Academic Appointments


Administrative Appointments


  • Senior Fellow, Stanford Institute for Economic Policy Research (2015 - Present)
  • Research Associate, National Bureau of Economic Research (2002 - Present)
  • Director of the Scholarly Concentration Program, Stanford University (2007 - Present)
  • Fellow, Stanford Center for Health Policy (2000 - Present)
  • Department Chair, Department of Health Research and Policy (2015 - 2019)
  • Chief of Health Services Research, Department of Health Research and Policy (2001 - 2015)
  • Catherine R. Kennedy and Daniel L. Grossman Fellow in Human Biology, Human Biology Program (2016 - 2020)

Honors & Awards


  • Elected member, National Academy of Medicine (2020-)
  • ASHE Medal, American Society of Health Economists (2008)
  • Alice S. Hersh Young Investigator Award, Academy for Health Services Research and Health Policy (2000)
  • NIHCM Research Award, National Institute for Health Care Management (1999)

Boards, Advisory Committees, Professional Organizations


  • Member, Board of Directors, AcademyHealth (2012 - 2020)
  • President, American Society of Health Economists (2018 - 2019)
  • Member, Board of Directors, American Society of Health Economists (2009 - 2017)
  • Member, Board of Directors, International Health Economics Association (2010 - 2016)

Program Affiliations


  • Public Policy

Professional Education


  • 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.

Stanford Advisees


All Publications


  • ACA Marketplace Premiums and Competition Among Hospitals and Physician Practices AMERICAN JOURNAL OF MANAGED CARE Polyakova, M., Bundorf, M., Kessler, D. P., Baker, L. C. 2018; 24 (2): 85-+

    Abstract

    To examine the association between annual premiums for health plans available in Federally Facilitated Marketplaces (FFMs) and the extent of competition and integration among physicians and hospitals, as well as the number of insurers.We used observational data from the Center for Consumer Information and Insurance Oversight on the annual premiums and other characteristics of plans, matched to measures of physician, hospital, and insurer market competitiveness and other characteristics of 411 rating areas in the 37 FFMs.We estimated multivariate models of the relationship between annual premiums and Herfindahl-Hirschman indices of hospitals and physician practices, controlling for the number of insurers, the extent of physician-hospital integration, and other plan and rating area characteristics.Premiums for Marketplace plans were higher in rating areas in which physician, hospital, and insurance markets were less competitive. An increase from the 10th to the 90th percentile of physician concentration and hospital concentration was associated with increases of $393 and $189, respectively, in annual premiums for the Silver plan with the second lowest cost. A similar increase in the number of insurers was associated with a $421 decrease in premiums. Physician-hospital integration was not significantly associated with premiums.Premiums for FFM plans were higher in markets with greater concentrations of hospitals and physicians but fewer insurers. Higher premiums make health insurance less affordable for people purchasing unsubsidized coverage and raise the cost of Marketplace premium tax credits to the government.

    View details for PubMedID 29461855

  • The effect of hospital/physician integration on hospital choice JOURNAL OF HEALTH ECONOMICS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2016; 50: 1-8

    Abstract

    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 PubMedID 27639202

  • Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays. Health affairs Baker, L. C., Bundorf, M. K., Devlin, A. M., Kessler, D. P. 2016; 35 (8): 1444-1451

    Abstract

    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

  • Does health plan generosity enhance hospital market power? Journal of health economics Baker, L. C., Bundorf, M. K., Kessler, D. P. 2015; 44: 54-62

    Abstract

    We test whether the generosity of employer-sponsored health insurance facilitates the exercise of market power by hospitals. We construct indices of health plan generosity and the price and volume of hospital services using data from Truven MarketScan for 601 counties from 2001 to 2007. We use variation in the industry and union status of covered workers within a county over time to identify the causal effects of generosity. Although OLS estimates fail to reject the hypothesis that generosity facilitates the exercise of hospital market power, IV estimates show a statistically significant and economically important positive effect of plan generosity on hospital prices in uncompetitive markets, but not in competitive markets. Our results suggest that most of the aggregate effect of hospital market structure on prices found in previous work may be coming from areas with generous plans.

    View details for DOI 10.1016/j.jhealeco.2015.08.007

    View details for PubMedID 26402570

  • Less Physician Practice Competition Is Associated With Higher Prices Paid For Common Procedures. Health affairs Austin, D. R., Baker, L. C. 2015; 34 (10): 1753-1760

    Abstract

    Concentration among physician groups has been steadily increasing, which may affect prices for physician services. We assessed the relationship in 2010 between physician competition and prices paid by private preferred provider organizations for fifteen common, high-cost procedures to understand whether higher concentration of physician practices and accompanying increased market power were associated with higher prices for services. Using county-level measures of the concentration of physician practices and county average prices, and statistically controlling for a range of other regional characteristics, we found that physician practice concentration and prices were significantly associated for twelve of the fifteen procedures we studied. For these procedures, counties with the highest average physician concentrations had prices 8-26 percent higher than prices in the lowest counties. We concluded that physician competition is frequently associated with prices. Policies that would influence physician practice organization should take this into consideration.

    View details for DOI 10.1377/hlthaff.2015.0412

    View details for PubMedID 26438753

  • No Significant Association between Anesthesia Group Concentration and Private Insurer Payments in the United States ANESTHESIOLOGY Sun, E. C., Dexter, F., Macario, A., Miller, T. R., Baker, L. C. 2015; 123 (3): 507-514

    Abstract

    Markets for physician services are becoming increasingly concentrated, with many areas being dominated by a few groups. Antitrust authorities are concerned that increasing concentration will lead to inappropriately high payments for physician services from private insurers. The authors examined the association between market concentration and private insurer payments for anesthesia services.The authors obtained data on average payments from private insurers for five commonly used anesthesia Current Procedure Terminology codes for physicians located in 229 counties in the United States between 2002 and 2010. The authors calculated a measure of market concentration (the Herfindahl-Hirschman Index [HHI]) for anesthesiologists in each county using Medicare claims data. The authors then estimated the association between market concentration and private insurer payments using a difference-in-differences approach to minimize confounding.Private insurer payments to anesthesiologists in more concentrated markets were not significantly different from payments in less concentrated markets. Compared with the 25% of counties with the least concentration (counties with an HHI in the 0th to 25th percentile), payments in counties in the 25th to 50th percentile of HHI were approximately 0.51% less (95% CI, -2.3 to 1.3%, P = 0.95), whereas payments in counties in the 50th to 75th percentile of HHI were approximately 2.8% less (95% CI, -6.7 to 1.4%, P = 0.41) and payments in counties in the 75th to 100th percentile were approximately 3.1% less (95% CI, -8.1 to 1.2%, P = 0.32).Increasing market concentration of anesthesia groups is not associated with significantly greater payments from private insurers.

    View details for DOI 10.1097/ALN.0000000000000779

    View details for Web of Science ID 000363536900005

    View details for PubMedID 26192028

  • Concentration In Orthopedic Markets Was Associated With A 7 Percent Increase In Physician Fees For Total Knee Replacements HEALTH AFFAIRS Sun, E., Baker, L. C. 2015; 34 (6): 916-921

    Abstract

    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

  • Physician Practice Competition and Prices Paid by Private Insurers for Office Visits JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Baker, L. C., Bundorf, M. K., Royalty, A. B., Levin, Z. 2014; 312 (16): 1653-1662

    Abstract

    Physician practice consolidation could promote higher-quality care but may also create greater economic market power that could lead to higher prices for physician services.To assess the relationship between physician competition and prices paid by private preferred provider organizations (PPOs) for 10 types of office visits in 10 prominent specialties.Retrospective study in 1058 US counties in urbanized areas, representing all 50 states, examining the relationship between measured physician competition and prices paid for office visits in 2010 and the relationship between changes in competition and prices between 2003 and 2010, using regression analysis to control for possible confounding factors.Variation in the mean Hirschman-Herfindahl Index (HHI) of physician practices within a county by specialty (HHIs range from 0, representing maximally competitive markets, to 10,000 in markets served by a single [monopoly] practice).Mean price paid by county to physicians in each specialty by private PPOs for intermediate office visits with established patients (Current Procedural Terminology [CPT] code 99213) and a price index measuring the county-weighted mean price for 10 types of office visits with new and established patients (CPT codes 99201-99205, 99211-99215) relative to national mean prices.In 2010, across all specialties studied, HHIs were 3 to 4 times higher in the 90th-percentile county than the 10th-percentile county (eg, for family practice: 10th percentile HHI = 1023 and 90th percentile HHI = 3629). Depending on specialty, mean price for a CPT code 99213 visit was between $70 and $75. After adjustment for potential confounders, depending on specialty, prices at the 90th-percentile HHI were between $5.85 (orthopedics; 95% CI, $3.46-$8.24) and $11.67 (internal medicine; 95% CI, $9.13-$14.21) higher than at the 10th percentile. Including all types of office visits, price indexes at the 90th-percentile HHI were 8.3% (orthopedics; 95% CI, 5.0%-11.6%) to 16.1% (internal medicine; 95% CI, 12.8%-19.5%) higher. Between 2003 and 2010, there were larger price increases in areas that were less competitive in 2002 than in initially more competitive areas.More competition among physicians is related to lower prices paid by private PPOs for office visits. These results may inform work on policies that influence practice competition.

    View details for DOI 10.1001/jama.2014.10921

    View details for Web of Science ID 000343301400022

  • Patients' Preferences Explain A Small But Significant Share Of Regional Variation In Medicare Spending HEALTH AFFAIRS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 33 (6): 957-963

    Abstract

    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

  • Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health affairs Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 33 (5): 756-763

    Abstract

    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

  • Private insurers' payments for routine physician office visits vary substantially across the United States. Health affairs Baker, L., Bundorf, M. K., Royalty, A. 2013; 32 (9): 1583-1590

    Abstract

    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

  • The Relationship between Low Back Magnetic Resonance Imaging, Surgery, and Spending: Impact of Physician Self-Referral Status HEALTH SERVICES RESEARCH Shreibati, J. B., Baker, L. C. 2011; 46 (5): 1362-1381

    Abstract

    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

  • Acquisition Of MRI Equipment By Doctors Drives Up Imaging Use And Spending HEALTH AFFAIRS Baker, L. C. 2010; 29 (12): 2252-2259

    Abstract

    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

  • Contextual Determinants of Time to Surgery for Patients With Hip Fracture. JAMA network open Welch, J. M., Gomez, G. I., Chatterjee, M., Shapiro, L. M., Morris, A. M., Gardner, M. J., Sox-Harris, A. H., Baker, L., Koltsov, J. C., Castillo, T., Giori, N., Salyapongse, A., Kamal, R. N. 2023; 6 (12): e2347834

    Abstract

    Importance: Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions.Objective: To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals.Design, Setting, and Participants: This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022.Main Outcomes and Measures: Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds).Results: A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work.Conclusions and Relevance: In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

    View details for DOI 10.1001/jamanetworkopen.2023.47834

    View details for PubMedID 38100104

  • Freestanding Ambulatory Surgery Centers and Patients Undergoing Outpatient Knee Arthroplasty. JAMA network open Rajasingh, C. M., Baker, L. C., Wren, S. M. 2023; 6 (8): e2328343

    Abstract

    Importance: In 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown.Objectives: To describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs.Design, Setting, and Participants: This observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022.Main Outcomes and Measures: Characteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared.Results: A total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P<.001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P<.001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P=.01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P=.25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P<.001).Conclusions: This study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.

    View details for DOI 10.1001/jamanetworkopen.2023.28343

    View details for PubMedID 37561458

  • Association Between "Balance Billing" Legislation and Anesthesia Payments in California: A Retrospective Analysis. Anesthesiology Dixit, A., Heavner, D. L., Baker, L. C., Sun, E. C. 2023

    Abstract

    Insured patients who receive out-of-network care may receive a "balance bill" for the difference between the practitioner's charge and their insurer's contracted rate. In 2017, California banned balance billing for anesthesia care. We examined the association between California's law and subsequent payments for anesthesia care. We hypothesized that following the law's implementation, there would be no change in-network payment amounts, and that out-of-network payment amounts and the portion of claims occurring out-of-network would decline.We used average, quarterly, California county-level payment data (2013-2020) derived from a claims database of commercially-insured patients. Using a difference-in-differences approach, we estimated the change in payment amounts for intraoperative/intrapartum anesthesia care, along with the portion of claims occurring out-of-network, following the law's implementation. The comparison group was office visit payments, expected to be unaffected by the law. We prespecified that we would refer to differences of ≥10% as policy significant.Our sample consisted of 43,728 procedure code-county-quarter-network combinations aggregated from 4,599,936 claims. The law's implementation was associated with a significant 13.6% decline in payments for out-of-network anesthesia care (95%CI -16.5 to -10.6%; p<0.001), translating to an average $108 decrease across all procedures (95%CI -$149 to -$64). There was a statistically significant 3.0% increase in payments for in-network anesthesia care (95%CI 0.9 to 5.1%; p=0.007), translating to an average $87 increase (95%CI $64 to $110), which may be notable in some circumstances but did not meet our threshold for identifying a change as policy significant. There was a non-statistically significant increase in the portion of claims occurring out-of-network (10.0%, 95%CI -4.1 to 24.2%, p=0.155).California's balance billing law was associated with significant declines in out-of-network anesthesia payments in the first three years following implementation. There were mixed statistical and policy significant results for in-network payments and the proportion of out-of-network claims.

    View details for DOI 10.1097/ALN.0000000000004675

    View details for PubMedID 37406154

  • Changes in Medicaid enrollment during the COVID-19 pandemic across 6 states. Medicine Sun, R., Staiger, B., Chan, A., Baker, L. C., Hernandez-Boussard, T. 2022; 101 (52): e32487

    Abstract

    The coronavirus disease 2019 public health emergency (PHE) caused extensive job loss and loss of employer-sponsored insurance. State Medicaid programs experienced a related increase in enrollment during the PHE. However, the composition of enrollment and enrollee changes during the pandemic is unknown. This study examined changes in Medicaid enrollment and population characteristics during the PHE. A retrospective study documenting changes in Medicaid new enrollment and disenrollment, and enrollee characteristics between March and October 2020 compared to the same time in 2019 using full-state Medicaid populations from 6 states of a wide geographical region. The primary outcomes were Medicaid enrollment and disenrollment during the PHE. New enrollment included persons enrolled in Medicaid between March and October 2020 who were not enrolled in January or February, 2020. Disenrollment included persons who were enrolled in March of 2020 but not enrolled in October 2020. The study included 8.50 million Medicaid enrollees in 2020 and 8.46 million in 2019. Overall, enrollment increased by 13.0% (1.19 million) in the selected states during the PHE compared to 2019. New enrollment accounted for 24.9% of the relative increase, while the remaining 75.1% was due to disenrollment. A larger proportion of new enrollment in 2020 was among adults aged 27 to 44 (28.3% vs 23.6%), Hispanics (34.3% vs 32.5%) and in the financial needy (44.0% vs 39.0%) category compared to 2019. Disenrollment included a larger proportion of older adults (26.1% vs 8.1%) and non-Hispanics (70.3% vs 66.4%) than in 2019. Medicaid enrollment grew considerably during the PHE, and most enrollment growth was attributed to decreases in disenrollment rather than increases in new enrollment. Our results highlight the impact of coronavirus disease 2019 on state health programs and can guide federal and state budgetary planning once the PHE ends.

    View details for DOI 10.1097/MD.0000000000032487

    View details for PubMedID 36596028

  • The Price-Quality Mismatch: Are Negotiated Prices for Total Joint Arthroplasty Associated With Hospital Quality in a Large California Health System? Clinical orthopaedics and related research Zhuang, T., Shapiro, L. M., Baker, L. C., Kamal, R. N. 2022

    Abstract

    BACKGROUND: Price variations in healthcare can be caused by quality or factors other than quality such as market share, negotiating power with insurers, or hospital ownership model. Efforts to improve care value (defined as the ratio between health outcomes and price) by making healthcare prices readily accessible to patients are driven by the assumption this can help patients more easily identify high-quality, low-price clinicians and health systems, thus reducing price variations. However, if price variations are driven by factors other than quality, then strategies that involve payments for higher-quality care are unlikely to reduce price variation and improve value. It is unknown whether prices for total joint arthroplasty (TJA) are correlated with the quality of care or whether factors other than quality are responsible for price variation.QUESTIONS/PURPOSES: (1) How do prices insurers negotiate for TJA paid to a single, large health system vary across payer types? (2) Are the mean prices insurers negotiate for TJA associated with hospital quality?METHODS: We analyzed publicly available data from 22 hospitals in a single, large regional health system, four of which were excluded owing to incomplete quality information. We chose to use data from this single health system to minimize the confounding effects of between-hospital reputation or branding and geographic differences in the cost of providing care. This health system consists of large and small hospitals serving urban and rural populations, providing care for more than 3 million individuals. For each hospital, negotiated prices for TJA were classified into five payer types: commercial in-network, commercial out-of-network, Medicare Advantage (plans to which private insurers contract to provide Medicare benefits), Medicaid, and discounted cash pay. Traditional Medicare plans were not included because the prices are set statutorily, not negotiated. We obtained hospital quality measures from the Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services quality measures included TJA-specific complication and readmission rates in addition to hospital-wide patient survey star rating (measure of patient care experience) and total performance scores (aggregate measure of clinical outcomes, safety, patient experience, process of care, and efficiency). We evaluated the association between the mean negotiated hospital prices and Centers for Medicare and Medicaid Services quality measures using Pearson correlation coefficients and Spearman rho across all payer types. Statistical significance was defined as p < 0.0025.RESULTS: The mean ± SD overall negotiated price for TJA was USD 54,500 ± 23,200. In the descriptive analysis, the lowest negotiated prices were associated with Medicare Advantage (USD 20,400 ± 1800) and Medicaid (USD 20,300 ± 8600) insurance plans, and the highest prices were associated with out-of-network care covered by commercial insurance plans (USD 78,800 ± 9200). There was no correlation between the mean negotiated price and TJA complication rate (discounted cash price: r = 0.27, p = 0.29; commercial out-of-network: r = 0.28, p = 0.26; commercial in-network: r = -0.07, p = 0.79; Medicare Advantage: r = 0.11, p = 0.65; Medicaid: r = 0.03, p = 0.92), readmission rate (discounted cash price: r = 0.19, p = 0.46; commercial out-of-network: r = 0.24, p = 0.33; commercial in-network: r = -0.13, p = 0.61; Medicare Advantage: r = -0.06, p = 0.81; Medicaid: r = 0.09, p = 0.74), patient survey star rating (discounted cash price: r = -0.55, p = 0.02; commercial out-of-network: r = -0.53, p = 0.02; commercial in-network: r = -0.37, p = 0.13; Medicare Advantage: r = -0.08, p = 0.75; Medicaid: r = -0.02, p = 0.95), or total hospital performance score (discounted cash price: r = -0.35, p = 0.15; commercial out-of-network: r = -0.55, p = 0.02; commercial in-network: r = -0.53, p = 0.02; Medicare Advantage: r = -0.28, p = 0.25; Medicaid: r = 0.11, p = 0.69) for any of the payer types evaluated.CONCLUSION: There is substantial price variation for TJA that is not accounted for by the quality of care, suggesting that a mismatch between price and quality exists. Efforts to improve care value in TJA are needed to directly link prices with the quality of care delivered, such as through matched quality and price reporting mechanisms. Future studies might investigate whether making price and quality data accessible to patients, such as through value dashboards that report easy-to-interpret quality data alongside price information, moves patients toward higher-value care decisions.CLINICAL RELEVANCE: Efforts to better match the quality of care with negotiated prices such as matched quality and price reporting mechanisms, which have been shown to increase the likelihood of choosing higher-value care in TJA, could improve the value of care.

    View details for DOI 10.1097/CORR.0000000000002489

    View details for PubMedID 36729581

  • Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures: A Systematic Review. JAMA network open Tewari, P., Sweeney, B. F., Lemos, J. L., Shapiro, L., Gardner, M. J., Morris, A. M., Baker, L. C., Harris, A. S., Kamal, R. N. 2022; 5 (9): e2231911

    Abstract

    Importance: Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors.Objective: To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS.Evidence Review: A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components.Findings: Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements.Conclusions and Relevance: In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

    View details for DOI 10.1001/jamanetworkopen.2022.31911

    View details for PubMedID 36112373

  • Adoption of hospital diagnosis-related group financing in Switzerland and the availability of computed tomography scanners. Health economics Baker, L. C., Lamiraud, K. 2022

    Abstract

    We study the relationship between diagnosis-related group (DRG) financing and the availability of computed tomography (CT) scanners in Switzerland. A number of Swiss hospitals switched to DRG payment for a portion of their payments progressively between 2002 and 2011. As of 2012, all hospitals were required to use DRG payment for a substantial portion of reimbursement. We conducted two main analyses. First, we studied hospitals switching in 2002-2011 and estimated event study models to compare changes in CT availability before and after the adoption of DRG financing, using the hospitals that did not switch during this time as a comparison group. In the second, we compared trends in CT availability before and after 2012, for the hospitals that switched in that year. In both analyses, we find a statistically significant association between the switch to DRG financing and lower levels of CT availability.

    View details for DOI 10.1002/hec.4594

    View details for PubMedID 36046948

  • Prevalence, Burden, and Sources of Out-of-Network Billing in Elective Hand Surgery: A National Claims Database Analysis. The Journal of hand surgery Zhuang, T., Michaud, J. B., Shapiro, L. M., Baker, L. C., Welch, J. M., Kamal, R. N. 2022

    Abstract

    PURPOSE: Surprise out-of-network (OON) bills can represent a considerable cost burden on patients. However, OON billing remains underexplored in elective, outpatient surgery procedures, which have greater latitude for patient choice. We aimed to answer the following questions: (1) What is the prevalence and magnitude of OON charges in hand surgery? (2) What are the sources of OON charges? and (3) What factors are associated with OON charges?METHODS: We analyzed patient-level data from the Clinformatics Data Mart database. We identified patients undergoing carpal tunnel release, trigger finger release, wrist ganglion removal, de Quervain release, limited palmar fasciectomy, or thumb carpometacarpal arthroplasty at in-network facilities with an in-network primary surgeon. The primary outcome was the proportion of surgical episodes with at least 1 OON charge. Secondary outcomes included the magnitude of potential balance bills (portion of OON bill exclusive of the standardized payment and expected patient cost-sharing), sources of OON charges, and factors associated with OON charges.RESULTS: Of 112,211 elective hand surgery episodes, 8% (9,158) had at least 1 OON charge. OON charges ranged from $1,154 (95% confidence interval, $1,018-$1,289) for wrist ganglion removal to $3,162 (95% confidence interval, $2,902-$3,423) for thumb carpometacarpal arthroplasty. In episodes with OON charges, the major sources of OON charges were anesthesiologists (75% of episodes), durable medical equipment (10% of episodes), and pathologists (9% of episodes). Site of service, geographic region, and health exchange-purchased plans were highly associated with OON charges.CONCLUSIONS: Out-of-network billing can represent a substantial cost burden to patients and should be considered in perioperative decision-making in elective hand surgery.CLINICAL RELEVANCE: Understanding the potential costs related to OON services during a surgical episode, and its drivers, allows surgeons to consider detailed cost discussions during perioperative decision making.

    View details for DOI 10.1016/j.jhsa.2022.06.002

    View details for PubMedID 35927122

  • Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis. Clinical orthopaedics and related research Welch, J. M., Zhuang, T., Shapiro, L. M., Harris, A. H., Baker, L. C., Kamal, R. N. 2022

    Abstract

    Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use.(1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not?In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use.When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually.Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies.Level III, therapeutic study.

    View details for DOI 10.1097/CORR.0000000000002255

    View details for PubMedID 35608508

  • The relationship between provider age and opioid prescribing behavior. The American journal of managed care Baker, L. C., Kessler, D. P., Vaska, G. K. 2022; 28 (5): 223-228

    Abstract

    OBJECTIVES: The relationship between provider age and quality of care is theoretically indeterminate. Older providers are more experienced, which could lead to a positive relationship between age and quality, but providers' practice patterns could become outdated as technology and scientific knowledge change, which could lead to a negative relationship between age and quality. However, little work has investigated the provider age/quality relationship, and no work has investigated the relationship between provider age and opioid prescribing behavior.STUDY DESIGN: We analyze Medicare Part D data to investigate how opioid prescribing differs by provider age.METHODS: We use regression analysis to estimate the effect of provider age, holding other factors constant.RESULTS: We find that older providers prescribe significantly more opioids, with the gap between older and younger providers increasing from 2010 to 2015.CONCLUSIONS: Assuming that older physicians follow patterns of previous generations, anticipated retirement of older providers and entry by younger providers will tend to reduce opioid volumes, undoing at least in part the rapid increase since 2000.

    View details for DOI 10.37765/ajmc.2022.89143

    View details for PubMedID 35546585

  • Cost-Effectiveness Analysis and Microsimulation of Serial Multiparametric Magnetic Resonance Imaging in Active Surveillance of Localized Prostate Cancer. The Journal of urology Magnani, C. J., Hernandez-Boussard, T., Baker, L. C., Goldhaber-Fiebert, J. D., Brooks, J. D. 2022: 101097JU0000000000002490

    Abstract

    PURPOSE: Many localized prostate cancers will follow an indolent course. Management has shifted towards active surveillance (AS), yet an optimal regimen remains controversial especially regarding expensive multiparametric magnetic resonance imaging (MRI). We aimed to assess cost-effectiveness of MRI in AS protocols.MATERIALS AND METHODS: A probabilistic microsimulation modeled individual patient trajectories for men diagnosed with low-risk cancer. We assessed no surveillance, up-front treatment (surgery or radiation), and scheduled AS protocols incorporating transrectal ultrasound-guided (TRUS) biopsy or MRI-based regimens at serial intervals. Lifetime quality-adjusted life years (QALYs) and costs adjusted to 2020-US$ were used to calculate expected net monetary benefit (NMB) at $50,000/QALY and incremental cost-effectiveness ratios (ICERs). Uncertainty was assessed with probabilistic sensitivity analysis and linear regression metamodeling.RESULTS: Conservative management with AS outperformed up-front definitive treatment in a modeled cohort reflecting characteristics from a multi-institutional trial. Biopsy decision conditional on positive imaging (MRI triage) at 2-year intervals provided the highest expected NMB (ICER $44,576). Biopsy after both positive and negative imaging (MRI pathway) and TRUS-based regimens were not cost-effective. MRI triage resulted in fewer biopsies while reducing metastatic disease or cancer death. Results were sensitive to test performance and cost. MRI triage was the most likely cost-effective strategy on probabilistic sensitivity analysis.CONCLUSIONS: For men with low-risk prostate cancer, our modeling demonstrated that AS with sequential MRI triage is more cost-effective than biopsy regardless of imaging, TRUS biopsy alone, or immediate treatment. AS-guidelines should specify the role of imaging, and prospective studies should be encouraged.

    View details for DOI 10.1097/JU.0000000000002490

    View details for PubMedID 35212570

  • Analysis of Medicare Payments and Patient Outcomes with Pre-Operative Imaging for Carotid Endarterectomy. Annals of vascular surgery Itoga, N. K., Martinez-Singh, K., Lee, J. T., John Harris, E., Baker, L. C., Garcia-Toca, M. 2021

    Abstract

    OBJECTIVE: The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in pre-operative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease.METHODS: We used a 20% Medicare sample from 2006-2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated pre-operative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use.RESULTS: A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8±7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4±1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5±2.1 ultrasounds, 0.95±0.86 neck CTs and 0.47±0.7 MRIs per patient. The average payment for ultrasound was $140±40, $282±94 for CT and $410±146 for MRI. The average inpatient reimbursements were $7,413±4,215 for patients without CSI compared with $7,792±3,921 for patients with CSI, P<.001. The average LOS during CEA admission was 2.5±3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by post-operative day two compared with ultrasound alone (88.9% vs. 91.5%, respectively, P<.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups.CONCLUSIONS: Our analysis found pre-operative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources.

    View details for DOI 10.1016/j.avsg.2021.06.001

    View details for PubMedID 34153493

  • Real-world Evidence to Estimate Prostate Cancer Costs for First-line Treatment or Active Surveillance. European urology open science Magnani, C. J., Bievre, N., Baker, L. C., Brooks, J. D., Blayney, D. W., Hernandez-Boussard, T. 2021; 23: 20–29

    Abstract

    Background: Prostate cancer is the most common cancer in men and second leading cause of cancer-related deaths. Changes in screening guidelines, adoption of active surveillance (AS), and implementation of high-cost technologies have changed treatment costs. Traditional cost-effectiveness studies rely on clinical trial protocols unlikely to capture actual practice behavior, and existing studies use data predating new technologies. Real-world evidence reflecting these changes is lacking.Objective: To assess real-world costs of first-line prostate cancer management.Design setting and participants: We used clinical electronic health records for 2008-2018 linked with the California Cancer Registry and the Medicare Fee Schedule to assess costs over 24 or 60 mo following diagnosis. We identified surgery or radiation treatments with structured methods, while we used both structured data and natural language processing to identify AS.Outcome measurements and statistical analysis: Our results are risk-stratified calculated cost per day (CCPD) for first-line management, which are independent of treatment duration. We used the Kruskal-Wallis test to compare unadjusted CCPD while analysis of covariance log-linear models adjusted estimates for age and Charlson comorbidity.Results and limitations: In 3433 patients, surgery (54.6%) was more common than radiation (22.3%) or AS (23.0%). Two years following diagnosis, AS ($2.97/d) was cheaper than surgery ($5.67/d) or radiation ($9.34/d) in favorable disease, while surgery ($7.17/d) was cheaper than radiation ($16.34/d) for unfavorable disease. At 5 yr, AS ($2.71/d) remained slightly cheaper than surgery ($2.87/d) and radiation ($4.36/d) in favorable disease, while for unfavorable disease surgery ($4.15/d) remained cheaper than radiation ($10.32/d). Study limitations include information derived from a single healthcare system and costs based on benchmark Medicare estimates rather than actual payment exchanges.Patient summary: Active surveillance was cheaper than surgery (-47.6%) and radiation (-68.2%) at 2 yr for favorable-risk disease, which decreased by 5 yr (-5.6% and -37.8%, respectively). Surgery was less costly than radiation for unfavorable risk for both intervals (-56.1% and -59.8%, respectively).

    View details for DOI 10.1016/j.euros.2020.11.004

    View details for PubMedID 33367287

  • Cost-Effectiveness of Open Versus Endoscopic Carpal Tunnel Release. The Journal of bone and joint surgery. American volume Barnes, J. I., Paci, G. n., Zhuang, T. n., Baker, L. C., Asch, S. M., Kamal, R. N. 2021; 103 (4): 343–55

    Abstract

    Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR.We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs).ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations.From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia.Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.19.01354

    View details for PubMedID 33591684

  • Are Changes in Medical Group Practice Characteristics Over Time Associated With Medicare Spending and Quality of Care? MEDICAL CARE RESEARCH AND REVIEW Baker, L. C., Pesko, M., Ramsay, P., Casalino, L. P., Shortell, S. M. 2020; 77 (5): 402–15
  • The Influence of Cost Information on Treatment Choice: A Mixed-Methods Study. The Journal of hand surgery Zhuang, T., Kortlever, J. T., Shapiro, L. M., Baker, L., Harris, A. H., Kamal, R. N. 2020

    Abstract

    PURPOSE: To test the null hypothesis that exposure to societal cost information does not affect choice of treatment for carpal tunnel syndrome (CTS).METHODS: We enrolled 304 participants using the Amazon Mechanical Turk platform to complete a survey in which participants were given the choice between carpal tunnel release (CTR) or a less-expensive option (orthosis wear) in a hypothetical mild CTS scenario. Patients were randomized to receive information about the societal cost of CTR (cost cohort) or no cost information (control). The primary outcome was the probability of choosing CTR measured on a 6-point ordinal scale. We employed qualitative content analysis to evaluate participants' rationale for their choice. We also explored agreement with various attitudes toward health care costs on an ordinal scale.RESULTS: Participants in the cost cohort exhibited a greater probability of choosing surgery than those in the control cohort. The relative risk of choosing surgery after exposure to societal cost information was 1.43 (95% confidence interval, 1.11-1.85). Among participants who had not previously been diagnosed with CTS (n= 232), the relative risk of choosing surgery after exposure to societal cost information was 1.55 (95% confidence interval, 1.17-2.06). Lack of personal monetary responsibility frequently emerged as a theme in those in the cost cohort who chose surgery. The majority (94%) of participants expressed at least some agreement that health care cost is a major problem whereas only 58% indicated that they consider the country's health care costs when making treatment decisions.CONCLUSIONS: Participants who received societal cost information were more likely to choose the more expensive treatment option (CTR) for mild CTS.CLINICAL RELEVANCE: Exposure to societal cost information may influence patient decision making in elective hand surgery. A complete understanding of this influence is required prior to implementing processes toward greater cost transparency for diagnostic/treatment options. Sharing out-of-pocket costs with patients may be a beneficial approach because discussing societal cost information alone will likely not improve value of care.

    View details for DOI 10.1016/j.jhsa.2020.05.019

    View details for PubMedID 32723572

  • Analysis of Medicare Payments for Preoperative Imaging Before Carotid Endarterectomy Itoga, N. K., Martinez-Singh, K., Harris, J., Lee, J. T., Baker, L., Garcia-Toca, M. MOSBY-ELSEVIER. 2020: E17–E18
  • Does Multispecialty Practice Enhance Physician Market Power? AMERICAN JOURNAL OF HEALTH ECONOMICS Baker, L. C., Bundorf, M., Kessler, D. P. 2020; 6 (3): 324–47

    View details for DOI 10.1086/708942

    View details for Web of Science ID 000571562500002

  • MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING AND RECLASSIFICATION FROM ACTIVE SURVEILLANCE Magnani, C. J., Bievre, N., Erdogdu, B., Baker, L. C., Brooks, J. D., Hernandez-Boussard, T. LIPPINCOTT WILLIAMS & WILKINS. 2020: E342–E343
  • Initial financial impact of office-based laboratories on Medicare payments for percutaneous interventions for peripheral artery disease. Journal of vascular surgery Itoga, N. K., Baker, L. C., Mell, M. W. 2020

    Abstract

    Percutaneous interventions for peripheral artery disease (PAD) are transitioning away from hospital-based settings to office-based laboratories (OBLs). Those in favor of OBL use reference lower hospitalization rates and high efficiency; however, critics claim financial incentives may lead to multiple procedures and higher atherectomy use. We sought to determine how Medicare payments are affected by OBL use.We identified physicians performing percutaneous interventions for PAD from 2006 to 2013 in a 20% Medicare sample. Physicians performing a majority of interventions at OBLs were classified as high OBL users; control physicians performed interventions at hospital-based settings. The primary outcomes were total Medicare payments at 30 days and 1 year. Generalized log-gamma regression models were used to evaluate factors influencing payments reported as a percentage change and 95% confidence interval (95% CI). A secondary analysis was performed of physicians who transitioned from hospital-based settings to OBLs, "switch physicians." A multivariate model with difference-in-differences regression was used to evaluate the effects of transitioning to OBLs.A total of 89 high OBL users performed percutaneous interventions on 887 patients, and 3715 control physicians treated 54,213 patients during the time period. Payments for patients treated by high OBL users were significantly higher compared with control physicians at 30 days ($4465), 90 days ($8925), and 1 year ($27,436). Major factors increasing payments at 1 year were treatment by a high OBL user (49%; 95% CI, 42%-56%), hospital admissions (127%; 95% CI, 123%-131%), repeated lower extremity procedures (41%; 95% CI, 39%-43%), and lower extremity wound (20%; 95% CI,18%-22%). Factors decreasing payments at 1 year were living in a rural setting (8%; 95% CI, 7%-9%) and dementia (5%; 95% CI, 3%-7%). Analysis of 292 switch physicians identified 3888 patients treated before OBLs (pre-switch) and 3246 after OBLs (post-switch). Transitioning to OBLs was associated with higher payments at 30 days and 90 days, and this increase was higher compared with control physicians.These findings highlight that OBL use for PAD interventions significantly influences Medicare payments, and its widespread adaptation should be made with caution. The main factors driving payments were hospitalization admissions, repeated lower extremity procedures, and wound status. Further work is needed to evaluate the appropriate use of OBLs to optimize patient outcomes and resource allocations.

    View details for DOI 10.1016/j.jvs.2019.09.064

    View details for PubMedID 31973948

  • Physical and Occupational Therapy Use and Cost After Common Hand Procedures. The Journal of hand surgery Shah, R. F., Zhang, S., Li, K., Baker, L., Sox-Harris, A., Kamal, R. N. 2019

    Abstract

    PURPOSE: The use of routine physical therapy (PT) and occupational therapy (OT) after certain hand procedures, such as carpal tunnel release, remains controversial. The objective of this study was to evaluate baseline use, the change in use, variation in prescribing patterns by region, and costs for PT/OT after common hand procedures.METHODS: Outpatient administrative claims data from patients who underwent procedures for carpal tunnel syndrome, trigger finger, carpometacarpal arthritis, de Quervain tenosynovitis, wrist ganglion cyst, and distal radius fracture were abstracted from the Truven Health MarketScan database from 2007 to 2015. The incidence of therapy and total reimbursement of therapy per patient were collected for each procedure over a 90-day postoperative observational period. Trends in use of therapy over time were described with average compound annual growth rates (CAGRs), a way of quantifying average growth over a specified observation period. Variations in the incidence of PT/OT use across 4 census regions were assessed.RESULTS: The incidence of 90-day utilization of PT and OT after hand procedures was 14.0% and increased for all procedures during the observation period with an average CAGR of 8.3%. Cost per therapy visit was relatively stable when adjusted for inflation, with an average CAGR of 0.63%. Patients in the northeast had a significantly higher incidence of PT/OT use than those in the south and west for all procedures except carpometacarpal arthritis.CONCLUSIONS: Use of PT and OT has increased over time after common hand procedures. Geographical variation in the utilization rate of these services is substantial. Limiting unwarranted variation of care is a health policy strategy for increasing value of care.TYPE OF STUDY/LEVEL OF EVIDENCE: Outcomes Research II.

    View details for DOI 10.1016/j.jhsa.2019.09.008

    View details for PubMedID 31753716

  • Why Don't Commercial Health Plans Use Prospective Payment? AMERICAN JOURNAL OF HEALTH ECONOMICS Baker, L., Bundorf, M., Devlin, A., Kessler, D. P. 2019; 5 (4): 465–80
  • The Usability and Feasibility of Conjoint Analysis to Elicit Preferences for DistalRadius Fractures in Patients 55Years andOlder. The Journal of hand surgery Shapiro, L. M., Eppler, S. L., Baker, L. C., Harris, A. S., Gardner, M. J., Kamal, R. N. 2019

    Abstract

    PURPOSE: Eliciting patient preferences is one part of the shared decision-making process-a process of decision making focused on the values and preferences of the patient. We evaluated the usability and feasibility of a point-of-care conjoint analysis tool for preference elicitation for shared decision making in the treatment of distal radius fractures in patients over the age of 55 years.METHODS: Twenty-seven patients 55 years of age or older with a displaced distal radius fracture were recruited from a hand and upper extremity clinic. A conjoint analysis tool was created describing the attributes of care (eg, return of grip strength) of surgical and nonsurgical treatment. This tool was administered to patients to determine their preferences for the treatment attributes when choosing between surgical and nonsurgical treatment. Patients completed a System Usability Scale (SUS) to evaluate usability, and time to complete the tool was measured to evaluate feasibility.RESULTS: Patients considered the conjoint analysis tool to be usable (SUS, 91.4; SD, 10.9). Mean time to complete the tool was 5.1 minutes (SD, 1.4 minutes). The most important attributes driving the decision for surgical treatment were return of grip strength at 1 year and time spent in a cast or brace. The most important attributes driving the decision for nonsurgical treatment were use of anesthesia during treatment and return of grip strength at 1 year.CONCLUSIONS: A point-of-care conjoint analysis tool for distal radius fractures in patients 55 years and older can be used to elicit patient preferences to inform the shared decision-making process. Further investigation evaluating the effect of preference elicitation on treatment choice, involvement in decision making, and patient-reported outcomes are needed.CLINICAL RELEVANCE: A conjoint analysis tool is a simple, structured process physicians can use during shared decision making to highlight trade-offs between treatment options and elicit patient preferences to inform treatment choices.

    View details for DOI 10.1016/j.jhsa.2019.07.010

    View details for PubMedID 31495523

  • Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals. JAMA internal medicine Sun, E. C., Mello, M. M., Moshfegh, J., Baker, L. C. 2019

    Abstract

    Importance: Although surprise medical bills are receiving considerable attention from lawmakers and the news media, to date there has been little systematic study of the incidence and financial consequences of out-of-network billing.Objective: To examine out-of-network billing among privately insured patients with an inpatient admission or emergency department (ED) visit at in-network hospitals.Design, Setting, and Participants: A retrospective analysis using data from the Clinformatics Data Mart database (Optum), which includes health insurance claims for individuals from all 50 US states receiving private health insurance from a large commercial insurer was conducted of all inpatient admissions (n=5 457 981) and ED visits (n=13 579 006) at in-network hospitals between January 1, 2010, and December 31, 2016. Data were collected and analyzed in March 2019.Exposures: Receipt of a bill for care from at least 1 out-of-network physician or medical transport service associated with patient admission or ED visit.Main Outcomes and Measures: The incidence of out-of-network billing and the potential amount of patients' financial liability associated with out-of-network bills from the admission or visit.Results: Of 5 457 981 inpatient admissions and 13 579 006 ED admissions between 2010 and 2016, the percentage of ED visits with an out-of-network bill increased from 32.3% to 42.8% (P<.001) during the study period, and the mean (SD) potential financial responsibility for these bills increased from $220 ($420) to $628 ($865) (P<.001; all dollar values in 2018 US$). Similarly, the percentage of inpatient admissions with an out-of-network bill increased from 26.3% to 42.0% (P<.001), and the mean (SD) potential financial responsibility increased from $804 ($2456) to $2040 ($4967) (P<.001).Conclusions and Relevance: Out-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals. The mean amounts billed appear to be sufficiently large that they may create financial strain for a substantial proportion of patients.

    View details for DOI 10.1001/jamainternmed.2019.3451

    View details for PubMedID 31403651

  • Demographics, Usage Patterns, and Safety of Male Users of Clomiphene in the United States. The world journal of men's health Guo, D. P., Zlatev, D. V., Li, S., Baker, L. C., Eisenberg, M. L. 2019

    Abstract

    PURPOSE: The aim of this study was to characterize the demographics, usage patterns and complication rates of clomiphene use in male patients.MATERIALS AND METHODS: We retrospectively analyzed male patients from ages 20 to 55 years old who were prescribed clomiphene citrate from 2001 to 2014 using the Truven Health MarketScan, a US claims database. We collected data regarding associated medical diagnoses, diagnostic testing, duration of use, and reported side effects including thrombotic events, vision problems, gynecomastia, mental disorders, liver disease, nausea, or skin problems.RESULTS: In total, 12,318 men took clomiphene and represented the primary study cohort, with a mean age of 37.8 years. The percentage of men prescribed clomiphene increased over the study period, as did the average age of clomiphene users. Associated diagnoses included male infertility (52.0%), testicular hypofunction (13.5%), erectile dysfunction (2.4%), and low libido (0.4%). Associated testing included semen analysis (43.7%), testosterone (23.5%), luteinizing hormone (19.3%), and follicle-stimulating hormone (21.1%) levels. The median time of clomiphene use was 3.6 months, with 63% of men stopping within 6 months. No increased risk of reported clomiphene side effects were apparent in men taking the medication.CONCLUSIONS: There is a rising prevalence of clomiphene usage without associated adverse side effects in the US. The variability in associated diagnoses, diagnostic testing, and duration of use suggest a need for greater awareness of the proper evaluation and treatment of the men who are prescribed clomiphene.

    View details for DOI 10.5534/wjmh.190028

    View details for PubMedID 31385473

  • Impact of office-based laboratories on physician practice patterns and outcomes after percutaneous vascular interventions for peripheral artery disease. Journal of vascular surgery Itoga, N. K., Baker, L. C., Mell, M. W. 2019

    Abstract

    BACKGROUND: Percutaneous vascular interventions (PVIs) for peripheral artery disease have shifted from hospital-based facilities to office-based laboratories (OBLs). The transition to OBLs is due to a variety of factors such as technology advancement, increased efficiency, and financial incentives. We evaluated the impact of physicians switching to OBLs use from hospital-based facilities on procedure volume, procedure type, and patient outcomes.METHODS: We identified patients with PVI for lower extremity peripheral artery disease from 2006 to 2013 in a 20% Medicare sample and identified physicians who transitioned from predominantly hospital-based facilities to OBLs (switch physicians) and compared them with those who did not use OBLs (control physicians). The main outcomes investigated were average number of PVIs at 30days and 1year and atherectomy usage. Patient outcomes included above-ankle amputation, major adverse limb events, and death. We used a difference-in-difference model to control for time effects in a multivariate regression model, reported as an odds ratio (OR) and 95% confidence interval (CI).RESULTS: The cohort comprised 292 switch physicians, who treated 7134 patients (3888 before OBL use and 3246 after transitioning to OBLs), and 3715 control physicians treating 54,213 patients (36,327 in the preperiod and 17,886 in the postperiod). Switch and control physicians both treated more patients with lower extremity wounds during the study period; however, this increase was greater for control physician (0.7% vs 5.5%, P< .001). On average, patients treated by switch physicians had 0.05 (95% CI, 0.03-0.07; P< .001) underwent more PVIs within 30days and 0.12 more PVIs (95% CI, 0.08-0.16; P< .001) within 1year of the initial revascularization procedure after the physician transitioned to an OBL. Similarly, patients treated by switch physicians underwent 0.02 (95% CI, 0.01-0.03; P= .002) more atherectomy procedures at 30days and 0.03 (95% CI, 0.01-0.05; P= .008) more atherectomy procedures at 1year. Transitioning to OBLs was also associated with a decreased risk in above-ankle amputation at 30days (OR, 0.58; 95% CI, 0.38-0.97; P= .009) and 1year (OR, 0.75; 95% CI, 0.60-0.95; P= .01). However, no statistical difference was observed for major adverse limb events and mortality rates at 30days and 1year because patients treated by switch and control physicians experienced similar decreases.CONCLUSIONS: Transitioning to OBLs was associated higher 30-day and 1-year PVI rates and atherectomy rates. Although transitioning to OBLs was associated with lower rates of above-ankle amputations, switch physicians treated a lower number of patients with lower extremity wounds.

    View details for DOI 10.1016/j.jvs.2019.01.060

    View details for PubMedID 31204219

  • Impact of Office-Based Laboratories on Medicare Payments for Percutaneous Interventions for Peripheral Artery Disease Itoga, N. K., Baker, L. C., Mell, M. W. MOSBY-ELSEVIER. 2019: E196–E197
  • Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty Chi, D., Mariano, E. R., Memtsoudis, S. G., Baker, L. C., Sun, E. C. LIPPINCOTT WILLIAMS & WILKINS. 2019: 1319–27
  • The effects of medicare advantage on opioid use. Journal of health economics Baker, L. C., Bundorf, M. K., Kessler, D. P. 2019; 70: 102278

    Abstract

    Despite a vast literature on the determinants of prescription opioid use, the role of health insurance plans has received little attention. We study how the form of Medicare beneficiaries' drug coverage affects the volume of opioids they consume. We find that enrollment in Medicare Advantage, which integrates drug coverage with other medical benefits, significantly reduces beneficiaries' likelihood of filling an opioid prescription, as compared to enrollment in a stand-alone drug plan. Approximately half of this effect was due to fewer fills from prescribers who write a very large number of opioid prescriptions.

    View details for DOI 10.1016/j.jhealeco.2019.102278

    View details for PubMedID 31972536

  • Competition in Outpatient Procedure Markets MEDICAL CARE Baker, L. C., Bundorf, M. K., Kessler, D. P. 2019; 57 (1): 36–41
  • Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty. Anesthesia and analgesia Chi, D. n., Mariano, E. R., Memtsoudis, S. G., Baker, L. C., Sun, E. C. 2019; 128 (6): 1319–27

    Abstract

    Total knee arthroplasty is a commonly performed procedure and an important contributor to national health care spending. Reducing the incidence of readmission could have important consequences for patient well-being and relevant financial implications. Whether regional anesthesia techniques are associated with decreased readmission rates and costs among privately insured patients remains unknown.Using administrative claims data, we identified 138,362 privately insured patients 18-64 years of age who underwent total knee arthroplasty between 2002 and 2013. We then examined whether the use of a nerve block was associated with decreases in readmission rates and related costs during the 90 days after discharge. Our analyses were adjusted for potential confounding variables including medical comorbidities and previous use of opioids and other medications.After adjusting for patient demographics, comorbidities, and preoperative medication use, the adjusted 90-day readmission rate was 1.8% (95% confidence interval [CI], 1.1-2.4) among patients who did not receive a block compared to 1.7% (95% CI, 1.1-2.4) among patients who did (odds ratio, 0.99; 95% CI, 0.91-1.09; P = .85). The adjusted readmission-related postoperative cost for patients who did not receive a block was $561 (95% CI, 502-619) and $574 (95% CI, 508-639) for patients who did (difference, $13; 95% CI, -75 to 102; P = .74). This lack of statistically significant differences held for subgroup and sensitivity analyses.Nerve blocks were not associated with improved measures of long-term postoperative resource use in this younger, privately insured study population.

    View details for PubMedID 31094807

  • Medical Group Characteristics and the Cost and Quality of Care for Medicare Beneficiaries. Health services research Casalino, L. P., Ramsay, P., Baker, L. C., Pesko, M. F., Shortell, S. M. 2018; 53 (6): 4970–96

    Abstract

    OBJECTIVE: To estimate the relationship between outcomes of care and medical practices' structure and use of organized care improvement processes.DATA SOURCES/STUDY SETTING: We linked Medicare claims data to our national survey of physician practices (2012-2013). Fifty percent response rate; 1,040 responding practices; 31,888 physicians; 868,213 attributed Medicare beneficiaries.STUDY DESIGN: Cross-sectional observational analysis of the relationship between practice characteristics and total spending, readmissions, and ambulatory care-sensitive admissions (ACSAs), for all beneficiaries and five categories of beneficiary defined by predicted need for care.PRINCIPAL FINDINGS: Practices with 100+ physicians and 50-99 physicians had, respectively, annual spending per high-need beneficiary that was $1,870 (12.5 percent) and $1,824 higher than practices with 1-2 physicians, and readmission rates 1.64 and 1.71 higher. ACSA rates did not vary significantly by practice size. Outcomes did not vary significantly by ownership or by practices' use of organized processes to improve care.CONCLUSIONS: Large practices had higher spending and readmission rates than the smallest practices, especially for high-need beneficiaries. There were no significant performance differences between physician-owned and hospital-owned practices. Policy makers should consider the effects of specific policies on provider organization, pending further research to learn which types of practice provide better care.

    View details for DOI 10.1111/1475-6773.13010

    View details for PubMedID 29978481

  • Competition in Outpatient Procedure Markets. Medical care Baker, L. C., Bundorf, M. K., Kessler, D. P. 2018

    Abstract

    BACKGROUND: More than half of all medical procedures performed in the United States occur in an outpatient setting, yet few studies have explored how competition among ambulatory surgery centers (ASCs) and hospitals affects prices for commercially insured outpatient services.OBJECTIVES: We examined the association between prices for commercially insured outpatient procedures and competition among ASCs and hospitals.RESEARCH DESIGN: Using claims from the Health Care Cost Institute for 2008-2012, we constructed county-level price indices for outpatient procedures in hospital outpatient departments and ASCs. Using regression analysis, we estimated the association between prices and ASC availability, outpatient and inpatient hospital competition, hospital/physician integration, and several other hospital market characteristics. Our estimates were identified from changes within counties over time.RESULTS: First, ASC availability was associated with decreases in overall outpatient procedure prices, mostly due to reductions in the prices paid to hospital outpatient departments. Second, competition among hospitals was also associated with decreases in outpatient procedure prices-and had an effect more than twice as large as the effect of ASC availability. Third, competition among ASCs was also associated with reductions in the prices paid to other ASCs.CONCLUSIONS: Our results suggest that competition from ASCs benefits consumers through lower prices for outpatient procedures. Any conclusions about the broader welfare implications of the rise in ASCs, however, must balance the price reductions that we found with the volume increases found in previous work, particularly the volume increases at physician-owned ASCs.

    View details for PubMedID 30507654

  • Are Changes in Medical Group Practice Characteristics Over Time Associated With Medicare Spending and Quality of Care? Medical care research and review : MCRR Baker, L. C., Pesko, M., Ramsay, P., Casalino, L. P., Shortell, S. M. 2018: 1077558718812939

    Abstract

    Physician practices have been growing in size, and becoming more commonly owned by hospitals, over time. We use survey data on physician practices surveyed at two points in time, linked to Medicare claims data, to investigate whether changes in practice size or ownership are associated with changes in the use of care management, health information technology (HIT), or quality improvement processes. We find that practice growth and becoming hospital-owned are associated with adoption of more quality improvement processes, but not with care management or HIT. We then investigate whether growth or becoming hospital-owned are associated with changes in Medicare spending, 30-day readmission rates, or ambulatory care sensitive admission rates. We find little evidence for associations with practice size and ownership, but the use of care management practices is associated with lower rates of ambulatory care sensitive admissions.

    View details for PubMedID 30465626

  • Anesthesia Care Team Composition and Surgical Outcomes ANESTHESIOLOGY Sun, E. C., Miller, T. R., Moshfegh, J., Baker, L. C. 2018; 129 (4): 700–709
  • With Roots In California, Managed Competition Still Aims To Reform Health Care HEALTH AFFAIRS Enthoven, A. C., Baker, L. C. 2018; 37 (9): 1425–30
  • With Roots In California, Managed Competition Still Aims To Reform Health Care. Health affairs (Project Hope) Enthoven, A. C., Baker, L. C. 2018; 37 (9): 1425–30

    Abstract

    Managed competition is a concept that was born in California and has achieved a measure of acceptance there. As California and the United States as a whole continue to struggle with the challenge of providing high-quality health care at a manageable cost, it is worth asking whether managed competition-with its tools for harnessing market forces-continues to hold promise as a means of improving value in health care, and whether the standard conceptualization of managed competition should be modified in any way. In this article we reflect on four aspects of California's health care ecosystem that provide insights into these questions: integrated delivery systems, patients' choice of health plans, quality measurement, and new health care marketplace architectures such as Covered California and private insurance exchanges. Overall, while California's experience with managed competition has resulted in some challenges and adaptations, it also gives reason to believe that principles of managed competition continue to have the potential to be a powerful force toward creating a more efficient health care system.

    View details for PubMedID 30179555

  • The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Gil, J. A., Goodman, A. D., Kleiner, J., Kamal, R. N., Baker, L. C., Akelman, E. 2018; 476 (5): 925–31

    Abstract

    The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics.(1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state?We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design.There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014.After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care.Level III, therapeutic study.

    View details for PubMedID 29672327

  • Anesthesia Care Team Composition and Surgical Outcomes. Anesthesiology Sun, E. C., Miller, T. R., Moshfegh, J. n., Baker, L. C. 2018

    Abstract

    In the United States, anesthesia care can be provided by an anesthesia care team consisting of nonphysician providers (nurse anesthetists and anesthesiologist assistants) working under the supervision of a physician anesthesiologist. Nurse anesthetists may practice nationwide, whereas anesthesiologist assistants are restricted to 16 states. To inform policies concerning the expanded use of anesthesiologist assistants, the authors examined whether the specific anesthesia care team composition (physician anesthesiologist plus nurse anesthetist or anesthesiologist assistant) was associated with differences in perioperative outcomes.A retrospective analysis was performed of national claims data for 443,098 publicly insured elderly (ages 65 to 89 yr) patients who underwent inpatient surgery between January 1, 2004, and December 31, 2011. The differences in inpatient mortality, spending, and length of stay between cases where an anesthesiologist supervised an anesthesiologist assistant compared to cases where an anesthesiologist supervised a nurse anesthetist were estimated. The approach used a quasirandomization technique known as instrumental variables to reduce confounding.The adjusted mortality for care teams with anesthesiologist assistants was 1.6% (95% CI, 1.4 to 1.8) versus 1.7% for care teams with nurse anesthetists (95% CI, 1.7 to 1.7; difference -0.08; 95% CI, -0.3 to 0.1; P = 0.47). Compared to care teams with nurse anesthetists, care teams with anesthesiologist assistants were associated with non-statistically significant decreases in length of stay (-0.009 days; 95% CI, -0.1 to 0.1; P = 0.89) and medical spending (-$56; 95% CI, -334 to 223; P = 0.70).The specific composition of the anesthesia care team was not associated with any significant differences in mortality, length of stay, or inpatient spending.

    View details for PubMedID 29847429

  • Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty. Anesthesia and analgesia Chi, D. n., Mariano, E. R., Memtsoudis, S. G., Baker, L. C., Sun, E. C. 2018

    Abstract

    Total knee arthroplasty is a commonly performed procedure and an important contributor to national health care spending. Reducing the incidence of readmission could have important consequences for patient well-being and relevant financial implications. Whether regional anesthesia techniques are associated with decreased readmission rates and costs among privately insured patients remains unknown.Using administrative claims data, we identified 138,362 privately insured patients 18-64 years of age who underwent total knee arthroplasty between 2002 and 2013. We then examined whether the use of a nerve block was associated with decreases in readmission rates and related costs during the 90 days after discharge. Our analyses were adjusted for potential confounding variables including medical comorbidities and previous use of opioids and other medications.After adjusting for patient demographics, comorbidities, and preoperative medication use, the adjusted 90-day readmission rate was 1.8% (95% confidence interval [CI], 1.1-2.4) among patients who did not receive a block compared to 1.7% (95% CI, 1.1-2.4) among patients who did (odds ratio, 0.99; 95% CI, 0.91-1.09; P = .85). The adjusted readmission-related postoperative cost for patients who did not receive a block was $561 (95% CI, 502-619) and $574 (95% CI, 508-639) for patients who did (difference, $13; 95% CI, -75 to 102; P = .74). This lack of statistically significant differences held for subgroup and sensitivity analyses.Nerve blocks were not associated with improved measures of long-term postoperative resource use in this younger, privately insured study population.

    View details for PubMedID 30286005

  • Cost-minimization Analysis of the Management of Acute Achilles Tendon Rupture. journal of the American Academy of Orthopaedic Surgeons Truntzer, J. N., Triana, B., Harris, A. H., Baker, L., Chou, L., Kamal, R. N. 2017; 25 (6): 449-457

    Abstract

    Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture.We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury.Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost.From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management.III, Economic Decision Analysis.

    View details for DOI 10.5435/JAAOS-D-16-00553

    View details for PubMedID 28459710

  • Under-Utilization of Routine Ultrasound Surveillance after Endovascular Aortic Aneurysm Repair. Annals of vascular surgery Mell, M. W., Garg, T., Baker, L. C. 2017

    Abstract

    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 Sun, E. C., Bateman, B. T., Memtsoudis, S. G., Neuman, M. D., Mariano, E. R., Baker, L. C. 2017

    Abstract

    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 Sun, E. C., Dixit, A., Humphreys, K., Darnall, B. D., Baker, L. C., Mackey, S. 2017; 356

    Abstract

    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. Anesthesiology Sun, E. C., Dexter, F., Miller, T. R., Baker, L. C. 2017; 126 (3): 461-471

    Abstract

    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

  • In Response. Anesthesia and analgesia Sun, E. C., Bateman, B. T., Memtsoudis, S. G., Neuman, M. D., Mariano, E. R., Baker, L. C. 2017

    View details for PubMedID 29239946

  • Lack of Association Between the Use of Nerve Blockade and the Risk of Persistent Opioid Use Among Patients Undergoing Shoulder Arthroplasty: Evidence From the Marketscan Database. Anesthesia and analgesia Mueller, K. G., Memtsoudis, S. G., Mariano, E. R., Baker, L. C., Mackey, S. n., Sun, E. C. 2017

    Abstract

    Persistent opioid use following surgery has received increasing attention from policymakers, researchers, and clinicians. Perioperative nerve blockade has been hypothesized to decrease the risk of persistent opioid use. We examined whether nerve blockade was associated with a decreased risk of persistent opioid use among patients undergoing shoulder arthroplasty, a procedure with high rates of persistent postoperative pain.Using health care claims data, we constructed a sample of 6695 patients undergoing shoulder arthroplasty between 2002 and 2012 and used billing data to identify the utilization of nerve blockade. We then used a multivariable logistic regression to estimate the association between nerve blockade and 2 measures of opioid use: having filled at least 1 prescription for an opioid between postoperative days (PODs) 0 and 90, and between POD 91 and 365. This regression adjusted for a variety of potential confounders, such as preoperative opioid use and medical history.There was no association between nerve blockade and our 2 measures of persistent opioid use: adjusted odds ratio, 1.12 (97.5% confidence interval, 0.939-1.34; P = .15) for opioid use between POD 0 and 90, and adjusted odds ratio, 0.997 (97.5% confidence interval, 0.875-1.14; P = .95) for opioid use between POD 91 and 365.Although the use of perioperative nerve blockade may offer short-term benefits, in this study, it was not associated with a reduction in the risk of persistent opioid use for patients undergoing shoulder arthroplasty.

    View details for PubMedID 28742777

  • Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release. journal of bone and joint surgery. American volume Zhang, S., Vora, M., Harris, A. H., Baker, L., Curtin, C., Kamal, R. N. 2016; 98 (23): 1970-1977

    Abstract

    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

  • Hospital Ownership of Physicians: Hospital Versus Physician Perspectives. Medical care research and review Baker, L. C., Bundorf, M. K., Devlin, A. M., Kessler, D. P. 2016

    Abstract

    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 Clarke, C. A., Asch, S. M., Baker, L., Bilimoria, K., Dudley, R. A., Fong, N., Holliday-Hanson, M. L., Hopkins, D. S., Imholz, E. M., Malin, J., Moy, L., O'Sullivan, M., Parker, J. P., Saigal, C. S., Spurlock, B., Teleki, S., Zingmond, D., Lang, L. 2016

    Abstract

    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 Sun, E. C., Darnall, B. D., Baker, L. C., Mackey, S. 2016; 176 (9): 1286-1293

    Abstract

    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

  • VARICOCELES ARE ASSOCIATED WITH INCREASED RISK OF CARDIAC DISEASE AND OTHER COMORBIDITIES: AN ANALYSIS OF US CLAIMS DATA. Dallas, K. B., Wang, N. N., Li, S., Baker, L. C., Eisenberg, M. ELSEVIER SCIENCE INC. 2016: E1155
  • INCREASED RISK OF AUTOIMMUNE DISORDERS IN INFERTILE MEN: ANALYSIS OF US CLAIMS DATA Brubaker, W. D., Li, S., Baker, L. C., Eisenberg, M. L. ELSEVIER SCIENCE INC. 2016: E1153–E1154
  • Increased risk of incident chronic medical conditions in infertile men: analysis of United States claims data FERTILITY AND STERILITY Eisenberg, M. L., Li, S., Cullen, M. R., Baker, L. C. 2016; 105 (3): 629-636

    Abstract

    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

  • Creating an online resource providing hospital cancer surgery volumes in California. Clarke, C. A., Baker, L. C., Malin, J., Parker, J., Holliday-Hanson, M., Fong, N., Teleki, S., Lang, L., O'Sullivan, M. AMER SOC CLINICAL ONCOLOGY. 2016
  • Does health plan generosity enhance hospital market power? JOURNAL OF HEALTH ECONOMICS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2015; 44: 54-62

    Abstract

    We test whether the generosity of employer-sponsored health insurance facilitates the exercise of market power by hospitals. We construct indices of health plan generosity and the price and volume of hospital services using data from Truven MarketScan for 601 counties from 2001 to 2007. We use variation in the industry and union status of covered workers within a county over time to identify the causal effects of generosity. Although OLS estimates fail to reject the hypothesis that generosity facilitates the exercise of hospital market power, IV estimates show a statistically significant and economically important positive effect of plan generosity on hospital prices in uncompetitive markets, but not in competitive markets. Our results suggest that most of the aggregate effect of hospital market structure on prices found in previous work may be coming from areas with generous plans.

    View details for DOI 10.1016/j.jhealeco.2015.08.007

    View details for Web of Science ID 000367408200005

  • Postoperative Surveillance and Long-term Outcomes After Endovascular Aneurysm Repair Among Medicare Beneficiaries JAMA SURGERY Garg, T., Baker, L. C., Mell, M. W. 2015; 150 (10): 957-963

    Abstract

    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

  • ANTITRUST FOR ACCOUNTABLE CARE ORGANIZATIONS JOURNAL OF COMPETITION LAW & ECONOMICS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2015; 11 (2): 317-329
  • Concentration In Orthopedic Markets Was Associated With A 7 Percent Increase In Physician Fees For Total Knee Replacements. Health affairs (Project Hope) Sun, E., Baker, L. C. 2015; 34 (6): 916-21

    Abstract

    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 PubMedID 26056195

  • Increased Risk of Cancer in Infertile Men: Analysis of US Claims Data JOURNAL OF UROLOGY Eisenberg, M. L., Li, S., Brooks, J. D., Cullen, M. R., Baker, L. C. 2015; 193 (5): 1596-1601

    Abstract

    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 HEALTH AFFAIRS Hsia, R. Y., Nath, J. B., Baker, L. C. 2015; 34 (4): 621-626

    Abstract

    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

    View details for PubMedCentralID PMC4507565

  • Impact of including readmissions for qualifying events in the patient safety indicators. American journal of medical quality Davies, S. M., Saynina, O., Baker, L. C., McDonald, K. M. 2015; 30 (2): 114-118

    Abstract

    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. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238

    Abstract

    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 Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238

    View details for DOI 10.1377/hlthaff.2014.1032

    View details for PubMedID 25646102

  • Impact of drug-eluting stents on the comparative effectiveness of coronary artery bypass surgery and percutaneous coronary intervention AMERICAN HEART JOURNAL Hlatky, M. A., Boothroyd, D. B., Baker, L. C., Go, A. S. 2015; 169 (1): 149-154

    Abstract

    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

    View details for PubMedCentralID PMC4268548

  • EXPANDING PATIENTS' PROPERTY RIGHTS IN THEIR MEDICAL RECORDS AMERICAN JOURNAL OF HEALTH ECONOMICS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2015; 1 (1): 82-100
  • Adherence to postoperative surveillance guidelines after endovascular aortic aneurysm repair among Medicare beneficiaries JOURNAL OF VASCULAR SURGERY Garg, T., Baker, L. C., Mell, M. W. 2015; 61 (1): 23-27

    Abstract

    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

  • Physician practice competition and prices paid by private insurers for office visits. JAMA Baker, L. C., Bundorf, M. K., Royalty, A. B., Levin, Z. 2014; 312 (16): 1653-1662

    Abstract

    Physician practice consolidation could promote higher-quality care but may also create greater economic market power that could lead to higher prices for physician services.To assess the relationship between physician competition and prices paid by private preferred provider organizations (PPOs) for 10 types of office visits in 10 prominent specialties.Retrospective study in 1058 US counties in urbanized areas, representing all 50 states, examining the relationship between measured physician competition and prices paid for office visits in 2010 and the relationship between changes in competition and prices between 2003 and 2010, using regression analysis to control for possible confounding factors.Variation in the mean Hirschman-Herfindahl Index (HHI) of physician practices within a county by specialty (HHIs range from 0, representing maximally competitive markets, to 10,000 in markets served by a single [monopoly] practice).Mean price paid by county to physicians in each specialty by private PPOs for intermediate office visits with established patients (Current Procedural Terminology [CPT] code 99213) and a price index measuring the county-weighted mean price for 10 types of office visits with new and established patients (CPT codes 99201-99205, 99211-99215) relative to national mean prices.In 2010, across all specialties studied, HHIs were 3 to 4 times higher in the 90th-percentile county than the 10th-percentile county (eg, for family practice: 10th percentile HHI = 1023 and 90th percentile HHI = 3629). Depending on specialty, mean price for a CPT code 99213 visit was between $70 and $75. After adjustment for potential confounders, depending on specialty, prices at the 90th-percentile HHI were between $5.85 (orthopedics; 95% CI, $3.46-$8.24) and $11.67 (internal medicine; 95% CI, $9.13-$14.21) higher than at the 10th percentile. Including all types of office visits, price indexes at the 90th-percentile HHI were 8.3% (orthopedics; 95% CI, 5.0%-11.6%) to 16.1% (internal medicine; 95% CI, 12.8%-19.5%) higher. Between 2003 and 2010, there were larger price increases in areas that were less competitive in 2002 than in initially more competitive areas.More competition among physicians is related to lower prices paid by private PPOs for office visits. These results may inform work on policies that influence practice competition.

    View details for DOI 10.1001/jama.2014.10921

    View details for PubMedID 25335147

  • Emergency department visits by children, adolescents, and young adults in California by insurance status, 2005-2010. JAMA Hsia, R. Y., Nath, J. B., Baker, L. C. 2014; 312 (15): 1587-1588

    View details for DOI 10.1001/jama.2014.9905

    View details for PubMedID 25321913

  • The Affordable Care Act Reduces Emergency Department Use By Young Adults: Evidence From Three States HEALTH AFFAIRS Hernandez-Boussard, T., Burns, C. S., Wang, N. E., Baker, L. C., Goldstein, B. A. 2014; 33 (9): 1648-1654

    Abstract

    The Affordable Care Act (ACA) extended eligibility for health insurance for young adults ages 19-25. This extension may have affected how young adults use emergency department (ED) care and other health services. To test the impact of the ACA on how young adults used ED services, we used 2009-11 state administrative records from California, Florida, and New York to compare changes in ED use in young adults ages 19-25 before and after the ACA provision was implemented with changes in the same period for people ages 26-31 (the control group). Following implementation of the ACA provision, the younger group had a decrease of 2.7 ED visits per 1,000 people compared to the older group-a relative change of -2.1 percent. The largest relative decreases were found in women (-3.0 percent) and blacks (-3.4 percent). This relative decrease in ED use implies a total reduction of more than 60,000 visits from young adults ages 19-25 across the three states in 2011. When we compared the probability of ever using the ED before and after implementation of the ACA provision, we found a minimal decrease (-0.4 percent) among the younger group compared to the older group. This suggests that the change in the number of visits was driven by fewer visits among ED users, not by changes in the number of people who ever visited the ED.

    View details for DOI 10.1377/hlthaff.2014.0103

    View details for Web of Science ID 000343401600020

  • The Affordable Care Act reduces emergency department use by young adults: evidence from three States. Health affairs Hernandez-Boussard, T., Burns, C. S., Wang, N. E., Baker, L. C., Goldstein, B. A. 2014; 33 (9): 1648-1654

    Abstract

    The Affordable Care Act (ACA) extended eligibility for health insurance for young adults ages 19-25. This extension may have affected how young adults use emergency department (ED) care and other health services. To test the impact of the ACA on how young adults used ED services, we used 2009-11 state administrative records from California, Florida, and New York to compare changes in ED use in young adults ages 19-25 before and after the ACA provision was implemented with changes in the same period for people ages 26-31 (the control group). Following implementation of the ACA provision, the younger group had a decrease of 2.7 ED visits per 1,000 people compared to the older group-a relative change of -2.1 percent. The largest relative decreases were found in women (-3.0 percent) and blacks (-3.4 percent). This relative decrease in ED use implies a total reduction of more than 60,000 visits from young adults ages 19-25 across the three states in 2011. When we compared the probability of ever using the ED before and after implementation of the ACA provision, we found a minimal decrease (-0.4 percent) among the younger group compared to the older group. This suggests that the change in the number of visits was driven by fewer visits among ED users, not by changes in the number of people who ever visited the ED.

    View details for DOI 10.1377/hlthaff.2014.0103

    View details for PubMedID 25201671

  • Payer Status, Preoperative Surveillance, and Rupture of Abdominal Aortic Aneurysms in the US Medicare Population. Annals of vascular surgery Mell, M. W., Baker, L. C. 2014; 28 (6): 1378-1383

    Abstract

    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 Shreibati, J. B., Baker, L. C., McConnell, M. V., Hlatky, M. A. 2014; 7 (4): 655-662

    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 Shreibati, J. B., Baker, L. C., McConnell, M. V., Hlatky, M. A. 2014; 7 (4): 655-662

    Abstract

    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

  • The Association Between Community-level Insurance Coverage and Emergency Department Use MEDICAL CARE Baker, L. C., Hsia, R. Y. 2014; 52 (6): 535-540

    Abstract

    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

    View details for PubMedCentralID PMC4117395

  • Postoperative Surveillance and Long-term Outcomes After Endovascular Aneurysm Repair Among Medicare Beneficiaries Garg, T., Baker, L. C., Mell, M. W. MOSBY-ELSEVIER. 2014: 8S
  • National Trends of Operative Approach and Mortality for Ruptured Abdominal Aortic Aneurysms from 2002 to 2011 Garg, T., Baker, L. C., Mell, M. W. MOSBY-ELSEVIER. 2014: 46S
  • Patients' preferences explain a small but significant share of regional variation in medicare spending. Health affairs (Project Hope) Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 33 (6): 957-63

    Abstract

    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 PubMedID 24889944

  • Vertical Integration: Hospital Ownership Of Physician Practices Is Associated With Higher Prices And Spending HEALTH AFFAIRS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 33 (5): 756-763

    Abstract

    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 Web of Science ID 000336666500006

  • Gaps in preoperative surveillance and rupture of abdominal aortic aneurysms among Medicare beneficiaries. Journal of vascular surgery Mell, M. W., Baker, L. C., Dalman, R. L., Hlatky, M. A. 2014; 59 (3): 583-588

    Abstract

    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 Hlatky, M. A., Boothroyd, D. B., Reitz, B. A., Shilane, D. A., Baker, L. C., Go, A. S. 2014; 63 (1): 33-39

    Abstract

    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

    View details for PubMedCentralID PMC3947230

  • Why Are Medicare and Commercial Insurance Spending Weakly Correlated? AMERICAN JOURNAL OF MANAGED CARE Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 20 (1): E8-E14

    Abstract

    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 Web of Science ID 000330599000009

  • Why Are Medicare and commercial insurance spending weakly correlated? American journal of managed care Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 20 (1): e8-14

    Abstract

    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 Davies, S., Saynina, O., Schultz, E., McDonald, K. M., Baker, L. C. 2013; 48 (6): 1978-1995

    Abstract

    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 Davies, S. M., Saynina, O., McDonald, K. M., Baker, L. C. 2013; 25 (6): 633-639

    Abstract

    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

    View details for PubMedCentralID PMC3842125

  • Trends in Adult Emergency Department Visits in California by Insurance Status, 2005-2010 JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hsia, R. Y., Brownell, J., Wilson, S., Gordon, N., Baker, L. C. 2013; 310 (11): 1181–83

    View details for DOI 10.1001/jama.2013.228331

    View details for Web of Science ID 000324500300025

    View details for PubMedID 24045743

    View details for PubMedCentralID PMC4011840

  • Effects of care management and telehealth: a longitudinal analysis using medicare data. Journal of the American Geriatrics Society Baker, L. C., Macaulay, D. S., Sorg, R. A., Diener, M. D., Johnson, S. J., Birnbaum, H. G. 2013; 61 (9): 1560-1567

    Abstract

    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

  • Effects of Care Management and Telehealth: A Longitudinal Analysis Using Medicare Data JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Baker, L. C., Macaulay, D. S., Sorg, R. A., Diener, M. D., Johnson, S. J., Birnbaum, H. G. 2013; 61 (9): 1560-1567

    Abstract

    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 Web of Science ID 000324307200015

  • Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries. Journal of vascular surgery Mell, M. W., Hlatky, M. A., Shreibati, J. B., Dalman, R. L., Baker, L. C. 2013; 57 (6): 1519-1523 e1

    Abstract

    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 Hlatky, M. A., Boothroyd, D. B., Baker, L., Kazi, D. S., Solomon, M. D., Chang, T. I., Shilane, D., Go, A. S. 2013; 158 (10): 727-734

    Abstract

    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 Shreibati, J. B., Baker, L. C., Hlatky, M. A., Mell, M. W. 2012; 172 (19): 1456-1462

    Abstract

    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 Meer, A. B., Basu, P. A., Baker, L. C., Atlas, S. W. 2012; 9 (4): 245-250

    Abstract

    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

  • Evaluation for Coronary Artery Disease and Medicare Spending Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Shreibati, J., Baker, L. C., Hlatky, M. A. 2012; 307 (9): 912
  • Association of Coronary CT Angiography or Stress Testing With Subsequent Utilization and Spending Among Medicare Beneficiaries JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Shreibati, J. B., Baker, L. C., Hlatky, M. A. 2011; 306 (19): 2128-2136

    Abstract

    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

  • Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic Disease Linked To Savings HEALTH AFFAIRS Baker, L. C., Johnson, S. J., Macaulay, D., Birnbaum, H. 2011; 30 (9): 1689-1697

    Abstract

    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

  • Analyzing Self-Referral: The Author Replies HEALTH AFFAIRS Baker, L. C. 2011; 30 (6)
  • Weighing Costs, Benefits Of Imaging: Author Response HEALTH AFFAIRS Baker, L. C. 2011; 30 (3)
  • Payment Reform HEALTH SERVICES RESEARCH Fraser, I., Encinosa, W., Baker, L. 2010; 45 (6): 1847-1853
  • Assessing Cost-Effectiveness And Value As Imaging Grows: The Case Of Carotid Artery CT HEALTH AFFAIRS Baker, L. C., Afendulis, C. C., Atlas, S. W. 2010; 29 (12): 2260-2267

    Abstract

    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

  • HMO Coverage Reduces Variations In The Use Of Health Care Among Patients Under Age Sixty-Five HEALTH AFFAIRS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2010; 29 (11): 2068-2074

    Abstract

    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 PubMedID 21041750

  • The contribution of health plans and provider organizations to variations in measured plan quality INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Baker, L. C., Hopkins, D. S. 2010; 22 (3): 210-218

    Abstract

    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 HEALTH AFFAIRS Baras, J. D., Baker, L. C. 2009; 28 (6): W1133-W1140

    Abstract

    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 Singer, S. J., Falwell, A., Gaba, D. M., Meterko, M., Rosen, A., Hartmann, C. W., Baker, L. 2009; 34 (4): 300-311

    Abstract

    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 HEALTH AFFAIRS Bundorf, M. K., Royalty, A., Baker, L. C. 2009; 28 (5): 1294-1304

    Abstract

    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 PubMedID 19738244

  • Relationship of Safety Climate and Safety Performance in Hospitals HEALTH SERVICES RESEARCH Singer, S., Lin, S., Falwell, A., Gaba, D., Baker, L. 2009; 44 (2): 399-421

    Abstract

    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 GESUNDHEITSWESEN Janus, K., Amelung, V. E., Baker, L. C., GAITANIDES, M., Rundall, T. G., Schwartz, F. W. 2009; 71 (4): 210-217

    Abstract

    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 MEDICAL CARE Singer, S. J., Gaba, D. M., Falwell, A., Lin, S., Hayes, J., Baker, L. 2009; 47 (1): 23-31

    Abstract

    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 Janus, K., Amelung, V. E., Baker, L. C., Gaitanides, M., Schwartz, F. W., Rundall, T. G. 2008; 33 (6): 1133-1167

    Abstract

    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

  • Patient Safety Climate in US Hospitals Variation by Management Level MEDICAL CARE Singer, S. J., Falwell, A., Gaba, D. M., Baker, L. C. 2008; 46 (11): 1149-1156

    Abstract

    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

  • Expanded Use Of Imaging Technology And The Challenge of Measuring Value HEALTH AFFAIRS Baker, L. C., Atlas, S. W., Afendulis, C. C. 2008; 27 (6): 1467-1478

    Abstract

    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

  • 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 Bundorf, M. K., Choudhry, K., Baker, L. 2008; 45 (2): 168-183

    Abstract

    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 PubMedID 18767382

  • Trends in charges and payments for nonhospitalized emergency department pediatric visits, 1996-2003. Academic emergency medicine Hsia, R. Y., MacIsaac, D., Palm, E., Baker, L. C. 2008; 15 (4): 347-354

    Abstract

    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 HEALTH AFFAIRS Baker, L. C., Fisher, E. S., Wennberg, J. E. 2008; 27 (2): W123-W134

    Abstract

    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 Hsia, R. Y., MacIsaac, D., Baker, L. C. MOSBY-ELSEVIER. 2008: 265–74

    Abstract

    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 HEALTH PSYCHOLOGY King, A. C., Friedman, R., Marcus, B., Castro, C., Napolitano, M., Alm, D., Baker, L. 2007; 26 (6): 718-727

    Abstract

    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 10.1037/0278-6133.26.6.718

    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 Singer, S., Meterko, M., Baker, L., Gaba, D., Falwell, A., Rosen, A. 2007; 42 (5): 1999-2021

    Abstract

    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 Baker, L. C., Chan, J. 2007; 42 (3): 990-1007

    Abstract

    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

    View details for PubMedCentralID PMC1955247

  • Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants NEW ENGLAND JOURNAL OF MEDICINE Phibbs, C. S., Baker, L. C., Caughey, A. B., Danielsen, B., Schmitt, S. K., Phibbs, R. H. 2007; 356 (21): 2165-2175

    Abstract

    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 NATURE BIOTECHNOLOGY Longaker, M. T., Baker, L. C., Greely, H. T. 2007; 25 (5): 513-521

    Abstract

    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? Hospital topics Alexander, J. A., Weiner, B. J., Shortell, S. M., Baker, L. C. 2007; 85 (2): 3-12

    Abstract

    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 Baker, L. C., Afendulis, C. C., Chandra, A., McConville, S., Phibbs, C. S., Fuentes-Afflick, E. 2007; 161 (1): 69-76

    Abstract

    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 HEALTH AFFAIRS Ketcham, J. D., Baker, L. C., MacIsaac, D. 2007; 26 (1): 195-205

    Abstract

    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 PEDIATRICS Haberland, C. A., Phibbs, C. S., Baker, L. C. 2006; 118 (6): E1667-E1679

    Abstract

    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 Hsia, R., MacIsaac, D., Tsai, A. C., Baker, L. C. MOSBY-ELSEVIER. 2006: S117–S117
  • Do mandates requiring insurers to pay for emergency care influence the use of the emergency department? HEALTH AFFAIRS Hsia, R. Y., Chan, J., Baker, L. C. 2006; 25 (4): 1086-1094

    Abstract

    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) Bundorf, M. K., Wagner, T. H., Singer, S. J., Baker, L. C. WILEY-BLACKWELL PUBLISHING, INC. 2006: 819–36

    Abstract

    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 PubMedID 16704514

  • Quality improvement implementation and hospital performance on quality indicators HEALTH SERVICES RESEARCH Weiner, B. J., Alexander, J. A., Shortell, S. M., Baker, L. C., Becker, M., Geppert, J. J. 2006; 41 (2): 307-334

    Abstract

    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

    View details for PubMedCentralID PMC1702526

  • Quality improvement implementation and hospital performance on patient safety indicators MEDICAL CARE RESEARCH AND REVIEW Weiner, B. J., Alexander, J. A., Baker, L. C., Shortell, S. M., Becker, M. 2006; 63 (1): 29-57

    Abstract

    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 Guarino, C. M., Ko, C. Y., Baker, L. C., KLEIN, D. J., Quiter, E. S., Escarce, J. J. 2006; 21 (1): 7-12

    Abstract

    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

    View details for PubMedCentralID PMC1484625

  • Evaluating the efficiency of California providers in caring for patients with chronic illnesses HEALTH AFFAIRS Wennberg, J. E., Fisher, E. S., Baker, L., Sharp, S. M., Bronner, K. K. 2006; 25 (1): W5526-W5543
  • The role of organizational infrastructure in implementation of hospitals' quality improvement. Hospital topics Alexander, J. A., Weiner, B. J., Shortell, S. M., Baker, L. C., Becker, M. P. 2006; 84 (1): 11-20

    Abstract

    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 Baker, L. C., Afendulis, C. 2005; 40 (5): 1466-1488

    Abstract

    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

    View details for PubMedCentralID PMC1361210

  • Internet use and stigmatized illness SOCIAL SCIENCE & MEDICINE Berger, M., Wagner, T. H., Baker, L. C. 2005; 61 (8): 1821-1827

    Abstract

    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 Baker, L., Rideout, J., Gertler, P., Raube, K. 2005; 12 (5): 530-536

    Abstract

    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

    View details for PubMedCentralID PMC1205601

  • Has prudent layperson legislation achieved its goals of increasing access for emergency care? Scientific Assembly of the American-College-of-Emergency-Physicians Hsia, R. Y., Chan, J., Baker, L. C. MOSBY-ELSEVIER. 2005: S119–S119
  • Evaluating the efficiency of california providers in caring for patients with chronic illnesses. Health affairs Wennberg, J. E., Fisher, E. S., Baker, L., Sharp, S. M., Bronner, K. K. 2005: W5-526 43

    Abstract

    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

  • Does Medicaid managed care affect access to care for the uninsured? Haberer, J. E., Garrett, B., Baker, L. C. PROJECT HOPE. 2005: 1095–1105

    Abstract

    This study investigates whether the implementation of Medicaid managed care from 1994 to 2001 was associated with changes in access to care for the uninsured. We used regression analysis to examine relationships between changes in county-level Medicaid managed care activity over time and changes in four measures of perceived access to care. After we controlled for sex, race, ethnicity, poverty, age, health, and education and included county fixed effects to account for unobserved county characteristics that are potentially associated with the implementation of Medicaid managed care and outcome measures, we found that Medicaid managed care has had no consistent effect on access.

    View details for DOI 10.1377/hlthaff.24.4.1095

    View details for Web of Science ID 000230621600024

    View details for PubMedID 16012150

  • Free Internet access, the digital divide, and health information MEDICAL CARE Wagner, T. H., Bundorf, M. K., Singer, S. J., Baker, L. C. 2005; 43 (4): 415-420

    Abstract

    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 Ko, C. Y., Escarce, J. J., Baker, L., Sharp, J., Guarino, C. 2005; 241 (2): 373-380

    Abstract

    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

    View details for PubMedCentralID PMC1356925

  • The relationship between SCHIP enrollment and hospitalizations for ambulatory care sensitive conditions in California JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Bermudez, D., Baker, L. 2005; 16 (1): 96-110

    Abstract

    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. Health affairs Baker, L. C. 2005: W5-22 W5 25

    Abstract

    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 Baker, L. C., Phillips, K. A., Haas, J. S., Liang, S. Y., Sonneborn, D. 2004; 39 (6): 1751-1772

    Abstract

    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 Wagner, T. H., Baker, L. C., Bundorf, M. K., Singer, S. 2004; 1 (4): A13-?

    Abstract

    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

    View details for PubMedCentralID PMC1277953

  • Predictors for medical students entering a general surgery residency: National survey results 65th Annual Meeting of the Society-of-University-Surgeons Ko, C. Y., Escarce, J. J., Baker, L., Klein, D., Guarino, C. MOSBY-ELSEVIER. 2004: 567–72

    Abstract

    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

  • Consumers' use of the Internet for health insurance AMERICAN JOURNAL OF MANAGED CARE Bundorf, M. K., Singer, S. J., Wagner, T. H., Baker, L. 2004; 10 (9): 609-616

    Abstract

    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 PubMedID 15515993

  • Relationship between HMO market share and the diffusion and use of advanced MRI technologies. Journal of the American College of Radiology Baker, L. C., Atlas, S. W. 2004; 1 (7): 478-487

    Abstract

    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 MEDICAL CARE Haas, J. S., Phillips, K. A., Sonneborn, D., McCulloch, C. E., Baker, L. C., Kaplan, C. P., Perez-Stable, E. J., Liang, S. Y. 2004; 42 (7): 707-714

    Abstract

    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 Baker, L. C., Afendulis, C. C., Heidenreich, P. A. AMER ECONOMIC ASSOC. 2004: 347–51
  • 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 Haberland, C. A., Phibbs, C. S., Baker, L. C. NATURE PUBLISHING GROUP. 2004: 517A–517A
  • Are gatekeeper requirements associated with cancer screening utilization? HEALTH SERVICES RESEARCH Phillips, K. A., Haas, J. S., Liang, S. Y., Baker, L. C., Tye, S., Kerlikowske, K., Sakowski, J., Spetz, A. 2004; 39 (1): 153-178

    Abstract

    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

    View details for PubMedCentralID PMC1360999

  • Do health plans influence quality of care? INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Baker, L. C., Hopkins, D., Dixon, R., Rideout, J., Geppert, J. 2004; 16 (1): 19-30

    Abstract

    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 Baker, L. C., Phibbs, C. S., Guarino, C., Supina, D., Reynolds, J. L. 2004; 23 (1): 191-211

    Abstract

    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

  • Managed Care, Information, and Diffusion: The Case of Treatment for Heart-Attack Patients. The American economic review Baker, L. C., Afendulis, C. C., Heidenreich, P. A. 2004; 94 (2): 347-51

    View details for PubMedID 29068187

  • The relationship between technology availability and health care spending HEALTH AFFAIRS Baker, L., Birnbaum, H., Geppert, J., Mishol, D., Moyneur, E. 2003; 22 (6): W537-W551
  • The relationship between technology availability and health care spending. Health affairs Baker, L., Birnbaum, H., Geppert, J., Mishol, D., Moyneur, E. 2003: W3-537 51

    Abstract

    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 Baker, L., Wagner, T. H., Singer, S., Bundorf, M. K. 2003; 289 (18): 2400-2406

    Abstract

    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 PubMedID 12746364

  • Is the prevalence of gatekeeping in a community associated with individual trust in medical care? MEDICAL CARE Haas, J. S., Phillips, K. A., Baker, L. C., Sonneborn, D., McCulloch, C. E. 2003; 41 (5): 660-668

    Abstract

    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

  • 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 Haas, J. S., Phillips, K., Sonneborn, D., McCulloch, C., Baker, L., Kaplan, C., Perez-Stable, E., Liang, S. SPRINGER. 2003: 174–175
  • 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 Phibbs, C. S., Baker, L. C., Schmitt, S. K., Danielsen, B., Phibbs, R. H. NATURE PUBLISHING GROUP. 2003: 442A–442A
  • 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 Phibbs, C. S., Baker, L. C., Schmitt, S. K., Phibbs, R. H. LIPPINCOTT WILLIAMS & WILKINS. 2003: S120–S120
  • Managed care spillover effects ANNUAL REVIEW OF PUBLIC HEALTH Baker, L. C. 2003; 24: 435-456

    Abstract

    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 Baker, L. C., Phibbs, C. S. BLACKWELL PUBLISHING. 2002: 524–48

    Abstract

    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 Alexander, M., Baker, L., Clark, C., McDonald, K. M., Rowell, R., Saynina, O., Hlatky, M. A. 2002; 144 (3): 431-439

    Abstract

    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 MEDICAL CARE Backus, L., Moron, M., Bacchetti, P., Baker, L. C., Bindman, A. B. 2002; 40 (4): 315-324

    Abstract

    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 Baker, L. 2002; 13 (2): 107-113

    Abstract

    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 Skarbinski, J., Walker, H. K., Baker, L. C., Kobaladze, A., Kirtava, Z., Raffin, T. A. 2002; 287 (8): 1043-1049

    Abstract

    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 Heidenreich, P. A., McClellan, M., Frances, C., Baker, L. C. 2002; 112 (3): 176-182

    Abstract

    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 Baker, L. C., McClellan, M. B. UNIV CHICAGO PRESS. 2001: 715–41
  • Managed care and technology adoption in health care: evidence from magnetic resonance imaging JOURNAL OF HEALTH ECONOMICS Baker, L. C. 2001; 20 (3): 395-421

    Abstract

    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 Baker, L. C. WILEY-BLACKWELL PUBLISHING, INC. 2001: 223–51

    Abstract

    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 Chehab, E. L., Panicker, N., Alper, P. R., Baker, L. C., Wilson, S. R., Raffin, T. A. 2001; 161 (2): 202-211

    Abstract

    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 Baker LC, McClellan MB 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 Spetz, J., Baker, L., Phibbs, C., Pedersen, R., TAFOYA, S. 2000; 2 (4): 203-212

    Abstract

    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 HEALTH AFFAIRS Baker, L. C., Cantor, J. C., Long, S. H., Marquis, M. S. 2000; 19 (5): 121-128

    Abstract

    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 Baker, L. C., Royalty, A. B. 2000; 35 (3): 480-502
  • Effect of managed care market share on treatment of fee-for service patients with myocardial infarction Heidenreich, P. A., McClellan, M., Frances, C. D., Baker, L. C. ELSEVIER SCIENCE INC. 2000: 268A
  • 'Competition' among employers offering health insurance JOURNAL OF HEALTH ECONOMICS Dranove, D., Spier, K. E., Baker, L. 2000; 19 (1): 121-140

    Abstract

    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 Baker LC, Royalty AB 2000; 35 (3): 480-502
  • Physicians' perceptions of autonomy and satisfaction in California HEALTH AFFAIRS Burdi, M. D., Baker, L. C. 1999; 18 (4): 134-145

    Abstract

    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 Baker, L. C., Brown, M. L. 1999; 30 (2): 351-U2

    Abstract

    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 Baker, L. C. 1999; 281 (5): 432-437

    Abstract

    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 Cantor, J. C., Bergeisen, L., Baker, L. C. 1998; 280 (9): 772-776

    Abstract

    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 HEALTH AFFAIRS Baker, L. C., Wheeler, S. K. 1998; 17 (5): 195-207

    Abstract

    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 Phillips, K. A., Kerlikowske, K., Baker, L. C., Chang, S. W., Brown, M. L. 1998; 33 (1): 29-53

    Abstract

    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? Phibbs, C. S., Baker, L. C., Wheeler, S. K., Phibbs, R. H. LIPPINCOTT WILLIAMS & WILKINS. 1998: 158A–158A
  • Factors associated with the perception that debt influences physicians' specialty choices ACADEMIC MEDICINE Baker, L. C., Barker, D. C. 1997; 72 (12): 1088-1096

    Abstract

    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 Burdi, M. D., Baker, L. C. 1997; 3 (9): 1357-1366

    Abstract

    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 Baker, L. C. 1997; 16 (4): 453-481

    Abstract

    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 Cantor, J. C., Miles, E. L., Baker, L. C., Barker, D. C. 1996; 33 (2): 167-180

    Abstract

    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 Baker, L. C., Corts, K. S. AMER ECONOMIC ASSOC. 1996: 389–94

    View details for Web of Science ID A1996UL37300074

    View details for PubMedID 10160551

  • Differences in earnings between male and female physicians NEW ENGLAND JOURNAL OF MEDICINE Baker, L. C. 1996; 334 (15): 960-964

    Abstract

    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 Baker, L. C., Krueger, A. B. 1995; 14 (5): 531-549

    Abstract

    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 Hughes, R. G., Baker, L. C. 1995; 4 (9): 759-765

    Abstract

    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? HMO practice Baker, L. C., Cantor, J. C., Miles, E. L., Sandy, L. G. 1994; 8 (2): 53-57

    Abstract

    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 HEALTH AFFAIRS Baker, L. C., Baker, L. S. 1994; 13 (5): 162-171

    Abstract

    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 Cantor, J. C., Baker, L. C., Hughes, R. G. 1993; 270 (9): 1035-1040

    Abstract

    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 HEALTH AFFAIRS Baker, L. C., Cantor, J. C. 1993; 12: 258-270

    Abstract

    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 HEALTH AFFAIRS Baker, L. C., Krueger, A. B. 1993; 12: 271-281

    Abstract

    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