Showing papers in "Medical Care Research and Review in 2018"
TL;DR: It is concluded that vertical integration poses a threat to the affordability of health services and merits special attention from policymakers and antitrust authorities.
Abstract: Hospital-physician vertical integration is on the rise. While increased efficiencies may be possible, emerging research raises concerns about anticompetitive behavior, spending increases, and uncertain effects on quality. In this review, we bring together several of the key theories of vertical integration that exist in the neoclassical and institutional economics literatures and apply these theories to the hospital-physician relationship. We also conduct a literature review of the effects of vertical integration on prices, spending, and quality in the growing body of evidence ( n = 15) to evaluate which of these frameworks have the strongest empirical support. We find some support for vertical foreclosure as a framework for explaining the observed results. We suggest a conceptual model and identify directions for future research. Based on our analysis, we conclude that vertical integration poses a threat to the affordability of health services and merits special attention from policymakers and antitrust authorities.
83 citations
TL;DR: Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income, and the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.
Abstract: This article reviews the literature on the use of financial incentives to improve the provision of value-based health care. Eighty studies of 44 schemes from 10 countries were reviewed. The proportion of positive and statistically significant outcomes was close to .5. Stronger study designs were associated with a lower proportion of positive effects. There were no differences between studies conducted in the United States compared with other countries; between schemes that targeted hospitals or primary care; or between schemes combining pay for performance with rewards for reducing costs, relative to pay for performance schemes alone. Paying for performance improvement is less likely to be effective. Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income. Finally, the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.
48 citations
TL;DR: It was found that NPs experienced greater day-to-day practice autonomy when they had prescriptive independence, which suggests that factors other than state scope of practice laws may influence NP practice as well.
Abstract: We explore the extent to which state scope of practice laws are related to nurse practitioners (NPs)' day-to-day practice autonomy. We found that NPs experienced greater day-to-day practice autonomy when they had prescriptive independence. Surprisingly, there were only small and largely insignificant differences in day-to-day practice autonomy between NPs in fully restricted states and those in states with independent practice but restricted prescription authority. The scope of practice effects were strong for primary care NPs. We also found that the amount of variation in day-to-day practice autonomy within the scope of practice categories existed, which suggests that factors other than state scope of practice laws may influence NP practice as well. Removing barriers at all levels that potentially prevent NPs from practicing to the full extent of their education and training is critical not only to increase primary care capacity but also to make NPs more efficient and effective providers.
37 citations
TL;DR: The pattern of utilization suggests that the newly uninsured are connecting with primary care after the 2014 Medicaid expansion and, unlike ongoing Medicaid enrollees; the newly insured have a declining reliance on the emergency department over time.
Abstract: We compared new Medicaid enrollees with similar ongoing enrollees for evidence of pent-up demand using claims data following Minnesota's 2014 Medicaid expansion. We hypothesized that if new enrollees had pent-up demand, utilization would decline over time as testing and disease management plans are put in place. Consistent with pent-up demand among new enrollees, the probability of an office visit, a new patient office visit, and an emergency department visit declines over time for new enrollees relative to ongoing Medicaid enrollees. The pattern of utilization suggests that the newly insured are connecting with primary care after the 2014 Medicaid expansion and, unlike ongoing Medicaid enrollees; the newly insured have a declining reliance on the emergency department over time.
24 citations
TL;DR: It is concluded that full understanding of the causes and consequences of hospital ownership of physicians requires data collected at the both the hospital and the physician level.
Abstract: Although there has been significant interest from health services researchers and policy makers about recent trends in hospitals' ownership of physician practices, few studies have investigated the strengths and weaknesses of available data sources. In this article, we compare results from two national surveys that have been used to assess ownership patterns, one of hospitals (the American Hospital Association survey) and one of physicians (the SK&A survey). We find some areas of agreement, but also some disagreement, between the two surveys. We conclude that full understanding of the causes and consequences of hospital ownership of physicians requires data collected at the both the hospital and the physician level. The appropriate measure of integration depends on the research question being investigated.
22 citations
TL;DR: There is evidence that the DCE reduced high out-of-pocket expenditures and frequent emergency room visits and increased behavioral health treatment, and suggestive of positive impacts on self-rated health and health behavior.
Abstract: The dependent coverage expansion (DCE), a component of the Affordable Care Act, required private health insurance policies that cover dependents to offer coverage for policyholders’ children through age 25. This review summarizes peer-reviewed research on the impact of the DCE on the chain of consequences through which it could affect public health. Specifically, we examine the impact of the DCE on insurance coverage, access to care, utilization of care, and health status. All studies find that the DCE increased insurance coverage, but evidence regarding downstream impacts is inconsistent. There is evidence that the DCE reduced high out-of-pocket expenditures and frequent emergency room visits and increased behavioral health treatment. Evidence regarding the impact of the DCE on health is sparse but suggestive of positive impacts on self-rated health and health behavior. Inferences regarding the public health impact of the DCE await studies with greater methodological diversity and longer follow-up periods.
22 citations
TL;DR: An investigation into the association between patient assessments of communication quality and an observer-rated measure of communication competence concludes that patient evaluations can be useful for measuring relative performance of physicians’ communication skills, but absolute scores should be interpreted with caution.
Abstract: Patient evaluations of physician communication are widely used, but we know little about how these relate to professionally agreed norms of communication quality. We report an investigation into the association between patient assessments of communication quality and an observer-rated measure of communication competence. Consent was obtained to video record consultations with Family Practitioners in England, following which patients rated the physician's communication skills. A sample of consultation videos was subsequently evaluated by trained clinical raters using an instrument derived from the Calgary-Cambridge guide to the medical interview. Consultations scored highly for communication by clinical raters were also scored highly by patients. However, when clinical raters judged communication to be of lower quality, patient scores ranged from "poor" to "very good." Some patients may be inhibited from rating poor communication negatively. Patient evaluations can be useful for measuring relative performance of physicians' communication skills, but absolute scores should be interpreted with caution.
21 citations
TL;DR: There are opportunities for public policies to support improved efficiency in the hospital sector using stochastic frontier analysis, and high-efficiency hospitals tended to be nonteaching, investor-owned, and members of multihospital systems.
Abstract: We compared performance, operating characteristics, and market environments of low- and high-efficiency hospitals in the 37 states that supplied inpatient data to the Healthcare Cost and Utilization Project from 2006 to 2010. Hospital cost-inefficiency estimates using stochastic frontier analysis were generated. Hospitals were then grouped into the 100 most- and 100 least-efficient hospitals for subsequent analysis. Compared with the least efficient hospitals, high-efficiency hospitals tended to have lower average costs, higher labor productivity, and higher profit margins. The most efficient hospitals tended to be nonteaching, investor-owned, and members of multihospital systems. Hospitals in the high-efficiency group were located in areas with lower health maintenance organization penetration and less competition, and they had a higher share of Medicaid and Medicare admissions. Results of the analysis suggest there are opportunities for public policies to support improved efficiency in the hospital sector.
21 citations
University of London1, University of Utah2, RAND Corporation3, Regions Hospital4, University of Pennsylvania5, University of North Carolina at Chapel Hill6, University of Alaska Anchorage7, Indiana University8, Harvard University9, Group Health Cooperative10, Palo Alto Medical Foundation11, University of Michigan12, University of Colorado Denver13, University of California, Berkeley14, Pennsylvania State University15, Agency for Healthcare Research and Quality16
TL;DR: Successful implementation was characterized by resource availability, identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices, which helps facilitate future context-specific implementation of CM within medical homes.
Abstract: Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.
18 citations
TL;DR: Attention to mental health measures in clinical settings could provide opportunities for improving medication adherence in the elderly, and the magnitude of the association was greater for mental than for physical health.
Abstract: The aging population routinely has comorbid conditions requiring complicated medication regimens, yet nonadherence can preclude optimal outcomes. This study explored the association of adherence in...
16 citations
TL;DR: Using Medicare data on physician patient-sharing relationships and the Dartmouth Atlas, it is found that 70.7% of ties between PCPs and other physicians that were present in 2012 persisted in 2013, and additional shared patients in 2012 increased the odds of being connected in 2013.
Abstract: Care coordination may be more challenging when the specific physicians with whom primary care physicians (PCPs) are expected to coordinate care change over time. Using Medicare data on physician patient-sharing relationships and the Dartmouth Atlas, we explored the extent to which PCPs tend to share patients with other physicians over time. We found that 70.7% of ties between PCPs and other physicians that were present in 2012 persisted in 2013, and additional shared patients in 2012 increased the odds of being connected in 2013. Regions with higher persistent ties tended to have lower rates of emergency room visits, and regions where PCPs had more physician connections were more likely to have higher emergency room visits. The results point to potential opportunities and challenges faced by health care reforms that seek to improve coordination.
TL;DR: Using national survey data during 2011 to 2013, it is found that 44% to 76% cases of hypertension, diabetes, and dyslipidemia went undiagnosed among Chinese adults aged 45 and older, and assuming that this level of efficiency would be possible under an integrated system, microsimulation analyses were conducted to project future benefits.
Abstract: Policy makers in China are considering consolidating the country's fragmented health insurance programs. This system consists of three components. The Urban Employee Basic Medical Insurance (UEBMI) covers formal employees, the New Cooperative Medical Scheme (NCMS) covers rural residents, and the Urban Resident Basic Medical Insurance (URBMI) covers urban residents. Consolidation could, in theory, create a more efficient health system that is better able to address noncommunicable diseases. Using national survey data during 2011 to 2013, I found that 44% to 76% cases of hypertension, diabetes, and dyslipidemia went undiagnosed among Chinese adults aged 45 and older. I found that the UEBMI enrollees had a greater number of health checks and 10% higher rates of diagnosis. Assuming that this level of efficiency would be possible under an integrated system, I conducted microsimulation analyses to project future benefits. Such consolidation could result in 46.2 million new diagnoses, and 30.0 million of these cases would be controlled.
TL;DR: Relaxing scope-of-practice laws could mitigate the adverse extraregulatory effect on physicians identified in this study and could also lead to improvements in access to care.
Abstract: Patients can hold physicians directly or vicariously liable for the malpractice of nurse practitioners under their supervision. Restrictive scope-of-practice laws governing nurse practitioners can ease patients’ legal burdens in establishing physician liability. We analyze the effect of restrictive scope-of-practice laws on the number of malpractice payments made on behalf of physicians between 1999 and 2012. Enacting less restrictive scope-of-practice laws decreases the number of payments made by physicians by as much as 31%, suggesting that restrictive scope-of-practice laws have a salient extraregulatory effect on physician malpractice rates. The effect of enacting less restrictive laws varies depending on the medical malpractice reforms that are in place, with the largest decrease in physician malpractice rates occurring in states that have enacted fewer malpractice reforms. Relaxing scope-of-practice laws could mitigate the adverse extraregulatory effect on physicians identified in this study and cou...
TL;DR: This study explored beneficiaries’ plan switching using a mixed-methods approach, with a focus on the concept of information processing, and suggests easier access to helpers as well as helpers’ extensive involvement in the decision-making process promote informed plan switching decisions.
Abstract: Medicare Part D beneficiaries tend not to switch plans despite the government's efforts to engage beneficiaries in the plan switching process. Understanding current and alternative plan features is a necessary step to make informed plan switching decisions. This study explored beneficiaries' plan switching using a mixed-methods approach, with a focus on the concept of information processing. We found large variation in beneficiary comprehension of plan information among both switchers and nonswitchers. Knowledge about alternative plans was especially poor, with only about half of switchers and 2 in 10 nonswitchers being well informed about plans other than their current plan. We also found that helpers had a prominent role in plan decision making-nearly twice as many switchers as nonswitchers worked with helpers for their plan selection. Our study suggests that easier access to helpers as well as helpers' extensive involvement in the decision-making process promote informed plan switching decisions.
TL;DR: It is shown that higher levels of incumbent physician power makes it less likely that a state will change jurisdictional boundaries, while increasing relative power among challenging CRNAs and the past successes of other challenging health professionals increase the likelihood.
Abstract: We further our understanding of jurisdictional disputes between established professional groups through a 10-year longitudinal analysis of the differential adoption by U.S. states of policies expanding Certified Registered Nurse Anesthetists' (CRNAs) autonomy. In the United States, CRNAs are trained to deliver anesthetics to patients in the same way as physician anesthesiologists but have more restrictions in practice. Following a 2001 federal decision regarding Medicare reimbursement, states were permitted but not required to allow CRNAs to practice without physician supervision, potentially reducing health care costs. We show that higher levels of incumbent physician power makes it less likely that a state will change jurisdictional boundaries, while increasing relative power among challenging CRNAs and the past successes of other challenging health professionals increase the likelihood. State labor deficiency and proximity to other adopting states also positively influenced the expansion of CRNAs' autonomy. Implications for the professions and health services literature are discussed.
TL;DR: It is found that Medicare Advantage hospitalizations were substantially less expensive and shorter for mental health stays but costlier and longer for injury and surgical stays and in readmissions for Traditional Medicare and Medicare Advantage.
Abstract: Medicare Advantage plans have incentives and tools to optimize patient care. Therefore, Medicare Advantage hospitalizations may have lower cost and higher quality than similar traditional Medicare hospitalizations. We applied a coarsened matching approach to 2013 Healthcare Cost and Utilization Project hospital discharge data from 22 states to compare hospital cost, length of stay, and readmissions for Traditional Medicare and Medicare Advantage. We found that Medicare Advantage hospitalizations were substantially less expensive and shorter for mental health stays but costlier and longer for injury and surgical stays. We found little difference in the cost and length of medical stays and in readmission rates. One explanation is that Medicare Advantage plans use outpatient settings for many patients with behavioral health conditions and for injury and surgical patients with less complex health needs. Alternatively, the observed differences in behavioral health cost and length of stay may represent skimping on appropriate care.
TL;DR: It is demonstrated that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care andMultimodal interventions were most effective in reducing disparities in CVD outcomes.
Abstract: Racial and ethnic disparities in cardiovascular disease (CVD) outcomes are widely reported, but research has largely focused on differences in quality of inpatient and urgent care to explain these disparate outcomes. The objective of this review is to synthesize recent evidence on racial and ethnic disparities in management of CVD in the ambulatory setting. Database searches yielded 550 articles of which 25 studies met the inclusion criteria. Reviewed studies were categorized into non-interventional studies examining the association between race and receipt of ambulatory CVD services with observational designs, and interventional studies evaluating specific clinical courses of action intended to ameliorate disparities. Based on the Donabedian framework, this review demonstrates that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care. Multimodal interventions were most effective in reducing disparities in CVD outcomes.
TL;DR: There is need for an up-to-date and comprehensive literature review and synthesis of lessons learned on the effects of health insurance prior to people becoming eligible for Medicare on a broad set of outcomes.
Abstract: Over the past decade, the number of studies examining the effects of health insurance has grown rapidly, along with the breadth of outcomes considered. In light of growing research in this area and the intense policy focus on coverage expansions in the United States, there is need for an up-to-date and comprehensive literature review and synthesis of lessons learned. We reviewed 112 experimental or quasi-experimental studies on the effects of health insurance prior to people becoming eligible for Medicare on a broad set of outcomes. Over the past decade, evidence related to the effect of increased access to health insurance has strengthened, illuminating that children and vulnerable adults are most likely to see health and economic benefits. We identified promising areas for future study in this active and burgeoning research area, noting benefit design of health insurance and outcomes such as government program participation and self-reported health status as targets.
TL;DR: It is found that the number of workers staying in health care has been slowly declining over time and as the United States moves toward team-based care, more attention should be paid to the needs of the lower skilled workers to reduce turnover and ensure delivery of quality care.
Abstract: Health care has been cited as a job engine for the U.S. economy. This study used the Current Population Survey to examine the sector and occupation shifts that underlie this growth trend. Health care has had a cyclical relationship with retail trade, leisure and hospitality, education, and professional services. The entering workforce has been increasingly taking on low-skilled occupations. The exiting workforce has not been necessarily retiring or going back to school, but appeared to be leaving without a job, with potentially more child care duties, and with high rates of disability and poverty levels. This study also found that the number of workers staying in health care has been slowly declining over time. As the United States moves toward team-based care, more attention should be paid to the needs of the lower skilled workers to reduce turnover and ensure delivery of quality care.
TL;DR: Rising benchmark premiums were associated with lower average after-subsidy premiums for the lowest-cost bronze and silver plans for older subsidy-eligible adults, but with higher after- Subsidies for younger adults purchasing the same plans, regardless of income.
Abstract: Since 2014, average premiums for health plans available in the Affordable Care Act marketplaces have increased. We examine how premium price changes affected the amount consumers pay after subsidies for the lowest-cost bronze and silver plans available by age in the federally facilitated exchanges. Between 2015 and 2016, benchmark plan premiums increased in 83.3% of counties. Overall, rising benchmark premiums were associated with lower average after-subsidy premiums for the lowest-cost bronze and silver plans for older subsidy-eligible adults, but with higher after-subsidy premiums for younger adults purchasing the same plans, regardless of income. With recent discussions to replace or overhaul the Affordable Care Act, it is critical that we learn from the successes and failures of the current policy. Our findings suggest that the subsidy design, which makes rising premiums costlier for younger adults looking to purchase an entry-level plan, may be contributing to adverse selection and instability in the marketplace.
TL;DR: Improved quality of life was consistently associated with strong bonds to primary care, consistent mental health care, and support from extended care team members, suggesting comprehensive, integrated care models within ACOs may improve quality ofLife for low-income Medicaid enrollees through coordinated primary and mental health health care.
Abstract: Despite limited program evaluations of Medicaid accountable care organizations (ACOs), no studies have examined if cost-saving goals negatively affect quality of life and health care experiences of low-income enrollees. The Hennepin Health ACO uses an integrated care model to address the physical, behavioral, and social needs of Medicaid expansion enrollees. As part of a larger evaluation, we conducted semistructured interviews with 35 primary care using Hennepin Health members enrolled for 2 or more years. Using fuzzy set qualitative comparative analysis, we assessed enrollee complexity and use of the care model and improvements in quality of life. We found improved quality of life was consistently associated with strong bonds to primary care, consistent mental health care, and support from extended care team members. Comprehensive, integrated care models within ACOs may improve quality of life for low-income Medicaid enrollees through coordinated primary and mental health care.
TL;DR: In multivariable models including payer, hospital, discharge year, residence location, and comorbidity, PPR disparities existed for some API subpopulations 65+ years, while many API groups 18 to 64 years had significantly lower PPR odds.
Abstract: Asian and Pacific Islander (API) 30-day potentially preventable readmissions (PPRs) are understudied. Hawaii Health Information Corporation data from 2007-2012 statewide adult hospitalizations ( N = 495,910) were used to compare API subgroup and White PPRs. Eight percent of hospitalizations were PPRs. Seventy-two percent of other Pacific Islanders, 60% of Native Hawaiians, and 52% of Whites with a PPR were 18 to 64 years, compared with 22% of Chinese and 21% of Japanese. In multivariable models including payer, hospital, discharge year, residence location, and comorbidity, PPR disparities existed for some API subpopulations 65+ years, including Native Hawaiian men (odds ratio [OR] = 1.14; 95% confidence interval [CI] = 1.04-1.24), Filipino men (OR = 1.19; 95% CI = 1.04-1.38), and other Pacific Islander men (OR = 1.30; 95% CI = 1.19-1.43) and women (OR = 1.23; 95% CI = 1.02-1.51) compared with Whites, while many API groups 18 to 64 years had significantly lower PPR odds. Distinct PPR characteristics across API subpopulations and age groups can inform policy and practice. Further research should determine why elderly API have higher PPR rates, while nonelderly rates are lower.
TL;DR: PMSYS of medical practices are underdeveloped, although both external incentives and organizational capabilities may support PMSYS development.
Abstract: Performance management systems (PMSYS) aid in improving the quality and efficiency of care, but little is known about factors that influence more robust PMSYS among physician organizations. Using a nationally representative survey of U.S. medical practices, we examined the extent to which organizational capabilities and external factors were associated with more developed PMSYS. Linear regression estimated the relative impact of these factors on PMSYS. On average, practices implemented a minority (32 points out of 100) of the PMSYS processes assessed. Practices evaluated ( p < .01) or financially incentivized by external entities ( p < .01), receiving data from health plans ( p < .01), participating in an accountable care organization ( p < .01), affiliating with an independent practice association and/or physician-hospital organization ( p < .01), and using health information technology ( p < .01) and chronic disease registries ( p < .01) to greater degrees had more robust PMSYS. PMSYS of medical practices are underdeveloped, although both external incentives and organizational capabilities may support PMSYS development.
TL;DR: Two theory perspectives are employed, principal–agent framework and street-level bureaucratic theory, to describe the relationship between program designers (principals) and case managers (agents/street-level bureaucrats) to review 65 case management studies, finding most programs were successful in limited program-specific process and outcome goals.
Abstract: Case management programs often designate a nurse or social worker to take responsibility for guiding care when patients are expected to be expensive or risk a major decline. We hypothesized that th...
TL;DR: While urban and rural populations have unique demographic profiles, rural populations appear to have benefited from Medicaid as much as urban.
Abstract: Medicaid expansions through the Affordable Care Act began in January 2014, but we have little information about what is happening in rural areas where provider access and patient resources might be more limited. In 2008, Oregon held a lottery for restricted access to its Medicaid program for uninsured low-income adults not otherwise eligible for public coverage. The Oregon Health Insurance Experiment used this opportunity to conduct the first randomized controlled study of a public insurance expansion. This analysis builds off of previous work by comparing rural and urban survey outcomes and adds qualitative interviews with 86 rural study participants for context. We examine health care access and use, personal finances, and self-reported health. While urban and rural populations have unique demographic profiles, rural populations appear to have benefited from Medicaid as much as urban. Qualitative interviews revealed the distinctive challenges still facing low-income uninsured and newly insured rural populations.
TL;DR: Despite new non-VA health options through MHR, VA enrollees continued to rely on VA PC, and among VA–Medicare dual enrollees, MHR was associated with an increase of 24.5 PC visits per 1,000 veterans per quarter.
Abstract: Massachusetts Health Reform (MHR), implemented in 2006, introduced new health insurance options that may have prompted some veterans already enrolled in the Veterans Affairs Healthcare System (VA) to reduce their reliance on VA health services. This study examined whether MHR was associated with changes in VA primary care (PC) use. Using VA administrative data, we identified 147,836 veterans residing in Massachusetts and neighboring New England (NE) states from October 2004 to September 2008. We applied difference-in-difference methods to compare pre–post changes in PC use among Massachusetts and other NE veterans. Among veterans not enrolled in Medicare, VA PC use was not significantly different following MHR for Massachusetts veterans relative to other NE veterans. Among VA–Medicare dual enrollees, MHR was associated with an increase of 24.5 PC visits per 1,000 veterans per quarter (p = .048). Despite new non-VA health options through MHR, VA enrollees continued to rely on VA PC.
TL;DR: Part D was associated with statistically and clinically significant reductions in the probability of admission and length of stay for several common conditions and was generally greater for younger, healthier, and male individuals.
Abstract: Medicare Part D was associated with reduced hospitalizations, yet little is known whether these effects varied across patients and how Part D was associated with length of stay and inpatient expenditures. We used Medicare claims and the Medicare Current Beneficiary Survey from 2002 to 2010 and an instrumental variables approach. Gaining drug insurance through Part D was associated with a statistically significant 8.0% reduction in likelihood of admission across conditions examined. Reductions were generally greater for younger, healthier, and male individuals. Across all conditions, mean length of stay decreased by 3.2% from a baseline of 5.1 days. Part D was associated with a 3.5% reduction in expenditures per admission, reflecting a decrease of $844 from a mean charge of $24,124 per admission prior to Part D. Thus, Part D was associated with statistically and clinically significant reductions in the probability of admission and length of stay for several common conditions.
TL;DR: It is concluded that well-organized PC systems can compensate for the negative influence of individual characteristics (socioeconomic position) on the care-seeking behaviors of patients.
Abstract: Available evidence has suggested that strong primary care (PC) systems are associated with better outcomes. This study aims to investigate whether PC strength is specifically related to the prevalence of patients' financially driven postponement of general practitioner (GP) care. Therefore, data from a cross-sectional multicountry study in 33 countries among GPs and their patients were analyzed using multilevel logistic regression modelling. According to the results, the variation between countries in the levels of patients' postponement of seeking GP care for financial reasons was large. More than one third of these cross-country differences could be explained by characteristics of the health care system and the GP practices. In particular, PC systems with good accessibility and those systems that offer comprehensive care were associated with lower levels of financially driven delay. Consequently, we can conclude that well-organized PC systems can compensate for the negative influence of individual characteristics (socioeconomic position) on the care-seeking behaviors of patients.
TL;DR: It is concluded that enrollment in MA seemed to be associated with significantly reduced readmission rate and potentially reduced racial disparity.
Abstract: This study determined potential racial and ethnic disparities in risk for all-cause 30-day readmission among traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries initially hospitalized for acute myocardial infarction, congestive heart failure, or pneumonia. Our analyses of New York State hospital administrative data between 2009 and 2012 found that overall 30-day readmission rate declined from 22.0% in 2009 to 20.7% in 2012 for TM beneficiaries, and from 20.2% in 2009 to 17.9% in 2012 for MA beneficiaries. However, persistent racial disparities were found in propensity-score-based analyses among TM beneficiaries (e.g., in 2012, adjusted odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.01-1.23, p = .029), though not among MA beneficiaries (in 2012, adjusted OR = 1.05, 95% CI = 0.92-1.19, p = .476). We did not find evidence of persistent ethnic disparity for TM (in 2012, adjusted OR = 1.08, 95% CI = 0.93-1.25, p = .303) or MA (in 2012, adjusted OR = 0.99, 95% CI = 0.88-1.11, p = .837) beneficiaries. We conclude that enrollment in MA seemed to be associated with significantly reduced readmission rate and potentially reduced racial disparity.
TL;DR: Partial effects show postdischarge follow-up care resulted in higher 30-day expenditures among low-cost rural beneficiaries, and Ensuring early follow- up care for high-cost beneficiaries may be advantageous to both rural and urban providers in helping reduce postdis discharge Medicare expenditures.
Abstract: Reducing postdischarge Medicare expenditures is a key focus for hospitals. Early follow-up care is an important piece of this focus, but it is unclear whether there are rural-urban differences in the impact of follow-up care on Medicare expenditures. To assess this difference, we use the Medicare Current Beneficiary Survey, Cost and Use Files, 2000-2010. We conduct a retrospective analysis of 30-day postdischarge Medicare expenditures using two-stage residual inclusion with a quantile regression, where the receipt of 7-day follow-up care was the main independent variable. Postdischarge follow-up care increased the 25th percentile of 30-day expenditures, decreased the 75th percentile, and there were no rural-urban differences. Partial effects show postdischarge follow-up care resulted in higher 30-day expenditures among low-cost rural beneficiaries. Ensuring early follow-up care for high-cost beneficiaries may be advantageous to both rural and urban providers in helping reduce postdischarge Medicare expenditures.