Showing papers in "Medical Care Research and Review in 2004"

Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up.

Abstract: This study reports results of the 2-year follow-up phase of a randomized study comparing outcomes of patients assigned to a nurse practitioner or a physician primary care practice. In the sample of 406 adults, no differences were found between the groups in health status, disease-specific physiologic measures, satisfaction or use of specialist, emergency room or inpatient services. Physician patients averaged more primary care visits than nurse practitioner patients. The results are consistent with the 6-month findings and with a growing body of evidence that the quality of primary care delivered by nurse practitioners is equivalent to that by physicians.

Frontier efficiency measurement in health care: a review of empirical techniques and selected applications.

Abstract: Health care institutions worldwide are increasingly the subject of analyses aimed at defining, measuring, and improving organizational efficiency. However, despite the importance of efficiency measurement in health care services, it is only relatively recently that the more advanced econometric and mathematical programming frontier techniques have been applied to hospitals, nursing homes, health management organizations, and physician practices, among others. This article provides a synoptic survey of the comparatively few empirical analyses of frontier efficiency measurement in health care services. Both the measurement of efficiency in a range of health care services and the posited determinants of health care efficiency are examined.

The rate and cost of hospital readmissions for preventable conditions.

Abstract: The study estimates the rate and cost of preventable readmissions within 6 months after a first preventable admission, by age-group, and by payer and race within age-group. The descriptive results are contrasted with several hypotheses. The hospital discharge data are for residents of New York, Pennsylvania, Tennessee, and Wisconsin in 1999, from files of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. About 19 percent of persons with an initial preventable admission had at least one preventable readmission rate within 6 months. Hospital cost for preventable readmissions during 6 months was about 730 million US dollars. There were substantial differences in readmission rates by payer group and by race. Some evidence suggests that preventable readmissions may partly reflect complexity of underlying problems. Interventions to reduce cost might focus on identifying high-risk patients before discharge and devising new approaches to follow-up.

A review of the literature examining linkages between organizational factors, medical errors, and patient safety.

Abstract: The potential role of organizational factors in enhanced patient safety and medical error prevention is highlighted in the systems approach advocated for by the Institute of Medicine and others. However, little is known about the extent to which these factors have been shown empirically to be associated with these favorable outcomes. The present study conducted an intensive review of the clinical and health services literatures in order to explore this issue. The results of this review support the general conclusion that there is little evidence for asserting the importance of any individual, group, or structural variable in error prevention or enhanced patient safety at the present time. Two major issues bearing on the development of future research in this area involve strengthening the theoretical foundations of organizational research on patient safety and overcoming definitional and observability problems associated with error-focused dependent variables.

Two Decades of Organizational Change in Health Care: What Have we Learned?

Abstract: The 1980s and 1990s witnessed a substantial wave of organizational restructuring among hospitals and physicians, as health providers rethought their organizational roles given perceived market imperatives. Mergers, acquisitions, internal restructuring, and new interorganizational relationships occurred at a record pace. Matching this was a large wave of study and discourse among health services researchers, industry experts, and consultants to understand the causes and consequences of organizational change. In many cases, this literature provides mixed signals about what was accomplished through these organizational efforts. The purpose of this review is to synthesize this diverse literature. This review examines studies of horizontal consolidation and integration of hospitals, horizontal consolidation and integration of physician organizations, and integration and relationship development between physicians and hospitals. In all, around 100 studies were examined to assess what was learned through two decades of research on organizational change in health care.

The impact of cost-sharing on appropriate utilization and health status: a review of the literature on seniors.

Abstract: This article provides a review of research that has addressed the impact of patient cost sharing on the use of services and resulting health status impacts, among the population age 65 and older. Nearly all of the 22 relevant studies examined that have been published since 1990-16 focusing on cost-sharing for prescription drugs and 6 on cost-sharing for medical services--conclude that increased cost-sharing reduces either or both the utilization and health status of seniors. Most of the studies, however, rely on cross-sectional and self-reported data. Further research, employing stronger study designs as well as clinical and administrative data, is necessary before drawing more definitive conclusions.

Increasing value: a research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States.

Abstract: There is growing consensus that the U.S. health care system is not producing value relative to the resources invested. Unwarranted variation exists in quality and outcomes of care and underutilization of both evidence-based medicine and evidence-management practices. To address these issues, this article calls for a broad-based social science approach focused on obtaining a greater understanding of change at the individual, group, organizational, and environmental levels as they influence each other. Specific examples and questions for research are suggested with regard to the redesign of care systems, enhancing learning and transferring knowledge, and creating effective financial incentives. The specific measurement, analysis, and study design issues involved in under-taking such a research agenda are discussed.

Penetrating the "black box": financial incentives for enhancing the quality of physician services.

Abstract: This article addresses the impact of financial incentives on physician behavior, focusing on quality of care. Changing market conditions, evolving social forces, and continuing organizational evolu...

Assessing the influence of incentives on physicians and medical groups.

Abstract: This article describes issues that should be considered in the development of a theory or theories about incentives from which testable hypotheses could be derived. Economic, psychological, and organizational theories are described, and issues that should be considered in hypothesis generation are presented. Psychological factors influencing incentives include decision framing, regret, heuristics, and reinforcements. Organizational factors influencing incentives include bundling of services or people, matching of incentive structure with work organization, and the incompletely contained hierarchical nesting of incentives. Finally, the dynamics of incentive change are considered, with a focus on describing the conditions under which physicians and physician organizations respond to incentive changes.

Relative Risk of Postpartum Complications in the Ohio Medicaid Population: Vaginal Versus Cesarean Delivery

Abstract: The objective of this study was to estimate the relative risk of postpartum complication by type of delivery among Ohio Medicaid beneficiaries. The study uses the linked Medicaid and Ohio birth certificate data for births occurring from July 1991 through April 1996 (N = 168,736). The results indicate that the incidence of major puerperal infection, thromboembolic events, anesthetic complications, and obstetrical surgical wound infection was higher among women undergoing a C-section as compared to those with vaginal delivery, even after limiting the analysis to elective cesarean deliveries and uncomplicated vaginal deliveries. On the other hand, women with C-sections were less likely to experience obstetrical trauma, and results on postpartum hemorrhage were inconclusive. Aside from obstetrical trauma, the relative risk of postpartum complications remains significantly higher among women undergoing C-section. These findings are of particular relevance in light of the substantial proportion of repeat C-sections performed on an elective basis.

Nursing homes with persistent high and low quality.

Abstract: This article examines the concentration of low- and high-quality care within particular nursing facilities over time. The authors explore three different explanations for persistent low and high quality over time including the level of public reimbursement, the presence of bed constraint policies such as certificate-of-need and construction moratoria, and the role of consumer information. Using 1991 through 1999 data from the On-Line Survey, Certification, and Reporting system, the authors show that both low- and high-quality nursing home care is concentrated in certain facilities over time. Their results further show that public reimbursement and asymmetric information are both important factors in explaining why low quality persists over time in certain facilities.

Value for taxpayers' dollars: what VA care would cost at medicare prices.

Abstract: Critics charge that Veterans Health Administration (VA) medical centers are inefficient and the cost of veteran health care would be reduced if VA purchased care for its patients directly from private-sector providers. This analysis compares VA medical care expenditures with estimates of total payments under a hypothetical Medicare fee-for-service payment system reimbursing providers for the same counts of each service VA medical centers provided in fiscal 1999. At six study sites, hypothetical payments were more than 20 percent greater than actual budgets. Nationally, this represented more than 3 billion US dollars in 1999 and more than 5 billion US dollars in 2003. Data limitations suggest the estimate is conservative. Less than half of the difference is due to VA's low pharmacy costs. The study demonstrates the potential savings to patients and taxpayers of the VA health care system.

Opportunities and challenges for measuring cost, quality, and clinical effectiveness in health care.

Abstract: Empirical studies of health care cost, productivity, and output have focused primarily on intermediate goods and services. Consumers are ultimately interested in final goods such as improved health or health-related quality of life, but health services research continues to address whether health services financing and delivery are structured in ways to maximize production of intermediate goods, regardless of the link between these services and final outcomes. Increasing rates of growth of health care cost and dissatisfaction with the quality of U.S. health care force us to reexamine how productivity and cost are analyzed so that research properly informs policy and practice. The authors examine recent changes in the U.S. health care sector that suggest the need to revise how health services research approaches analyses of cost, production, and output; consider alternative notions of final goods; and review the availability and quality of data necessary to conduct this research.

The sensitivity of Medicare billing claims data for monitoring mammography use by elderly women.

Abstract: Mammography use is monitored through Medicare billing claims; however, the sensitivity of this data source has not been previously described. This study included 10,852 Colorado women ages 65 and older with a mammogram in 1998 as registered by the Colorado Mammography Project who were Medicare fee-for-service (FFS) enrollees. These records were matched to Medicare billing data to assess the proportion of those mammograms submitted for payment to Medicare. The overall sensitivity of the FFS Medicare billing data for screening mammography was 85 percent. Medicare billing claims were less sensitive for younger women, African Americans, women with some college education, and women with supplementary private insurance. In Colorado, the Medicare FFS billing claims understates mammography usage by 15 percent. Care must be taken when comparing mammography use derived from Medicare billing claims, as the sensitivity of billing data can vary substantially by age, race, and socioeconomic status.

Translating research into practice: are physicians following evidence-based guidelines in the treatment of hypertension?

Abstract: Despite the widespread availability of evidence-based guidelines for treating hypertension, recent evidence suggests that physicians may not be prescribing first-line drugs for their patients with high blood pressure. Using administrative claims data from 1998 through 2000, this study investigates whether drug treatment provided to 6,736 hypertensives in a privately insured, non-HMO population follows practice guidelines. The authors also examine physician and patient-related factors associated with guideline adherence in a subset of patients with newly diagnosed hypertension. Among members with high blood pressure alone, only 38 percent were on a diuretic, while less than a third were prescribed a beta-blocker, the JNC VI recommended first-line antihypertensives for essential hypertension. Approximately half of individuals with high blood pressure and certain comorbidities received non-first-line interventions. Such findings indicate the need to reconsider how guidelines are communicated and shared with medical practitioners and patients, particularly in light of the drug industry's promotion of newer, more expensive drugs.

The economies of scale for nursing home care.

Abstract: Using a modified hybrid short-term operating cost function and a national sample of nursing homes in 1994, the authors examined the scale economies of nursing home care. The results show that scale economies exist for Medicare postacute care, with an elasticity of -0.15 and an optimal scale of around 4,000 patient days annually. However, more than 68 percent of nursing homes in the analytic sample produced Medicare days at a level below the optimal scale. The financial pressures resulting from the implementation of a prospective payment system for Medicare skilled nursing facilities may further reduce the quantity of Medicare days served by nursing homes. In addition, the results show that chain-owned nursing homes do not have lower short-term operating costs than do independent facilities. This indicates that the rationale behind recent increasing horizontal integration among nursing homes may not be seeking greater cost efficiency but some other consideration.

The effect of insurance status on travel time for rural Medicare patients.

Abstract: Managed care has been hypothesized to increase patient travel by directing patients toward network providers. The purpose of this study is to measure the effect of Medicare HMO enrollment on hospital travel time in rural areas. Hospital travel times were determined for 85,586 inpatient discharges among rural Pennsylvania residents admitted to Pennsylvania hospitals in 1998. Medicare HMO enrollees traveled up to 10.2 minutes further for acute care than Medicare fee-for-service patients (39 versus 29 minutes). Medicare HMO enrollees were 50 percent more likely to travel outside their own counties and 70 percent more likely to travel to urban areas for acute care. The distance premium associated with HMO enrollment was largest in counties with the lowest managed care penetration.

Decreased home health use: does it decrease satisfaction?

Abstract: This study investigates differences in satisfaction and quality of life for Medicare beneficiaries using home health care services before and after implementation of the Interim Payment System (IPS...

What matters to low-income patients in ambulatory care facilities?

Abstract: Poor, uninsured, and minority patients depend disproportionately on hospital outpatient departments (OPDs) and freestanding health centers for ambulatory care. These providers confront significant challenges, including limited resources, greater demand for services, and the need to improve quality and patient satisfaction. The authors use a survey of patients in OPDs and health centers in New York City to determine which aspects of the ambulatory care visit have the greatest influence on patients’ overall site evaluation. The personal interaction between patients and physicians, provider continuity, and the general cleanliness/appearance of the facility stand out as high priorities. Access to services and interactions with other facility staff are of significant, although lesser, importance. These findings suggest ways to restructure the delivery of care so that it is more responsive to the concerns of low-income patients.

Does consumer satisfaction information matter? Evidence on member retention in FEHBP plans.

Abstract: Taking advantage of a natural experiment, this study explores the crucial link between consumer satisfaction, distribution of consumer satisfaction information, and member retention at open enrollment. Multiple data sources, panel data regression analysis, and instrumental variable techniques inform how retention is affected by consumer satisfaction, before and after free distribution of report card information, controlling for market structure, consumer characteristics, premiums, benefits, and other plan attributes in about 250 Federal Employee Health Benefit Program (FEHBP) plans nationwide. Study results suggest that consumer satisfaction boosts member retention. Free distribution of consumer satisfaction information to federal employees during open enrollment is associated with lower member retention, which may suggest that consumers might have used this newly distributed information and then decided to withdraw from their previous plans.

Commentary on "Penetrating the 'black box': financial incentives for enhancing the quality of physician services," by Douglas A. Conrad and Jon B. Christianson.

Abstract: Conrad and Christianson present an ambitious framework for penetrating the “black box” of health care management practices to improve our understanding of the methods that can be adopted by health care organizations to affect both the quality and efficiency of care (Conrad and Christianson 2002). It has been more than a decade since the publication of groundbreaking work by Hillman and colleagues set the foundation for this area of inquiry, yet few studies to date have been published that adequately control for both organizationaland provider-level financial incentives (Hillman, Pauly, and Kerstein 1989; Hillman, Welch, and Pauly 1992; Kralewski et al. 2000; Conrad et al. 1996). Other work in this area is just getting under way. This lack of productivity should not be construed to reflect a lack of interest. Rather, it is ample proof of the difficulties that must be overcome when answering questions of this nature. The framework presented by Conrad and Christianson explains the slow progress in this area to date and helps to put this body of research into context (Conrad and Christianson 2002). The challenges presented by this area of inquiry are daunting. First, it is clear that organizational characteristics, even when studied well, will only explain a relatively small amount of the variance observed in clinical practice. Factors related to individual patients and their

How health policy and health services researchers are compensated: analysis of a nationwide salary survey.

Abstract: The membership of Academy Health, a professional organization, was invited to complete an anonymous Web-based survey in 2002. Responses were received from 1,140 of 2,633 surveyed (43 percent). Fifty-six percent worked in academic institutions or teaching hospitals, 34 percent in the private sector or foundations, and 10 percent in government. Most (96 percent) had at least one advanced degree, and the diversity of educational backgrounds was pronounced. The median annual salary was $99,000. Salaries were highest in the private sector, followed by academic and government settings. There were large regional variations, with higher salaries in the Mid-Atlantic and New England regions. Adjusted data suggested these higher regional salaries were inadequate to compensate for higher local cost of living. Among academic respondents, nonadjusted salaries increased with advancing faculty job titles, but this seniority effect was inconsistent across geographic regions. Junior faculty salaries, when adjusted for cost of living, were more similar across regions than salaries at the full professor level.

Low-Income Workers with Employer-Sponsored Insurance: Who’s at Risk When Employer Coverage Is No Longer an Option?:

Abstract: A firm's decision to drop the offer of employer-sponsored insurance (ESI), reduce eligibility for ESI, or significantly increase employee costs would have serious implications for the health insurance status of currently covered low-income workers. The authors find that at least a third of currently covered low-income workers do not have affordable insurance options outside of the group market. Furthermore, a simulation analysis shows that 54 percent of those workers would become uninsured if their employers were to drop ESI. This would result in an additional 1 million uninsured adults if 10 percent of low-income workers lost their ESI offer, and at least 350,000 uninsured adults if 10 percent of workers in firms with fewer than 100 employees (the firms most likely to drop coverage) lost their ESI. The authors also find that expanding public programs to cover low-income workers would reduce the high uninsurance rate by half, but substantial minorities would remain uninsured.

Framing the public policy questions: financial incentives for efficiency and effectiveness.

Abstract: Despite the efforts of many policy researchers, there is a growing sense that we do not yet have or understand the policy levers needed to produce quality health care efficiently and effectively. In part, this reflects the relatively late recognition that much of what is done in health care is based on “art” rather than science and occurs without the underlying clinical rigor of scientific testing. In part, it is also the recognition that too often, research and analysis have not kept pace with the changing organizational structures involved in the delivery of health care. Creating the understanding needed to develop such policy tools will require the efforts of individuals with a variety of disciplines and policy experiences. In this article, I try and set the stage for some of the more detailed discussions of the types of research needed to better understand how physicians respond to differing financial incentives and to differing relationships with health plans that themselves bear risk differentially. First, I briefly consider how research and researchers can and should inform the policy process. Second, I review some of the policy levers available in Medicare and ways to make use of these policy levers to produce and/or monitor change in the delivery of health care.

Individual incentives to fix organizational problems

Abstract: The incentive-quality connection. What kind of theoretical connection might we envision between economic incentives and quality of services as provided by physicians? That is, what is our underlying theory regarding the role of physician incentives when it comes to quality? Atheory of physician behavior would seem useful if one is generating hypotheses about circumstances that might lead the higher quality. We might believe, for example, that doctors, by virtue of their training and professional socialization, will provide good quality care, up to the limits of their ability and skill, unless their decisions become distorted by economic incentives. This view emphasizes the physician as professional and would focus on financial incentives that have the potential to modify physician behavior in ways that detract from or interfere with quality. Alternatively, we might believe that doctors do what they are rewarded for doing and thus will provide good quality care only to the extent that they are financially rewarded for doing so. If we view the physician as economic being, we might start with the question of what behavior we want to encourage and try to figure out what incentives will most likely get us there.

Commentary on "Opportunities and challenges for measuring cost, quality, and clinical effectiveness in health care": the fault lies not in our stars but in our system.

Abstract: As a practicing family physician, I am frequently frustrated by studies that, while interesting, do not seem to have direct applicability to my clinical practice. The “POEMS” (patient-oriented evidence that matters) approach to evidence-based medicine addresses this problem by focusing on studies whose outcomes are relevant clinical end points and not intermediate or process outcomes (Shaughnessy, Slawson, and Bennett 1994). The history of medicine is full of cases, such as the use of hormone therapy for cardiovascular prevention and Type Ic antiarrhythmics for cardiac arrhythmias, in which intermediate outcome-based and epidemiological studies have supported practices subsequently shown by prospective, randomized trials examining clinical outcomes to be useless or harmful. Why, then, don’t most studies focus on “final goods” such as health and health-related quality of life and provide patientoriented evidence that matters? Why aren’t there easily accessible measures of quality for all health plans and providers? Unfortunately, as a health services researcher, I know the answers to these questions too well. Many clinical outcomes are uncommon or require a long observation period for assessment so that associating them with interventions demands large, long-term, expensive studies. Given the limited pot of money available for clinical research studies, it is simply not feasible to conduct expensive, long-term studies of even a substantial minority of pressing

Assessing the influence of incentives on physician and medical groups: a comment.

Abstract: “What is the effect of incentives on the performance of physicians in medical groups?” “How should medical groups be incentivized to obtain optimal performance?” These two questions, which are of enormous interest to health economists and health services researchers, motivate the article by Town and colleagues (2004) in this issue of Medical Care Research and Review. Of course, the answers to these questions are important, both to researchers trying to understand how incentives work and to public and private policy makers seeking to hold down health care costs and improve the quality of care. It is worth considering, however, whether it is reasonable to expect that definitive and generalizable answers to these questions can be found. Town and colleagues’ article begins with an observation that is familiar to all health researchers interested in physician responses to incentives, namely, that research studies must rigorously account for the institutional features of the physician services market. These features, which make good studies difficult, include the fact that physicians practice in groups of varying size and composition, that most clinical decisions are made under uncertainty, that physicians’ work is cognitively complex and requires proficiency over many different types of tasks, that physicians generally treat patients with heterogeneous insurance arrangements, that physicians are motivated by more than just economics, and others. Where the article breaks with much of the work in health economics and health services research is in its recognition that theories from a variety of disciplines must be brought to bear on efforts to elucidate the

Focusing on the dependent variable: comments on "Opportunities and challenges for measuring cost, quality, and clinical effectiveness in health care," by Paul A. Fishman, Mark C. Hornbrook, Richard T. Meenan, and Michael J. Goodman.

Abstract: Paul Fishman and colleagues address an issue of crucial importance for our Conference on Penetrating the Black Box of Managed Care. Before one spends much time asking what is going on inside the “black box” of managed care, it is worthwhile to think carefully about what managed care is supposed to do. In this commentary, I will focus largely on what one might expect managed care to do in some type of long-run equilibrium. Thus, many of these statements and expectations have little relevance to some of the “managed care plans” of the late 1990s. In that era of market turmoil, significant competitive advantage might have been gained not through the hard work of altering clinical processes and incentives but merely by using bargaining power to negotiate lower prices from suppliers (usually hospitals and other clinicians) and thus transfer economic “rents.” Much of the discussion about the performance of managed care plans either is explicitly focused on direct comparisons with the predominant feefor-service (FFS ) environment or implicitly uses performance measures that are primarily relevant to the FFS system. Fishman and colleagues touch upon this issue in the opening sections of their article, particularly with respect to measures of productivity. Although this is but a part of their article, it is the