller families, higher education and income, and a recent Pap smear; reported breast problems; and lived in an area with a higher percentage of mammography facilities with reminder systems, no shortage of primary care providers, higher HMO market share, and higher screening charges.A small percentage of women adhere to screening guidelines, suggesting that adherence needs to become a focus of clinical, programmatic, and policy efforts.
View details for Web of Science ID 000072969900004
View details for PubMedID 9566176
Can we explain the differences in neonatal mortality between patients insured by health maintenance organizations and patients insured by other private insurance in California?
LIPPINCOTT WILLIAMS & WILKINS. 1998: 158A–158A
View details for Web of Science ID 000071684700847
Factors associated with the perception that debt influences physicians' specialty choices
1997; 72 (12): 1088-1096
To investigate the responses of individual physicians to educational debt.Data on 5,175 physicians were taken from the 1991 Robert Wood Johnson Foundation Survey of Young Physicians, a nationally representative survey of physicians under age 45 who had had two to ten years of practice experience as of 1991. The physicians' overall perceptions about the extents to which debt had been an important determinant of specialty choice were explored using multivariate logistic regression analyses.Only 3.2% of the physicians indicated that debt had had a major influence on their specialty choices. About half (56%) of those who felt that debt had been a major influence indicated that they had foregone some training because of their debt levels. Controlling for debt level, the physicians who had had children during medical school and those whose parents had less education and lower incomes were more likely to say that debt had been an influence (p < .05). An examination of the specialties that the physicians reported having foregone because of debt indicated that these physicians had reacted to debt in different ways--some had chosen more specialized fields while others had chosen more generalized fields.While the overall effect of debt was small, some individuals were influenced by debt in a variety of ways. Paying attention to the effects of debt on this small population may improve training for some physicians and help better target programs that attempt to influence physicians by alleviating debt.
View details for Web of Science ID 000071232800028
View details for PubMedID 9435716
Market-level health maintenance organization activity and physician autonomy and satisfaction
AMERICAN JOURNAL OF MANAGED CARE
1997; 3 (9): 1357-1366
Managed care is widely expected to affect physicians throughout the healthcare system. In this study, we examined the relationship between health maintenance organization (HMO) activity and the level of competition, autonomy, and satisfaction perceived by physicians who do not work for HMOs. We obtained data on physicians from the 1991 Survey of Young Physicians, which contains a nationally representative sample of physicians younger than age 45 who had 2 to 9 years of practice experience in 1991. We examined the relationships between HMO market share and perceived competition, autonomy, and satisfaction using multivariate logistic regression. The main outcome measures were perceived level of competition; several measures of physicians' freedom to undertake common tasks that might be threatened by managed care (e.g., hospitalizing patients, ordering tests and procedures); satisfaction with current practice situation; perceived ability to practice quality medicine; whether the physician would attend medical school again; and satisfaction with medicine as a career. We found that an increase of 10 percentage points in HMO market share was associated with a 28% increase in the probability that physicians will regard their practice situation as very competitive as opposed to somewhat or not competitive (P < 0.01). Examinations of the relationship between HMO market share and autonomy and satisfaction revealed few significant results. We found no evidence that increases in HMO activity adversely affect physician autonomy. Only a limited amount of evidence indicates that increases in HMO activity reduce the satisfaction of specialist physicians, and no evidence associates HMO activity with the satisfaction of generalists. Although physicians perceive HMOs as competitors, HMO activity has not had a strong negative effect on the autonomy and satisfaction of physicians.
View details for Web of Science ID A1997YJ15500008
View details for PubMedID 10178484
The effect of HMOs on fee-for-service health care expenditures: Evidence from Medicare
JOURNAL OF HEALTH ECONOMICS
1997; 16 (4): 453-481
This paper examines the relationship between HMO market share and fee-for-service health care expenditures using 1986-1990 county- and metropolitan statistical area-level data on Medicare expenditures and HMO market share. Fixed-effects estimates imply that fee-for-service expenditures are concave and decreasing in market share. Increases in market share from 20% to 30% are associated with 3-7% expenditure reductions. Instrumental variable estimates that exploit cross-sectional variation in HMO activity also indicate a concave relationship, with expenditures declining in market share for market shares above 15-18%, but imply larger expenditure responses to market share changes.
View details for Web of Science ID A1997XJ67900005
View details for PubMedID 10169101
Physician service to the underserved: Implications for affirmative action in medical education
INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING
1996; 33 (2): 167-180
Affirmative action is under increasing scrutiny. In medicine, the observation that minority physicians disproportionately serve minority patients has been one rationale for affirmative action. Using two large physician surveys, we find that minority and women physicians are much more likely to serve minority, poor, and Medicaid populations. Weaker, but significant association exists between physician and patient socioeconomic background. Service patterns are sustained over time and are generally consistent with physician career preferences. Ending affirmative action in medicine may imperil access to care. Results do not support affirmative action based on economic disadvantage instead of race, ethnicity, and sex.
View details for Web of Science ID A1996UW89300009
View details for PubMedID 8675280
- HMO penetration and the cost of health care: Market discipline or market segmentation? 108th Annual Meeting of the American-Economic-Association AMER ECONOMIC ASSOC. 1996: 389–94
Differences in earnings between male and female physicians
NEW ENGLAND JOURNAL OF MEDICINE
1996; 334 (15): 960-964
Male physicians have long earned more than female physicians, even after differences in the number of hours worked, specialty, practice setting, and other characteristics are taken into account. Whether earnings patterns have changed recently is not known.I examined data on earnings from the 1991 Survey of Young Physicians, a nationwide survey of physicians under 45 years of age with two to nine years of practice experience. The results were compared with data from the 1987 Survey of Young Physicians and with data on the earnings of physicians with 10 or more years of experience from the American Medical Association's 1991 Socioeconomic Monitoring System survey.In 1990, young male physicians earned 41 percent more per year than young female physicians (male:female earnings ratio, 1.41; 95 percent confidence interval, 1.34 to 1.49). Per hour, young men earned 14 percent more than young women (ratio, 1.14; 95 percent confidence interval, 1.09 to 1.20). However, after adjusting for differences in specialty, practice setting, and other characteristics, no earnings difference was evident (ratio, 1.00; 95 percent confidence interval, 0.96 to 1.04). In general practice and family practice, women earned more than men, after adjustment for differences in other characteristics (ratio, 0.87; 95 percent confidence interval, 0.78 to 0.97). In internal-medicine subspecialties and emergency medicine, men earned more than women (ratio, 1.26; 95 percent confidence interval, 1.10 to 1.44). Among physicians with 10 or more years of experience, men also earned more than women (ratio, 1.17; 95 percent confidence interval, 1.07 to 1.27).Young male and female physicians with similar characteristics earn equal amounts of money. However, differences in earnings between men and women remain among older physicians and in some specialties.
View details for Web of Science ID A1996UD59600006
View details for PubMedID 8596598
Medical costs in workers' compensation insurance
JOURNAL OF HEALTH ECONOMICS
1995; 14 (5): 531-549
We examine whether patients covered by workers' compensation insurance, which covers the cost of medical care for injured workers without cost sharing and with relatively little oversight, are charged more for treatment or receive more services than patients covered by traditional insurance. Our findings indicate that workers compensation recipients are charged more for treatment. This difference persists in individual services--workers' compensation recipients are charged more per X-ray and per examination than our patients. We consider different explanations and argue that price discrimination probably plays a role.
View details for Web of Science ID A1995TX26300002
View details for PubMedID 10156500
Tracking the changes in physician practice settings.
Archives of family medicine
1995; 4 (9): 759-765
To describe the relationships among types of practice settings and physician characteristics and to document changes in these relationships over time.Two national telephone surveys of randomly selected young physicians were conducted in 1987 and 1991. The 1991 survey included reinterviews of 1987 respondents, providing both cohort and repeated cross-sectional data.The 1987 survey included data on 5312 physicians who had between 2 and 6 years of practice experience and were under age 41 years. The 1991 survey included data on 5002 physicians under age 45 years and in practice between 2 and 10 years, including 2151 reinterviews of 1987 respondents.Practice settings were classified as traditional, government, group, or managed, based on ownership, practice type, group size, and managed care contracts.Physician sex, race/ethnicity, specialty, and type of medical school were related to the type of practice setting. Young physicians were less likely to practice in traditional settings in 1991 than in 1987 and were more likely to practice in organized practice settings, especially in managed practices.Between 1987 and 1991, there was a significant shift away from traditional physician practice settings toward organized practice settings.
View details for PubMedID 7647941
What makes young HMO physicians satisfied?
1994; 8 (2): 53-57
While much attention has been paid to the effect of managed care on patient outcomes and health care costs, little attention has been focused on the ways in which managed care affects the satisfaction of physicians. Examination of the practice and career satisfaction of 189 young physicians practicing in group and staff model HMOs finds high levels of satisfaction. More than 82% are satisfied with their current practice. The most important factor influencing physician satisfaction appears to be the extent of perceived autonomy. Neither the number of hours worked per week nor yearly income were strongly associated with decreases in satisfaction. The fact that minority and female physicians report less satisfaction with some dimensions of practice raises important issues for HMO physicians and managers.
View details for PubMedID 10135262
EXCESS COST OF EMERGENCY DEPARTMENT VISITS FOR NONURGENT CARE
1994; 13 (5): 162-171
After examining data for patients with selected conditions and statistically adjusting for patient, diagnosis, and treatment characteristics, this Data Watch finds that charges for emergency department visits were two to three times more than charges for visits in other settings. Large differences persist when conditions are examined individually and when total episode charges are examined. Based on our findings, a rough estimate of nationwide excess charges is $5-$7 billion for 1993.
View details for Web of Science ID A1994QB58700017
View details for PubMedID 7868020
PREPAREDNESS FOR PRACTICE - YOUNG PHYSICIANS VIEWS OF THEIR PROFESSIONAL-EDUCATION
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1993; 270 (9): 1035-1040
To describe the views of young physicians (younger than age 45 years) regarding the appropriateness of specific aspects of medical training that have often been criticized as inadequate.Proportional analysis of survey data, stratified by medical school type and graduate medical education specialty and adjusted for demographics.National sample of 4756 allopathic and osteopathic physicians trained in allopathic residencies representing a variety of practice settings. DEPENDENT VARIABLES: Overall satisfaction with medical training, including medical school through residency and fellowship; satisfaction with preparedness for five aspects of practice and six types of patients; and satisfaction with the amount of time spent in each of six training settings.Eighty percent of young physicians reported that their formal medical training did an excellent or good job of preparing them for medical practice. Much smaller proportions (21% to 78%) reported excellent or good preparation to treat specific conditions or types of patients, and few (3%) reported being well prepared to manage business aspects of practice. Large proportions (35% to 63%) would prefer to have received more training in settings outside of hospitals, including managed care settings (67%). Significant differences in preparedness were observed by type of training; those trained in general and family practice reported better preparedness along many dimensions than did those trained in general internal medicine.Young physicians generally confirm critiques of medical training noted by scholars and commissions. Health care reform is likely to increase the urgency for remedial action.
View details for Web of Science ID A1993LU51200002
View details for PubMedID 8350444
PHYSICIAN SATISFACTION UNDER MANAGED CARE
1993; 12: 258-270
Data from a survey of young physicians have been analyzed to study the relationship between practicing medicine under managed care and the levels of perceived professional autonomy, practice satisfaction, and career satisfaction. Although practicing under managed care is associated with lower levels of perceived autonomy in patient selection and time allocation, it is associated with higher levels of perceived autonomy in use of hospital care, tests, and procedures. Specialists associated with managed care perceive more autonomy than generalists. Analyses of physicians' satisfaction with their practices and careers show that practicing under managed care is not uniformly associated with lower levels of satisfaction. Overall, managed care does not seem to have had the deleterious impact on medical practice that was forecast for it.
View details for Web of Science ID A1993KT25500020
View details for PubMedID 8477938
24-HOUR COVERAGE AND WORKERS COMPENSATION INSURANCE
1993; 12: 271-281
Workers' compensation insurance provides cash benefits and health care for workers who are injured on the job. This DataWatch considers the costs and benefits of combining the health insurance component of workers' compensation with universal health insurance, creating a twenty-four-hour coverage plan. The paper documents a large potential savings from twenty-four-hour coverage: Workers' compensation medical charges are about twice as high as those for comparable off-work injuries. This disparity seems to result from price discrimination and lack of cost controls in workers' compensation. Twenty-four-hour coverage, however, may be difficult to implement.
View details for Web of Science ID A1993KT25500021