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1.  Despite Resources From The ACA, Most States Do Little To Help Addiction Treatment Programs Implement Health Care Reform 
Health affairs (Project Hope)  2015;34(5):828-835.
The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment—the state governmental organizations charged with overseeing addiction treatment programs—are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACA’s promise to improve access to and quality of addiction treatment.
doi:10.1377/hlthaff.2014.1330
PMCID: PMC4706741  PMID: 25941285
2.  AGING & HEALTH Expectations About Future Use Of Long-Term Services And Supports Vary By CurrentLiving Arrangement 
Health affairs (Project Hope)  2015;34(1):39-47.
Most Americans know little about options for long-term services and supports and underestimate their likely future needs for such assistance. Using data from the 2012 National Health Interview Survey, we examined expectations about future use of long-term services and supports among adults ages 40–65 and how these expectations varied by current living arrangement. We found differences by living arrangement in expectations about both future need for long-term services and supports and who would provide such care if needed. Respondents living with minor children were the least likely to expect to need long-term services and supports and to require paid care if the need arose. In contrast, respondents living alone were the most likely to expect that it was “very likely” that they would need long-term services and supports and to rely on paid care. Overall, we found a disconnect between expectations of use and likely future reality: 60 percent of respondents believed that they were unlikely to need long-term services and supports in the future, whereas the evidence suggests that nearly 70 percent of older adults will need them at some point. These findings both underscore the need for programs that encourage people to plan for long-term services and supports and indicate that information about living arrangements can be useful in developing and targeting such programs.
doi:10.1377/hlthaff.2014.0556
PMCID: PMC4285622  PMID: 25561642
3.  Dependent Coverage Provision Led To Uneven Insurance Gains And Unchanged Mortality Rates In Young Adult Trauma Patients 
Health affairs (Project Hope)  2015;34(1):125-133.
Insurance coverage has increased among young adults due to the 2010 dependent coverage provision of the Affordable Care Act. However, little is known about the provision's effects on clinical outcomes and insurance coverage of patients with trauma – the most frequent cause of death and physical disability among young adults. Using the 2007-2012 National Trauma Databank, we conducted a difference-in-differences analysis of coverage rates among 19-25 year-old trauma patients, compared to 26-34 year-old controls, and examined trauma-relevant outcomes by patient, injury, and hospital characteristics. We found a 3.4 percentage point decrease in uninsured status among younger trauma patients following the policy change, concentrated among nonminority patients, those with less severe injuries, and those with lower trauma-related mortality risk. We did not detect significant changes in intensive care use or overall mortality. The heterogeneous coverage impact of this provision on high- versus low-risk trauma patients has implications for future efforts to expand coverage.
doi:10.1377/hlthaff.2014.0880
PMCID: PMC4692158  PMID: 25561653
4.  Medicare Advantage Members’ Expected Out-Of-Pocket Spending For Inpatient And Skilled Nursing Facility Services 
Health affairs (Project Hope)  2015;34(6):1019-1027.
Inpatient and skilled nursing facility (SNF) cost sharing in Medicare Advantage (MA) plans may reduce unnecessary use of these services. However, large out-of-pocket expenses potentially limit access to care and encourage beneficiaries at high risk of needing inpatient and postacute care to avoid or leave MA plans. In 2011 new federal regulations restricted inpatient and skilled nursing facility cost sharing and mandated limits on out-of-pocket spending in MA plans. After these regulations, MA members in plans with low premiums averaged $1,758 in expected out-of-pocket spending for an episode of seven hospital days and twenty skilled nursing facility days. Among members with the same low-premium plan in 2010 and 2011, 36 percent of members belonged to plans that added an out-of-pocket spending limit in 2011. However, these members also had a $293 increase in average cost sharing for an inpatient and skilled nursing facility episode, possibly to offset plans’ expenses in financing out-of-pocket limits. Some MA beneficiaries may still have difficulty affording acute and postacute care despite greater regulation of cost sharing.
doi:10.1377/hlthaff.2014.1146
PMCID: PMC4681704  PMID: 26056208
5.  High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare 
Health affairs (Project Hope)  2015;34(10):1675-1681.
Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.
doi:10.1377/hlthaff.2015.0272
PMCID: PMC4676406  PMID: 26438743
6.  Waiving the Three-Day Rule: Admissions and Length-of-Stay at Hospitals and Skilled Nursing Facilities did not Increase 
Health affairs (Project Hope)  2015;34(8):1324-1330.
The traditional Medicare program requires an enrollee to have a hospital stay of at least three consecutive calendar days to qualify for coverage of subsequent postacute care in a skilled nursing facility. This long-standing policy, implemented to discourage premature discharges from hospitals, might now be inappropriately lengthening hospital stays for patients who could be transferred sooner. To assess the implications of eliminating the three-day qualifying stay requirement, we compared hospital and postacute skilled nursing facility utilization among Medicare Advantage enrollees in matched plans that did or did not eliminate that requirement in 2006–10. Among hospitalized enrollees with a skilled nursing facility admission, the mean hospital length-of-stay declined from 6.9 days to 6.7 days for those no longer subject to the qualifying stay but increased from 6.1 to 6.6 days among those still subject to it, for a net decline of 0.7 day when the three-day stay requirement was eliminated. The elimination was not associated with more hospital or skilled nursing facility admissions or with longer lengths-of-stay in a skilled nursing facility. These findings suggest that eliminating the three-day stay requirement conferred savings on Medicare Advantage plans and that study of the requirement in traditional Medicare plans is warranted.
doi:10.1377/hlthaff.2015.0054
PMCID: PMC4675655  PMID: 26240246
7.  North Carolina Physician-Based Preventive Oral Health Services Improve Access And Use Among Young Medicaid Enrollees 
Health affairs (Project Hope)  2014;33(12):2144-2152.
To combat disparities in oral health and access to dental care among infants and toddlers, most state Medicaid programs now reimburse physician-based preventive oral health services, such as fluoride varnish applications. We used geospatial data to examine the distribution of dental and medical Medicaid providers of pediatric oral health services throughout North Carolina to determine if these services have improved access to care for Medicaid enrollees younger than three years old. We then used claims data to examine the association between distance from these practices and use of dental services for a cohort of approximately 1,000 young children. Among 100 counties, four counties had no physician-based preventive oral health services and nine counties had no dental practice. While children who lived further from the nearest dental practice were less likely to make dental visits, distance from physician-based preventive oral health services did not predict use. For young Medicaid enrollees, oral health services provided in medical offices can improve access and increase use.
doi:10.1377/hlthaff.2014.0927
PMCID: PMC4331078  PMID: 25489032
8.  Inequities In Health Care Needs For Children With Medical Complexity 
Health affairs (Project Hope)  2014;33(12):2190-2198.
Children with special health care needs are believed to be susceptible to inequities in health and health care access. Within the group with special needs, there is a smaller group of children with medical complexity: children who require medical services beyond what is typically required by children with special health care needs. We describe health care inequities for the children with medical complexity compared to children with special health care needs but without medical complexity, based on a secondary analysis of the 2005–06 and 2009–10 National Survey of Children with Special Health Care Needs. The survey examines the prevalence, health care service use, and needs of children and youth with special care needs, as reported by their families. The inequities we examined were those based on race or ethnicity, primary language in the household, insurance type, and poverty status. We found that children with medical complexity were twice as likely to have at least one unmet need, compared to children without medical complexity. Among the children with medical complexity, uninsured status was associated with more unmet needs than privately insured status. We conclude that medical complexity itself can be a primary determinant of unmet needs.
doi:10.1377/hlthaff.2014.0273
PMCID: PMC4334319  PMID: 25489038
Chronic Care; Children's Health; Disparities; Maternal And Child Health
9.  The ACA's Pediatric Essential Health Benefit Has Resulted In A State-By-State Patchwork of Coverage With Exclusions 
Health affairs (Project Hope)  2014;33(12):2136-2143.
The ACA establishes “essential health benefits” (EHBs) as the coverage standard for health plans sold in the individual and small group markets, including the health insurance Marketplace. “Pediatric services” are a required EHB coverage class. However, other than oral health and vision care, neither the statute nor the implementing regulations define the term. This study aimed to determine how state benchmark plans address pediatric coverage in EHB-governed plans. Our review of state benchmark plan summaries for all 50 states and D.C. found that no state specified a distinct “pediatric services” benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many state benchmark plans also specifically excluded services for children with special health care needs. These findings suggest important policy directions in preparing for the 2016 plan year.
doi:10.1377/hlthaff.2014.0743
PMCID: PMC4587658  PMID: 25489031
Children's Health; Consumer Issues; Health Reform; Children Insurance Coverage
10.  Evaluating State Options for Reducing Medicaid Churning 
Health affairs (Project Hope)  2015;34(7):1180-1187.
Medicaid churning - the constant exit and re-entry of beneficiaries as their eligibility changes - has long been a problem for both Medicaid administrators and recipients. Churning will continue under the Affordable Care Act, because despite new federal rules, Medicaid eligibility will continue to be based on current monthly income. We developed a longitudinal simulation model to evaluate four policy options for modifying or extending Medicaid eligibility to reduce churning. The simulations suggest that two options, extending Medicaid eligibility either to the end of a calendar year or for twelve months after enrollment, would be far more effective in reducing churning than the other options of a three-month extension or eligibility based on projected annual income. States should consider implementation of the option that best balances costs, including both administration and services, with improved health of Medicaid enrollees.
doi:10.1377/hlthaff.2014.1204
PMCID: PMC4664196  PMID: 26153313
11.  Specialty Drug Spending Trends Among Medicare And Medicare Advantage Enrollees, 2007–11 
Health affairs (Project Hope)  2014;33(11):2018-2024.
Specialty pharmaceuticals include most injectable and biologic agents used to treat complex conditions such as rheumatoid arthritis, multiple sclerosis, and cancer. We analyzed trends in specialty drug spending among Medicare beneficiaries ages sixty-five and older using 2007–11 pharmacy claims data from a 20 percent sample of Medicare beneficiaries. Annual specialty drug spending per beneficiary who used specialty drugs increased considerably during the study period, from $2,641 to $8,976. However, specialty drugs accounted for only 6.7 percent of total drug spending per beneficiary in 2007 and 9.1 percent in 2011. Moreover, in 2011 cost-sharing reductions under the Affordable Care Act significantly reduced specialty drug users’ out-of-pocket burden, which decreased 26 percent from 2010. Oral cancer agents accounted for a significant proportion of the increase in specialty drug spending among the study population. This suggests that the migration of specialty drug coverage from Medicare’s Part B medical benefit to the Part D pharmacy benefit because of new treatment options may play an important role in specialty pharmacy trends. This shift is likely to continue as pharmaceutical innovations enable more specialty therapeutics to be self-administered and to be covered under the pharmacy instead of the medical benefit.
doi:10.1377/hlthaff.2014.0538
PMCID: PMC4250050  PMID: 25367998
12.  Medical Malpractice Reform: Noneconomic Damages Caps Reduced Payments 15 Percent, With Varied Effects By Specialty 
Health affairs (Project Hope)  2014;33(11):2048-2056.
The impact of medical malpractice reforms on the average size of malpractice payments in specific physician specialties is unknown and subject to debate. We analyzed a national sample of 220,653 malpractice claims from 1985–2010 merged with information on state liability reforms. We estimated the impact of state noneconomic damage caps on average malpractice payment size for physicians overall and for 10 different specialties, and compared how the effects differed according to the restrictiveness of the cap ($250,000 vs. $500,000 cap). We found noneconomic damage caps reduced payments by $42,980 (15%; p<0.001), with a $250,000 cap reducuing average payments by $59,331 (20%; p<0.001), while a $500,000 cap had no significant effect. Effects varied according to specialty and were largest in specialties with high average payments, such as pediatrics. This suggests that the effect of noneconomic damage caps differs by specialty, and only more restrictive caps result in lower average payments.
doi:10.1377/hlthaff.2014.0492
PMCID: PMC4278571  PMID: 25339633
13.  Housing Code Violation Density Associated With Emergency Department And Hospital Use By Children With Asthma 
Health affairs (Project Hope)  2014;33(11):1993-2002.
Local agencies that enforce housing policies can partner with the health care system to target pediatric asthma care. These agencies retain data that can be used to pinpoint potential clusters of high asthma morbidity. We sought to assess whether the density of housing code violations in census tracts—the in-tract asthma-relevant violations (such as the presence of mold or cockroaches) divided by the number of housing units—was associated with population-level asthma morbidity and could be used to predict a hospitalized patient’s risk of subsequent morbidity. We found that increased density in housing code violations was associated with population-level morbidity independent of poverty, and that the density explained 22 percent of the variation in rates of asthma-related emergency department visits and hospitalizations. Children who had been hospitalized for asthma had 1.84 greater odds of a revisit to the emergency department or a rehospitalization within twelve months if they lived in the highest quartile of housing code violation tracts, compared to those living in the lowest quartile. Integrating housing and health data could highlight at-risk areas and patients for targeted interventions.
doi:10.1377/hlthaff.2014.0496
PMCID: PMC4458371  PMID: 25367995
14.  Federal Parity Law Associated With Increased Probability Of Using Out-Of-Network Substance Use Disorder Treatment Services 
Health affairs (Project Hope)  2015;34(8):1331-1339.
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires commercial insurers providing group coverage for substance use disorder services to offer benefits for those services at a level equal to those for medical or surgical benefits. Unlike previous parity policies instituted for federal employees and in individual states, the law extends parity to out-of-network services. We conducted an interrupted time-series analysis using insurance claims from large self-insured employers to evaluate whether federal parity was associated with changes in out-of-network treatment for 525,620 users of substance use disorder services. Federal parity was associated with an increased probability of using out-of-network services, an increased average number of out-of-network outpatient visits, and increased average total spending on out-of-network services among users of those services. Our findings were broadly consistent with the contention of federal parity proponents that extending parity to out-of-network services would broaden access to substance use disorder care obtained outside of plan networks.
doi:10.1377/hlthaff.2014.1384
PMCID: PMC4607035  PMID: 26240247
15.  National Trends In Spending On And Use Of Oral Oncologics, First Quarter 2006 Through Third Quarter 2011 
Health affairs (Project Hope)  2014;33(10):1721-1727.
Oral prescription drugs are an increasingly important treatment option for cancer. Yet contemporaneous US trends in spending on anticancer drugs known as oral oncologics have not been described. Using nationally representative data, we describe trends in national spending on and use of forty-seven oral oncologics between the first quarter of 2006 and the third quarter of 2011. Average quarterly national spending on oral oncologics increased 37 percent, from $940.3 million to $1.4 billion in 2012 dollars, a significant change. Average quarterly use of oral oncologics in the same time period measured in extended units increased at a significant pace but more slowly than spending (10 percent). Within this broader trend, differences in spending among categories of oral oncologics were observed. High levels of and increases in both spending and use were concentrated among new brand-name and patent-protected oral oncologics, including second-generation tyrosine kinase inhibitors used to treat chronic myelogenous leukemia. Decreased spending but increased use was observed among oral oncologics that lost patent protection during the study period and were available in generic form, including hormonal therapies used to treat breast and prostate cancers. Spending on new and patent-protected oral oncologics and associated price increases are significant drivers of increased spending.
doi:10.1377/hlthaff.2014.0001
PMCID: PMC4594844  PMID: 25288415
16.  The 340B Drug Discount Program: Hospitals Generate Profits By Expanding To Reach More Affluent Communities 
Health affairs (Project Hope)  2014;33(10):1786-1792.
The federal 340B program gives participating hospitals and other medical providers deep discounts on outpatient drugs. Named for a section of the Veterans Health Care Act of 1992, the program’s original intent was to help low-income and uninsured patients. But the program has come under scrutiny by critics who contend that some hospitals exploit the drug discounts to generate profits instead of either investing in programs for the poor or passing the discounts along to patients and insurers. We examined whether the program is expanding in ways that could maximize hospitals’ ability to generate profits from the 340B drug discounts. We matched data for 960 hospitals and 3,964 affiliated clinics registered with the 340B program in 2012 with the socioeconomic characteristics of their communities from the US Census Bureau’s American Community Survey. We found that hospital-affiliated clinics that registered for the 340B program in 2004 or later served communities that were wealthier and had higher rates of health insurance compared to communities served by hospitals and clinics that registered for the program before 2004. Our findings support the criticism that the 340B program is being converted from one that serves vulnerable patient populations to one that enriches hospitals and their affiliated clinics.
doi:10.1377/hlthaff.2014.0540
PMCID: PMC4591849  PMID: 25288423
17.  Acute Hospital Care Is The Chief Driver of Regional Spending Variation in Medicare Patients with Advanced Cancer 
Health affairs (Project Hope)  2014;33(10):1793-1800.
The root causes of regional variation in medical spending are poorly understood and vary by clinical condition. To identify drivers of regional spending variation for Medicare patients with advanced cancer, we used linked Surveillance, Epidemiology, and End Results (SEER) program–Medicare data from 2004–10. We broke down Medicare spending into thirteen cancer-relevant service categories. We then calculated the contribution of each category to spending and regional spending variation. Acute hospital care was the largest component of spending and the chief driver of regional spending variation, accounting for 48 percent of spending and 67 percent of variation. In contrast, chemotherapy accounted for 16 percent of spending and 10 percent of variation. Hospice care comprised 5 percent of spending; however variation in hospice spending was fully offset by opposing variation in other categories. Our analysis suggests that the strategy with the greatest potential to improve the value of care for patients with advanced cancer is to reduce reliance on acute hospital care for this patient population.
doi:10.1377/hlthaff.2014.0280
PMCID: PMC4203442  PMID: 25288424
18.  The effect of ACGME resident duty hour reforms on outcomes of physicians after completion of residency 
Health affairs (Project Hope)  2014;33(10):1832-1840.
In 2003, work hours for physicians in training (residents) were mandatorily reduced to be no more than 80 hours per week, leading to the hotly debated but unexplored issue of whether physicians today are less well trained as a result of these work hour reforms. Using a unique database of nearly all hospitalizations in Florida during 2000–2009 which were linked to detailed information on the medical training history of the physician of record for each hospitalization, we studied whether hospital mortality and length of stay for internists varied according to the number of years an internist was exposed to the 2003 duty hour regulations during their own residency. Using a difference-in-difference analysis which compared trends in outcomes of junior physicians pre- and post-2003 to a control group of senior physicians who were not exposed to these reforms during their own residency, we found that the 2003 reforms did not affect the quality of physician training reflected by hospital mortality and length of stay.
doi:10.1377/hlthaff.2014.0318
PMCID: PMC4269477  PMID: 25288430
19.  Patient-To-Physician Messaging: Volume Nearly Tripled As More Patients Joined System, But Per Capita Rate Plateaued 
Health affairs (Project Hope)  2014;33(10):1817-1822.
Patients want to be able to communicate with their physicians by e-mail. However, physicians are often concerned about the impact that such communications will have on their time, productivity, and reimbursement. Typically, physicians are not reimbursed for time spent communicating with patients electronically. But under federal meaningful-use criteria for information technology, physicians can receive a modest incentive for such communications. Little is known about trends in secure e-mail messaging between physicians and patients. To understand these trends, we analyzed the volume of messages in a large academic health care system’s patient portal in the period 2001–10. At the end of 2010, 49,778 patients (22.7 percent of all patients seen within the system) had enrolled in the portal, and 36.9 percent of enrolled patients (8.4 percent of all patients) had sent at least one message to a physician. Physicians in the aggregate saw a near tripling of e-mail messages during the study period. However, the number of messages per hundred patients per month stabilized between 2005 and 2010, at an average of 18.9 messages. As physician reimbursement moves toward global payments, physicians’ and patients’ participation in secure messaging will likely increase, and electronic communication should be considered part of physicians’ job descriptions.
doi:10.1377/hlthaff.2013.1145
PMCID: PMC4418542  PMID: 25288428
20.  Estimating The Health And Economic Burden Of Cancer Among Those Diagnosed As Adolescents And Young Adults 
Health affairs (Project Hope)  2014;33(6):1024-1031.
Adolescent and young adult cancer survivors—those who were ages 15–39 at their first cancer diagnosis—have important health limitations. These survivors are at risk for higher health care expenditures and lost productivity, compared to adults without a history of cancer. Using Medical Expenditure Panel Survey data, we present nationally representative estimates of the economic burden among people who were diagnosed with cancer in adolescence or young adulthood. Our findings demonstrate that surviving cancer at this age is associated with a substantial economic burden. Compared to adults without a history of cancer, adolescent and young adult cancer survivors had excess annual medical expenditures of $3,170 per person and excess annual productivity losses of $2,250 per person. Multifaceted prevention strategies, including education and sustained intervention programs to ensure access to lifelong risk-based follow-up care, may be effective ways to improve the economic outcomes associated with cancer survivorship in this population.
doi:10.1377/hlthaff.2013.1425
PMCID: PMC4582764  PMID: 24889952
21.  The 340B Discount Program: Outpatient Prescription Dispensing Patterns Through Contract Pharmacies In 2012 
Health affairs (Project Hope)  2014;33(11):2012-2017.
Section 340B of the Public Health Service Act provides qualified organizations serving vulnerable populations with deep discounts for some outpatient medications. A 2010 regulatory change widely expanded the 340B program’s reach, allowing these organizations to contract with retail pharmacies to dispense medications for eligible patients. Little is known about which medications are dispensed by contract pharmacies under the expanded program. We provide the first comparison of 340B prescriptions and all prescriptions dispensed in contract pharmacies. We used 2012 data from Walgreens, the national leader in 340B contract pharmacies. Medications used to treat chronic conditions such as diabetes, high cholesterol levels, asthma, hypertension, and depression accounted for an overwhelming majority of all prescriptions dispensed at Walgreens as part of the 340B program. A higher percentage of antiretrovirals used to treat HIV/AIDS were dispensed through 340B prescriptions than through all prescriptions dispensed at Walgreens. The majority of 340B prescriptions dispensed at Walgreens originated at tuberculosis clinics, consolidated health centers, disproportionate-share hospitals, and Ryan White clinics. Our results suggest that 340B contract pharmacies dispense medications used to treat Americans’ chronic disease burden and disproportionately dispense medications used by key vulnerable populations targeted by the program.
doi:10.1377/hlthaff.2014.0833
PMCID: PMC4545491  PMID: 25367997
22.  California Emergency Department Closures Are Associated With Increased Inpatient Mortality At Nearby Hospitals 
Health affairs (Project Hope)  2014;33(8):1323-1329.
Between 1996 and 2009 the annual number of emergency department (ED) visits in the United States increased by 51 percent while the number of EDs nationwide decreased by 6 percent, which placed unprecedented strain on the nation’s EDs. To investigate the effects of an ED closing on surrounding communities, we identified all ED closures in California during the period 1999–2010 and examined their association with inpatient mortality rates at nearby hospitals. We found that 24.9 percent of hospital admissions in this period occurred near an ED closure, and that these admissions had 5 percent higher odds of inpatient mortality than admissions not occurring near a closure. This association persisted whether we considered ED closures as affecting all future nearby admissions or only those occurring in the subsequent two years. These results suggest that ED closures have ripple effects on patient outcomes that should be considered when health systems and policy makers decide how to regulate ED closures.
doi:10.1377/hlthaff.2013.1203
PMCID: PMC4214135  PMID: 25092832
23.  Geographic clustering of diabetic lower extremity amputations in low income regions of California 
Health affairs (Project Hope)  2014;33(8):1383-1390.
A large body of work demonstrates income-related disparities in access to coordinated preventive care in patients with diabetes and other chronic conditions. Much less information exists on associations between poverty and consequential negative health outcomes. Few studies have assessed geographic patterns linking household incomes to major, preventable complications of chronic diseases.
Using statewide facility discharge data for California during 2009, we identified 7,973 lower extremity amputations in 6,828 diabetic adults. We mapped amputation events based on residential zip codes, and used US census data to produce corresponding maps of poverty rate. Comparisons of the maps show amputation “hotspots” in lower income urban and rural regions of California. Prevalence-adjusted amputation rates varied ten-fold between high-income and low-income regions.
While our analysis does not support detailed causal inferences, our method for mapping complication “hot spots” using existing public data sources may help target interventions to communities most in need.
doi:10.1377/hlthaff.2014.0148
PMCID: PMC4242846  PMID: 25092840
24.  Gains in medication affordability following Medicare Part D are eroding among elderly with multiple chronic conditions 
Health affairs (Project Hope)  2014;33(8):1435-1443.
Elderly Americans, especially those with multiple chronic conditions, face difficulties paying for prescriptions, resulting in worse adherence and discontinuation of therapy (“cost-related medication nonadherence” or CRN). We investigated whether the gains in medication affordability attributable to Medicare Part D implementation in January 2006 persisted during the six years that followed. Overall, we found continued incremental improvements in medication affordability in the early years of Part D (2007–2009), which then eroded during more recent years (2009–2011). Among elderly beneficiaries with four or more chronic conditions, we observed an increase in the prevalence of CRN from 14.4% in 2009 to 17.0% in 2011, reversing previous downward trends. Similarly, the prevalence of forgoing basic needs in order to purchase medicines among the sickest elderly decreased from 8.7% in 2007 to 6.8% in 2009, then rose to 10.2% in 2011. Our findings highlight the need for targeted policy efforts to alleviate the persistent burden of drug treatment costs in this vulnerable population.
doi:10.1377/hlthaff.2013.1067
PMCID: PMC4340076  PMID: 25092846
25.  Policy Makers Will Need A Way To Update Bundled Payments That Reflects Highly Skewed Spending Growth Of Various Care Episodes 
Health affairs (Project Hope)  2013;32(5):944-951.
Bundled payment entails paying a single price for all services delivered as part of an episode of care for a specific condition. It is seen as a promising way to slow the growth of health care spending while maintaining or improving the quality of care. To implement bundled payment, policy makers must set base payment rates for episodes of care and update the rates over time to reflect changes in the costs of delivering care and the components of care. Adopting the fee-for-service paradigm of adjusting payments with uniform update rates would be fair and accurate if costs increased at a uniform rate across episodes. But our analysis of 2003 and 2007 US commercial claims data showed spending growth to be highly skewed across episodes: 10 percent of episodes accounted for 82.5 percent of spending growth, and within-episode spending growth ranged from a decline of 75 percent to an increase of 323 percent. Given that spending growth was much faster for some episodes than for others, a situation known as skewness, policy makers should not update episode payments using uniform update rates. Rather, they should explore ways to address variations in spending growth, such as updating episode payments one by one, at least at the outset.
doi:10.1377/hlthaff.2012.1246
PMCID: PMC4492307  PMID: 23650329

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