To estimate the relationship between variations in medical spending and health outcomes of the elderly.
1992–2002 Medicare Current Beneficiary Surveys.
We used instrumental variable (IV) estimation to identify the relationships between alternative measures of elderly Medicare beneficiaries' medical spending over a 3-year observation period and health status, measured by the Health and Activity Limitation Index (HALex) and survival status at the end of the 3 years. We used the Dartmouth Atlas End-of-Life Expenditure Index defined for hospital referral regions in 1996 as the exogenous identifying variable to construct the IVs for medical spending.
Data Collection/Extraction Methods
The analysis sample includes 17,438 elderly (age >64) beneficiaries who entered the Medicare Current Beneficiary Survey in the fall of each year from 1991 to 1999, were not institutionalized at baseline, stayed in fee-for-service Medicare for the entire observation period, and survived for at least 2 years. Measures of baseline health were constructed from information obtained in the fall of the year the person entered the survey, and changes in health were from subsequent interviews over the entire observation period. Medicare and total medical spending were constructed from Medicare claims and self-reports of other spending over the entire observation period.
IV estimation results in a positive and statistically significant relationship between medical spending and better health: 10 percent greater medical spending over the prior 3 years (mean = U.S.$2,709) is associated with a 1.9 percent larger HALex value (p = .045; range 1.2–2.2 percent depending on medical spending measure) and a 1.5 percent greater survival probability (p = .039; range 1.2–1.7 percent).
On average, greater medical spending is associated with better health status of Medicare beneficiaries, implying that across-the-board reductions in Medicare spending may result in poorer health for some beneficiaries.
Medicare efficiency; medical spending; health outcomes
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.
Data Collection/Extraction Methods
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.
Low back pain; low back MRI; low back surgery; instrumental variables; physician self-referral
To examine whether high-deductible health plans (HDHPs) that exempt prescription drugs from full cost sharing preserve medication use for major chronic illness, compared with traditional HMOs with similar drug cost sharing.
Data Sources/Study Setting
We examined 2001–2008 pharmacy claims data of 3,348 continuously enrolled adults in a Massachusetts health plan for 9 months before and 24 months after an employer-mandated switch from a traditional HMO plan to a HDHP, compared with 20,534 contemporaneous matched HMO members. Both study groups faced similar three-tiered drug copayments. We calculated daily medication availability for all prescription drugs and four chronic medication classes: hypoglycemics, lipid-lowering agents, antihypertensives, and chronic obstructive pulmonary disease (COPD)/asthma controllers.
Interrupted time-series with comparison group study design examining monthly level and trend changes in prescription drug utilization.
The HDHP and control groups had comparable changes in the level and trend of all drugs after the index date; we detected similar patterns in the use of lipid-lowering agents, antihypertensives, and COPD/asthma controllers. Some evidence suggested a small relative decline in hypoglycemic use among diabetic patients in HDHPs.
Switching to an HDHP that included modest drug copayments did not change medication availability or reduce use of essential medications for three common chronic illnesses.
High-deductible health plans; pharmaceutical use; chronic disease; differential cost-sharing
To compare the characteristics, health behaviors, and health services utilization of U.S. adults who use complementary and alternative medicine (CAM) to treat illness to those who use CAM for health promotion.
The 2007 National Health Interview Survey (NHIS).
We compared adult (age ≥18 years) NHIS respondents based on whether they used CAM in the prior year to treat an illness (n = 973), for health promotion (n = 3,281), or for both purposes (n = 3,031). We used complex survey design methods to make national estimates and examine respondents' self-reported health status, health behaviors, and conventional health services utilization.
Adults who used CAM for health promotion reported significantly better health status and healthier behaviors overall (higher rates of physical activity and lower rates of obesity) than those who used CAM as treatment. While CAM Users in general had higher rates of conventional health services utilization than those who did not use CAM; adults who used CAM as treatment consumed considerably more conventional health services than those who used it for health promotion.
This study suggests that there are two distinct types of CAM User that must be considered in future health services research and policy decisions.
Complementary and alternative medicine; health services; preventive health services
To test whether nonprofit, for-profit, or government hospital ownership affects medical service provision in rural hospital markets, either directly or through the spillover effects of ownership mix.
Data Sources/Study Setting
Data are from the American Hospital Association, U.S. Census, CMS Healthcare Cost Report Information System and Prospective Payment System Minimum Data File, and primary data collection for geographic coordinates. The sample includes all nonfederal, general medical, and surgical hospitals located outside of metropolitan statistical areas and within the continental United States from 1988 to 2005.
We estimate multivariate regression models to examine the effects of (1) hospital ownership and (2) hospital ownership mix within rural hospital markets on profitable versus unprofitable medical service offerings.
Rural nonprofit hospitals are more likely than for-profit hospitals to offer unprofitable services, many of which are underprovided services. Nonprofits respond less than for-profits to changes in service profitability. Nonprofits with more for-profit competitors offer more profitable services and fewer unprofitable services than those with fewer for-profit competitors.
Rural hospital ownership affects medical service provision at the hospital and market levels. Nonprofit hospital regulation should reflect both the direct and spillover effects of ownership.
Hospitals; rural health care; nonprofit; for-profit; hospital markets
To determine the impact of unit-level nurse staffing on quality of discharge teaching, patient perception of discharge readiness, and postdischarge readmission and emergency department (ED) visits, and cost-benefit of adjustments to unit nurse staffing.
Patient questionnaires, electronic medical records, and administrative data for 1,892 medical–surgical patients from 16 nursing units within four acute care hospitals between January and July 2008.
Nested panel data with hospital and unit-level fixed effects and patient and unit-level control variables.
Registered nurse (RN) staffing was recorded monthly in hours-per-patient-day. Patient questionnaires were completed before discharge. Thirty-day readmission and ED use with reimbursement data were obtained by cross-hospital electronic searches.
Higher RN nonovertime staffing decreased odds of readmission (OR = 0.56); higher RN overtime staffing increased odds of ED visit (OR = 1.70). RN nonovertime staffing reduced ED visits indirectly, via a sequential path through discharge teaching quality and discharge readiness. Cost analysis projected total savings from 1 SD increase in RN nonovertime staffing and decrease in RN overtime of U.S.$11.64 million and U.S.$544,000 annually for the 16 study units.
Postdischarge utilization costs could potentially be reduced by investment in nursing care hours to better prepare patients before hospital discharge.
Hospital discharge; discharge readiness; readmission; emergency department utilization; cost
To study the impact of minimum direct care staffing (MDCS) requirements on nurse staffing levels, nurse skill mix, and quality.
U.S. nursing home facility data from the Online Survey Certification and Reporting (OSCAR) System merged with MDCS requirements.
Facility-level outcomes of nurse staffing levels, nurse skill mix, and quality measures are regressed on the level of nurse staffing required by MDCS requirements in the prior year and other controls using fixed effect panel regression. Quality measures are care practices, resident outcomes, and regulatory deficiencies.
Data Extraction Method
Analysis used all OSCAR surveys from 1999 to 2004, resulting in 17,552 unique facilities with a total of 94,371 survey observations.
The effect of MDCS requirements varied with reliance of the nursing home on Medicaid. Higher MDCS requirements increase nurse staffing levels, while their effect on nurse skill mix depends on the reliance of the nursing home on Medicaid. MDCS have mixed effects on care practices but are generally associated with improved resident outcomes and meeting regulatory standards.
MDCS requirements change staffing levels and skill mix, improve certain aspects of quality, but can also lead to use of care practices associated with lower quality.
Minimum direct care staffing ratios; quality; nursing homes
A fundamental assumption of the quality-adjusted life year model is mutual utility independence between life years and health status. However, this assumption may not hold for severe health states: living in a severe health state may cause disutility beyond a so-called maximal endurable time (MET). It is unknown, however, whether persons without experience of a disease, who are often used in health state valuation exercises, account for MET. Using data from 159 respondents from two convenience samples in Germany who were presented a health state description of depression, this study shows that persons without experience of depression had a lower rate of MET than persons with a history of depression. Furthermore, they had more preference reversals in case of MET, thus violating a fundamental principle of rational choice theory. While these findings suggest that severe health states should be assessed by patients rather than the community, confirmation in additional studies outside Germany and based on other health-state valuation techniques and diseases is recommended.
QALYs; patient preferences; maximal endurable time; preference reversals
To assess the internal consistency and agreement between the Health Care Information and Management Systems Society (HIMSS) and the Leapfrog computerized provider order entry (CPOE) data.
Secondary hospital data collected by HIMSS Analytics, the Leapfrog Group, and the American Hospital Association from 2005 to 2007.
Dichotomous measures of full CPOE status were created for the HIMSS and Leapfrog datasets in each year. We assessed internal consistency by calculating the percent of full adopters in a given year that report full CPOE status in subsequent years. We assessed the level of agreement between the two datasets by calculating the κ statistic and McNemar's test. We examined responsiveness by assessing the change in full CPOE status rates, over time, reported by HIMSS and Leapfrog data, respectively.
Findings indicate minimal agreement between the two datasets regarding positive hospital CPOE status, but adequate agreement within a given dataset from year to year. Relative to each other, the HIMSS data tend to overestimate increases in full CPOE status over time, while the Leapfrog data may underestimate year over year increases in national CPOE status.
Both Leapfrog and HIMSS data have strengths and weaknesses. Those interested in studying outcomes associated with CPOE use or adoption should be aware of the strengths and limitations of the Leapfrog and HIMSS datasets. Future development of a standard definition of CPOE status in hospitals will allow for a more comprehensive validation of these data.
Computerized provider order entry; reliability; validity; responsiveness; HIMSS data; Leapfrog data
To examine the strengths and limitations of the Center for Medicare and Medicaid Services' Chronic Condition Data Warehouse (CCW) algorithm for identifying chronic conditions in older persons from Medicare beneficiary data.
Records from participants of the NHANES I Epidemiologic Follow-up Study (NHEFS 1971–1992) linked to Medicare claims data from 1991 to 2000.
We estimated the percent of preexisting cases of chronic conditions correctly identified by the CCW algorithm during its reference period and the number of years of claims data necessary to find a preexisting condition.
The CCW algorithm identified 69 percent of preexisting diabetes cases but only 17 percent of preexisting arthritis cases. Cases identified by the CCW are a mix of preexisting and newly diagnosed conditions.
The prevalence of conditions needing less frequent health care utilization (e.g., arthritis) may be underestimated by the CCW algorithm. The CCW reference periods may not be sufficient for all analytic purposes.
CCW; NHEFS; Medicare claims; chronic conditions
Logic models have been used to evaluate policy programs, plan projects, and allocate resources. Logic Modeling for policy analysis has been used rarely in health services research but can be helpful in evaluating the content and rationale of health policies. Comparative Logic Modeling is used here on human immunodeficiency virus (HIV) policy statements from the Department of Veterans Affairs (VA) and Centers for Disease Control and Prevention (CDC). We created visual representations of proposed HIV screening policy components in order to evaluate their structural logic and research-based justifications.
Data Sources and Study Design
We performed content analysis of VA and CDC HIV testing policy documents in a retrospective case study.
Using comparative Logic Modeling, we examined the content and primary sources of policy statements by the VA and CDC. We then quantified evidence-based causal inferences within each statement.
VA HIV testing policy structure largely replicated that of the CDC guidelines. Despite similar design choices, chosen research citations did not overlap. The agencies used evidence to emphasize different components of the policies.
Comparative Logic Modeling can be used by health services researchers and policy analysts more generally to evaluate structural differences in health policies and to analyze research-based rationales used by policy makers.
Evidence-based practice; HIV; health policy; Centers for Disease Control and Prevention (U.S.); Veterans Affairs (U.S.)
To understand reasons why California has lower Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores than the rest of the country, including differing patterns of CAHPS scores between Medicare Advantage (MA) and fee-for-service, effects of additional demographic characteristics of beneficiaries, and variation across MA plans within California.
Study Design/Data Collection
Using 2008 CAHPS survey data for fee-for-service Medicare beneficiaries and MA members, we compared mean case mix adjusted Medicare CAHPS scores for California and the remainder of the nation.
California fee-for-service Medicare had lower scores than non-California fee-for-service on 11 of 14 CAHPS measures; California MA had lower scores only for physician services measures and higher scores for other measures. Adding race/ethnicity and urbanity to risk adjustment improved California standing for all measures in both MA and fee-for-service. Within the MA plans, one large plan accounted for the positive performance in California MA; other California plans performed below national averages.
This study shows that the mix of fee-for-service and MA enrollees, demographic characteristics of populations, and plan-specific factors can all play a role in observed regional variations. Anticipating value-based payments, further study of successful MA plans could generate lessons for enhancing patient experience for the Medicare population.
Patient experience of care; Geographic variations; Medicare
To compare the effects of lottery-based and fixed incentives on clinicians' response to surveys.
Three randomized trials with fixed payments and actuarially equivalent lotteries.
Trial 1 compared a low-probability/high-payout lottery, a high-probability/low-payout lottery, and no incentive. Trial 2 compared a moderate-probability/moderate-payout lottery with an unconditional fixed payment (payment sent with questionnaire). Trial 3 compared a moderate-probability/moderate-payout lottery with a conditional fixed payment (payment promised following response).
Neither the low-probability nor high-probability lotteries improved response compared with no incentive. Unconditional fixed payments produced significantly greater response than actuarially equivalent lotteries, but conditional fixed payments did not.
Lottery-based incentives do not improve clinicians' response rates compared with no incentives, and they are inferior to unconditional fixed payments.
Incentives; response rate; surveys; lottery; behavioral economics
To evaluate the utility of offering physicians electronic options as alternatives to completing mail questionnaires.
A survey of colorectal cancer screening practices of Alabama primary care physicians, conducted May–June 2010.
In the follow-up to a mail questionnaire, physicians were offered options of completing surveys by telephone, fax, email, or online.
Data Collection Method
Detailed records were kept on the timing and mode of completion of surveys.
Eighty-eight percent of surveys were returned by mail, 10 percent were returned by fax, and only 2 percent were completed online; none were completed by telephone or email.
Offering fax options increases response rates, but providing other electronic options does not.
Physician surveys; survey methodology; multimodal surveys; response rates
To identify factors associated with the cost of treating high-cost Medicare beneficiaries.
A national sample of 1.6 million elderly, Medicare beneficiaries linked to 2004–2005 Community Tracking Study Physician Survey respondents and local market data from secondary sources.
Using 12 months of claims data from 2005 to 2006, the sample was divided into predicted high-cost (top quartile) and lower cost beneficiaries using a risk-adjustment model. For each group, total annual standardized costs of care were regressed on beneficiary, usual source of care physician, practice, and market characteristics.
Among high-cost beneficiaries, health was the predominant predictor of costs, with most physician and practice and many market factors (including provider supply) insignificant or weakly related to cost. Beneficiaries whose usual physician was a medical specialist or reported inadequate office visit time, medical specialist supply, provider for-profit status, care fragmentation, and Medicare fees were associated with higher costs.
Health reform policies currently envisioned to improve care and lower costs may have small effects on high-cost patients who consume most resources. Instead, developing interventions tailored to improve care and lowering cost for specific types of complex and costly patients may hold greater potential for “bending the cost curve.”
Medicare; health care costs; market factors; heath reform; payment policy
To determine whether the change in prescription drug insurance coverage associated with Medicare Part D reduced hospitalization rates for conditions sensitive to drug adherence.
Data Sources/Study Setting
Hospital discharge data from 2005 to 2007 for 23 states, linked with state-level data on drug coverage.
We use a difference-in-difference-in-differences approach, comparing changes in the probability of hospitalization before and after the introduction of the Part D benefit in 2006, for individuals aged 65 and older (versus individuals aged 60–64) in states with low drug coverage in 2005 (versus those in states with high pre-Part D drug coverage).
Data Collection/Extraction Methods
Hospitalization rates for selected ambulatory care sensitive conditions in 23 states were computed using data from the Census and Health Care Utilization Project. Drug coverage rates were computed using data from several sources.
For the conditions studied, our point estimates suggest that Part D reduced the overall rate of hospitalization by 20.5 per 10,000 (4.1 percent), representing approximately 42,000 admissions, about half of the reduction in admissions over our study period.
The increase in drug coverage associated with Medicare Part D had positive effects on the health of elderly Americans, which reduced use of nondrug health care resources.
Medicare; prescription drugs; hospitalization
To examine whether disparities in health care experiences of Medicare beneficiaries differ between managed care (Medicare Advantage [MA]) and traditional fee-for-service (FFS) Medicare.
132,937 MA and 201,444 FFS respondents to the 2007 Medicare Consumer Assessment of Health Care Providers and Systems (CAHPS) survey.
We defined seven subgroup characteristics: low-income subsidy eligible, no high school degree, poor or fair self-rated health, age 85 and older, female, Hispanic, and black. We estimated disparities in CAHPS experience of care scores between each of these groups and beneficiaries without those characteristics within MA and FFS for 11 CAHPS measures and assessed differences between MA and FFS disparities in linear models.
The seven subgroup characteristics had significant (p<.05) negative interactions with MA (larger disparities in MA) in 27 of 77 instances, with only four significant positive interactions.
Managed care may provide less uniform care than FFS for patients; specifically there may be larger disparities in MA than FFS between beneficiaries who have low incomes, are less healthy, older, female, and who did not complete high school, compared with their counterparts. There may be potential for MA quality improvement targeted at the care provided to particular subgroups.
Managed care; vulnerable populations; patient experience; Medicare; CAHPS
To investigate whether having a usual source of care (USOC) resulted in lower depression prevalence among the elderly.
The 2001–2003 Medicare Current Beneficiaries Survey and 2002 Area Resource File.
Twenty thousand four hundred and fifty-five community-dwelling person-years were identified for respondents aged 65+, covered by both Medicare Parts A and B in Medicare fee-for-service for a full year. USOC was defined by the question “Is there a particular medical person or a clinic you usually go to when you are sick or for advice about your health?” Ambulatory care use (ACU) was defined by having at least one physician office visit and/or hospital outpatient visit using Medicare claims. Depression was identified by a two-item screen (sadness and/or anhedonia). All measures were for the past 12 months. A simultaneous-equations (trivariate probit) model was estimated, adjusted for sampling weights and study design effects.
Based on the simultaneous-equations model, USOC is associated with 3.8 percent lower probability of having depression symptoms (p = .03). Also, it had a positive effect on having any ACU (p<.001). Having any ACU had no statistically significant effect on depression (p = .96).
USOC was associated with lower depression prevalence and higher realized access (ACU) among community-dwelling Medicare beneficiaries.
Access to care; health care use; usual source of care; depression; Medicare
To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001–2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice.
A dataset of linked Medicaid claims and birth certificates for the time period by clustering Medicaid claims by pregnancy episode. Pregnancy episodes were linked to residential county-level demographic and medical resource characteristics. Deliveries occurring before 35 weeks gestation (n = 5,150) were used for analysis.
Logistic regression analysis was used to examine time trends and individual, county, and intervention characteristics associated with delivery at hospitals with NICU, and delivery at the academic medical center.
Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting.
Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.
Medicaid; preterm births; perinatal regionalization; NICU
To quantify the impact of Medicare Part D eligibility on medication utilization, emergency department use, hospitalization, and preference-based health utility among civilian noninstitutionalized Medicare beneficiaries.
Difference-in-differences analyses were used to estimate the effects of Part D eligibility on health outcomes by comparing a 12-month period before and after Part D implementation using the Medical Expenditure Panel Survey. Models adjusted for sociodemographic characteristics and health status and compared Medicare beneficiaries aged 65 and older with near elderly aged 55–63 years old.
Five hundred and fifty-six elderly and 549 near elderly were included. After adjustment, Part D was associated with a U.S.$179.86 (p = .034) reduction in out-of-pocket costs and an increase of 2.05 prescriptions (p = .081) per patient year. The associations between Part D and emergency department use, hospitalizations, and preference-based health utility did not suggest cost offsets and were not statistically significant.
Although there was a substantial reduction in out-of-pocket costs and a moderate increase in medication utilization among Medicare beneficiaries during the first year after Part D, there was no evidence of improvement in emergency department use, hospitalizations, or preference-based health utility for those eligible for Part D during its first year of implementation.
Medicare Part D; health care utilization; health outcomes; insurance; prescriptions
To examine the cost-effectiveness of improving blood pressure management from the payer perspective.
Data Source/Study Setting
Medical record data for 4,500 U.S. adults with hypertension from the Community Quality Index (CQI) study (1996–2002), pharmaceutical claims from four Massachusetts health plans (2004–2006), Medicare fee schedule (2009), and published literature.
A probability tree depicted blood pressure management over 2 years.
Data Collection/Extraction Methods
We determined how frequently CQI study subjects received recommended care processes and attained accepted treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided.
Relative to current care, improved care would cost payers U.S.$170 more per hypertensive person annually (2009 dollars). The incremental cost per person newly attaining treatment goals over 2 years would be U.S.$1,696 overall, U.S.$801 for moderate hypertension, and U.S.$850 for severe hypertension. Among people with severe hypertension, blood pressure would decline substantially but seldom reach goal; the incremental cost per person attaining a relaxed goal (≤stage 1) would be U.S.$185.
Under the Health Care Effectiveness Data and Information Set program, which monitors the attainment of blood pressure treatment goals, payers will find it slightly more cost-effective to improve care for moderate than severe hypertension. Having a secondary, relaxed goal would substantially increase payers' incentive to improve care for severe hypertension.
Quality of health care; cost and cost analysis; cost-benefit analysis; hypertension