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Shearer E, Bundorf MK. Changes in emergency department use associated with Medicaid expansion under the Affordable Care Act: A comparison of waiver and traditional expansion states. J Am Coll Emerg Physicians Open 2023; 4:e13060. [PMID: 37915356 PMCID: PMC10616539 DOI: 10.1002/emp2.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/24/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023] Open
Abstract
Objective To determine whether changes in emergency department use associated with Medicaid expansions differed between states undergoing waiver and traditional expansions. Methods Design: This study was a cross-sectional difference-in-difference and event studies of Medicaid Expansion among states that expanded during or after 2014. Setting: We used a nationally representative cross-sectional survey from all 50 United States and the District of Columbia from 2010 to 2016. Participants: Adults aged 19-65 years with incomes <138% of the federal poverty level were included. Main Outcomes and Measures: Main outcomes were self-reported emergency department (ED) utilization in the last 12 months. Results Individuals in states across all expansion types were not more likely to report any ED use in the previous year (2.8 percentage point increase [0.0-5.5], P = 0.052) but were more likely to report visiting an ED 2 times or more in the previous year (2.0 [0.0-4.1], P = 0.049) than those in non-expansion states. Individuals in states undergoing traditional expansions likewise were not more likely to report any ED use (2.2 [-0.7 to 1.5], P = 0.136) but were more likely to report visiting an ED 2 times or more in the previous year (2.3 [0.1-4.4], P = 0.038). Conversely, individuals in waiver states were more likely to report increase in any ED use (5.6 [0.3-11.0], P = 0.038), but were not more likely to report use of EDs 2 times or more in the previous year (0.8 [-3.2-4.9], P = 0.688). The differences between traditional and waiver states in any ED use and ED use 2 times or more in the previous 12 months were not statistically significant (P = 0.215 and P = 0.501, respectively). Conclusions Three years after expanding Medicaid under the Affordable Care Act, there is little evidence of differences between traditional and waiver expansion states in changes in any ED use or intensive ED use. Future studies should investigate longer term changes in ED use.
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Affiliation(s)
- Emily Shearer
- Department of Emergency MedicineAlpert School of Medicine at Brown UniversityProvidenceRhode IslandUSA
| | - M. Kate Bundorf
- Sanford School of Public PolicyDuke UniversityDurhamNorth CarolinaUSA
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Bromley-Dulfano RA, Rossin-Slater M, Bundorf MK. Association Between Cervical Cancer Screening Guidelines and Preterm Delivery Among Females Aged 18 to 24 Years. JAMA Health Forum 2023; 4:e231974. [PMID: 37477927 PMCID: PMC10362467 DOI: 10.1001/jamahealthforum.2023.1974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
Importance Cervical cancer screening is associated with reduced cervical cancer mortality; however, clinical trials have also shown an association between excisional procedures for cervical neoplasia and an increased risk of preterm delivery (PTD). National screening guidelines must weigh adverse effects on birth outcomes against benefits of cancer prevention. Objective To ascertain the population-level association between the number of guideline-recommended cervical cancer screenings and downstream PTD risk among females aged 18 to 24 years. Design, Setting, and Participants This cross-sectional study used a difference-in-differences approach based on variation in the recommended number of cervical cancer screenings (over time and across individuals giving birth at different ages) to estimate the association between the cumulative recommended number of screenings (by the time of childbirth) and PTD risk. National Vital Statistics System data from females aged 18 to 24 years who had a singleton, nulliparous birth in the US between 1996 and 2018 were used. Regression models were adjusted for maternal educational level, race and ethnicity, comorbidities, marital status, and prenatal care visits. Data were analyzed between June 2020 and March 2023. Exposure A constructed variable capturing the cumulative number of guideline-recommended cervical cancer screenings for an individual based on their age and year of childbirth. Main Outcomes and Measures Binary indicators for PTD and very preterm delivery (VPTD), defined as delivery before 37 and 34 weeks' gestational age, respectively, and gestational age was measured in weeks from the first day of the last menstrual period. Results Among 11 333 151 females aged 18 to 24 years who gave birth between 1996 and 2018, 2 069 713 were Black (18.3%), 2 601 225 were Hispanic (23.0%), 6 068 498 were White (53.5%) individuals, and 593 715 (5.2%) were individuals of other race or ethnicity (Alaska Native; American Indian; Asian; Pacific Islander; multiracial; or unknown or missing race or ethnicity). Mean (SD) age was 20.9 (1.9) years, and 766 001 individuals (6.8%) had hypertension or diabetes. The mean (SD) number of guideline-recommended screenings by time of childbirth was 2.4 (2.2). Overall, PTD and VPTD occurred in 1 140 490 individuals (10.1%) and 333 040 (2.9%) of births, respectively. One additional recommended screening was associated with a 0.073 (95% CI, 0.026-0.120) percentage-point increase in PTD risk but no statistically significant change in VPTD risk. Females with hypertension or diabetes had a higher increase in PTD risk than those without these comorbidities (0.26 [95% CI, 0.11-0.4] vs 0.06 [95% CI, 0.01-0.10] percentage points; Wald test P < .001). Conclusions and Relevance Findings of this cross-sectional study suggest that additional recommended cervical cancer screenings before birth were associated with an increased risk of PTD. These results can be used in future simulation models integrating oncological trade-offs to help ascertain optimal screening strategies.
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Affiliation(s)
- Rebecca A Bromley-Dulfano
- Stanford University School of Medicine, Stanford, California
- Now with Department of Health Care Policy, Graduate School of Arts and Sciences, Harvard University Medical School, Cambridge, Massachusetts
| | - Maya Rossin-Slater
- Department of Health Policy, Stanford University School of Medicine, Stanford, California
| | - M Kate Bundorf
- Sanford School of Public Policy, Duke University, Durham, North Carolina
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Kaufman BG, Jones KA, Greiner MA, Giri A, Stewart L, He A, Clark AG, Taylor DH, Bundorf MK, Whitaker RG, Van Houtven CH, Higgins A. Health Care Use and Spending Among Need-Based Subgroups of Medicare Beneficiaries With Full Medicaid Benefits. JAMA Health Forum 2023; 4:e230973. [PMID: 37171797 PMCID: PMC10182424 DOI: 10.1001/jamahealthforum.2023.0973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Importance Beneficiaries dual eligible for Medicare and Medicaid account for a disproportionate share of expenditures due to their complex care needs. Lack of coordination between payment programs creates misaligned incentives, resulting in higher costs, fragmented care, and poor health outcomes. Objective To inform the design of integrated programs by describing the health care use and spending for need-based subgroups in North Carolina's full benefit, dual-eligible population. Design, Setting, and Participants This cross-sectional study using Medicare and North Carolina Medicaid 100% claims data (2014-2017) linked at the individual level included Medicare beneficiaries with full North Carolina Medicaid benefits. Data were analyzed between 2021 and 2022. Exposure Need-based subgroups: community well, home- and community-based services (HCBS) users, nursing home (NH) residents, and intensive behavioral health (BH) users. Measures Medicare and Medicaid utilization and spending per person-year (PPY). Results The cohort (n = 333 240) comprised subgroups of community well (64.1%, n = 213 667), HCBS users (15.0%, n = 50 095), BH users (15.2%, n = 50 509), and NH residents (7.5%, n = 24 927). Overall, 61.1% reported female sex. The most common racial identities included Asian (1.8%), Black (36.1%), and White (58.7%). Combined spending for Medicare and Medicaid was $26 874 PPY, and the funding of care was split evenly between Medicare and Medicaid. Among need-based subgroups, combined spending was lowest among community well at $19 734 PPY with the lowest portion (38.5%) of spending contributed by Medicaid ($7605). Among NH residents, overall spending ($68 359) was highest, and the highest portion of spending contributed by Medicaid (70.1%). Key components of spending among HCBS users' combined total of $40 069 PPY were clinician services on carrier claims ($14 523) and outpatient facility services ($9012). Conclusions and relevance Federal and state policy makers and administrators are developing strategies to integrate Medicare- and Medicaid-funded health care services to provide better care to the people enrolled in both programs. Substantial use of both Medicare- and Medicaid-funded services was found across all need-based subgroups, and the services contributing a high proportion of the total spending differed across subgroups. The diversity of health care use suggests a tailored approach to integration strategies with comprehensive set benefits that comprises Medicare and Medicaid services, including long-term services and supports, BH, palliative care, and social services.
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Affiliation(s)
- Brystana G Kaufman
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina
| | - Kelley A Jones
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Melissa A Greiner
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Abhigya Giri
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Lucas Stewart
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Amanda He
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Amy G Clark
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Donald H Taylor
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Sanford School of Public Health Policy, Duke University, Durham, North Carolina
| | - M Kate Bundorf
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Sanford School of Public Health Policy, Duke University, Durham, North Carolina
| | - Rebecca G Whitaker
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Courtney H Van Houtven
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina
| | - Aparna Higgins
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Founder, Ananya Health Solutions LLC, Dunn Loring, Virginia
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Kaye DR, Lee HJ, Gordee A, George DJ, Ubel PA, Scales CD, Bundorf MK. Medication Payments by Insurers and Patients for the Treatment of Metastatic Castrate-Resistant Prostate Cancer. JCO Oncol Pract 2023; 19:e600-e617. [PMID: 36689695 PMCID: PMC10113111 DOI: 10.1200/op.22.00645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/27/2022] [Accepted: 12/01/2022] [Indexed: 01/24/2023] Open
Abstract
PURPOSE The implications of high prices for cancer drugs on health care costs and patients' financial burdens are a growing concern. Patients with metastatic castrate-resistant prostate cancer (mCRPC) are often candidates for multiple first-line systemic therapies with similar impacts on life expectancy. However, little is known about the gross and out-of-pocket (OOP) payments associated with each of these drugs for patients with employer-sponsored health insurance. We therefore aimed to determine the gross and OOP payments of first-line drugs for mCRPC and how the payments vary across drugs. METHODS This retrospective cohort study included 4,298 patients with prostate cancer who initiated therapy with one of six drugs approved for first-line treatment of mCRPC between July 1, 2013, and June 30, 2019. We compared gross and OOP payments during the 6 months after initiation of treatment for mCRPC using private payer claims data across patients using different first-line drugs. RESULTS Gross payments varied across drugs. Over the 6 months after the index prescription, mean unadjusted gross drug payments were highest for patients receiving sipuleucel-T ($115,525 USD) and lowest for patients using docetaxel ($12,804 USD). OOP payments were lower than gross drug payments; mean 6-month OOP payments were highest for cabazitaxel ($1,044 USD) and lowest for docetaxel ($296 USD). There was a wide distribution of OOP payments within drug types. CONCLUSION Drugs for mCRPC are expensive with large differences in payments by drug type. OOP payments among patients with employer-sponsored health insurance are much lower than gross drug payments, and they vary both across and within first-line drug types, with some patients making very high OOP payments. Although lowering drug prices would reduce pharmaceutical spending for patients with mCRPC, decreasing patient financial burden requires understanding an individual patient's benefit design.
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Affiliation(s)
- Deborah R. Kaye
- Department of Surgery, Duke University, Durham, NC
- Duke-Margolis Center for Public Policy, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Hui-Jie Lee
- Department of Biostatistics, Duke University, Durham, NC
| | | | - Daniel J. George
- Department of Surgery, Duke University, Durham, NC
- Duke Cancer Institute, Durham, NC
- Department of Medicine, Duke University, Durham, NC
| | - Peter A. Ubel
- Department of Medicine, Duke University, Durham, NC
- Fuqua School of Business, Duke University, Durham, NC
- Sanford School of Public Policy, Duke University, Durham, NC
| | - Charles D. Scales
- Department of Surgery, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - M. Kate Bundorf
- Duke-Margolis Center for Public Policy, Duke University, Durham, NC
- Sanford School of Public Policy, Duke University, Durham, NC
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Bundorf MK, Banthin JS, Kim CY, Gupta S. Employer-Sponsored Coverage Stabilized And Uninsurance Declined In The Second Year Of The COVID-19 Pandemic. Health Aff (Millwood) 2023; 42:130-139. [PMID: 36623213 DOI: 10.1377/hlthaff.2022.01070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The health risks of COVID-19, combined with widespread economic instability in the US, spurred Congress to pass temporary measures to improve access to health insurance. Using data from the Household Pulse Survey, a high-frequency, population-based survey, we examined trends in health coverage during 2021 and early 2022 among nonelderly adults. We estimated that eight million people gained coverage during this period, primarily because of increases in Medicaid and other public coverage. Despite rising employment, rates of employer-sponsored coverage remained flat. In Medicaid expansion states, employment rates increased significantly among Medicaid enrollees. Our results suggest that when the public health emergency ends, many people currently enrolled in Medicaid might no longer be eligible, particularly in Medicaid expansion states. Policy makers and employers should be prepared to help people who lose Medicaid eligibility identify and navigate enrollment in alternative sources of health insurance, including both Affordable Care Act Marketplace and employer-sponsored coverage.
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Affiliation(s)
- M Kate Bundorf
- M. Kate Bundorf , Duke University, Durham, North Carolina
| | | | | | - Sumedha Gupta
- Sumedha Gupta, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana
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Abstract
IMPORTANCE About half of people younger than 65 years with private insurance are enrolled in a high-deductible health plan (HDHP). While these plans entail substantially higher out-of-pocket costs for patients with chronic medical conditions who require ongoing care, their effect on patients undergoing surgery who require acute care is poorly understood. It is plausible that higher out-of-pocket costs may lead to delays in care and more complex surgical conditions. OBJECTIVE To determine the association between enrollment in HDHPs and presentation with incarcerated or strangulated hernia. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis included privately insured patients aged 18 to 63 years from a large commercial insurance claims database who underwent a ventral or groin hernia operation from January 2016 through June 2019 and classified their coverage as either a traditional health plan or an HDHP per the Internal Revenue Service's definition. Multivariable regression, adjusting for demographic and clinical covariates, was used to examine the association between enrollment in an HDHP and the primary outcome of presentation with an incarcerated or strangulated hernia. EXPOSURES Traditional health plan vs HDHP. MAIN OUTCOMES AND MEASURES Presence of an incarcerated or strangulated hernia per International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes. RESULTS Among 83 281 patients (71.9% men and 28.1% women; mean [SD] age, 48.7 [10.9] years) who underwent hernia surgery, 27 477 (33.0%) were enrolled in an HDHP and 21 876 (26.2%) had a hernia that was coded as incarcerated or strangulated. The mean annual deductible was considerably higher for those in the HDHP group than their traditional health plan counterparts (unadjusted mean [SD], $3635 [$2094] vs $705 [$737]; adjusted, -$2931; P < .001). Patients in the HDHP group were more likely to present with an incarcerated or strangulated hernia (adjusted odds ratio, 1.07; 95% CI, 1.03-1.11; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, enrollment in an HDHP was associated with higher odds of presenting with an incarcerated or strangulated hernia, which is more likely to require emergency surgery that precludes medical optimization. These data suggest that, among patients with groin and ventral hernias, enrollment in an HDHP may be associated with delays in surgical care that result in complex disease presentation.
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Affiliation(s)
- Kirbi Yelorda
- Department of Surgery, Stanford University School of Medicine, Stanford, California,S-SPIRE Center, Palo Alto, California
| | - Liam Rose
- S-SPIRE Center, Palo Alto, California,Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California
| | - M. Kate Bundorf
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Huda A. Muhammad
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Arden M. Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, California,S-SPIRE Center, Palo Alto, California
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Abstract
Importance While most working-age adults in the US obtain health insurance through an employer, little is known about the implications of the massive pandemic-related job loss in March 2020 and subsequent rebound for rates of employer-sponsored coverage and uninsurance. Objective To determine how health insurance coverage changed during the COVID-19 pandemic. Design Setting and Participants Analysis of trends in insurance coverage based on repeated cross sections of the US Census Bureau's Household Pulse Survey data, using linear regression to adjust for respondent's demographic and socioeconomic characteristics and state of residence. More than 1.2 million US adults aged 18 to 64 years were surveyed from April 23 through December 21, 2020. Exposures The COVID-19 pandemic, separated into spring and summer and fall and winter time periods during 2020, as well as state Medicaid expansion status. Main Outcomes and Measures Regression-based estimates of the weekly percentage-point change in respondents' health insurance status, including having any health insurance, any employer-sponsored health insurance, or only nonemployer sponsored coverage. Nonemployer-sponsored coverage is categorized into private, Medicaid, and other public in some analyses. Results The study population included 1 212 816 US adults (51% female; mean [SD] age, 42 [13] years) across all 50 US states and Washington DC. Among these respondents, rates of employer-sponsored coverage declined by 0.2 percentage points each week during the COVID-19 pandemic. Other types of coverage, particularly from public sources, increased by 0.1 and 0.2 percentage points in the spring and summer and fall and winter periods, respectively. Overall, health insurance coverage of any type declined, particularly during the spring and summer period, during which uninsurance increased by 1.4 percentage points, representing more than 2.7 million newly uninsured people, over a 12-week period. Conclusions and Relevance In this cross-sectional study of data from the US Census Bureau's Household Pulse Survey, results showed that while public programs played an important role in protecting US adults from pandemic-driven declines in employment-sponsored coverage, many people became uninsured during 2020.
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Affiliation(s)
- M. Kate Bundorf
- Sanford School of Public Policy, Duke University, Durham, North Carolina
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Sumedha Gupta
- Indiana University–Purdue University Indianapolis, Indianapolis
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Polyakova M, Bhatia V, Bundorf MK. Analysis of Publicly Funded Reinsurance-Government Spending and Insurer Risk Exposure. JAMA Health Forum 2021; 2:e211992. [PMID: 35977191 PMCID: PMC8796983 DOI: 10.1001/jamahealthforum.2021.1992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/11/2021] [Indexed: 11/14/2022] Open
Abstract
This analysis compares the design of section 1332 reinsurance policies across states based on their potential for reducing insurer risk exposure and likely level of government spending.
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Affiliation(s)
- Maria Polyakova
- School of Medicine, Stanford University, Stanford, California.,National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - M Kate Bundorf
- National Bureau of Economic Research, Cambridge, Massachusetts.,Sanford School of Public Policy, Duke University, Durham, North Carolina
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Cyr PR, Pedersen K, Iyer AL, Bundorf MK, Goldhaber-Fiebert JD, Gyrd-Hansen D, Kristiansen IS, Burger EA. Providing more balanced information on the harms and benefits of cervical cancer screening: A randomized survey among US and Norwegian women. Prev Med Rep 2021; 23:101452. [PMID: 34221852 PMCID: PMC8242055 DOI: 10.1016/j.pmedr.2021.101452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 11/26/2022] Open
Abstract
Additional information did not impact intentions to participate in CC screening. Additional information increased uncertainty to seek precancer treatment in Norway. Women reported strong system-specific preferences for sources of information. Having a prior Pap-test was an important predictor of intentions-to-participate. Socioeconomic factors influenced follow-up intentions in the U.S. but not in Norway.
We aimed to identify how additional information about benefits and harms of cervical cancer (CC) screening impacted intention to participate in screening, what type of information on harms women preferred receiving, from whom, and whether it differed between two national healthcare settings. We conducted a survey that randomized screen-eligible women in the United States (n = 1084) and Norway (n = 1060) into four groups according to the timing of introducing additional information. We found that additional information did not significantly impact stated intentions-to-participate in screening or follow-up testing in either country; however, the proportion of Norwegian women stating uncertainty about seeking precancer treatment increased from 7.9% to 14.3% (p = 0.012). Women reported strong system-specific preferences for sources of information: Norwegians (59%) preferred it come from a national public health agency while Americans (59%) preferred it come from a specialist care provider. Regression models revealed having a prior Pap-test was the most important predictor of intentions-to-participate in both countries, while having lower income reduced the probabilities of intentions-to-follow-up and seek precancer treatment among U.S. women. These results suggest that additional information on harms is unlikely to reduce participation in CC screening but could increase decision uncertainty to seek treatment. Providing unbiased information would improve on the ethical principle of respect for autonomy and self-determination. However, the clinical impact of additional information on women’s understanding of the trade-offs involved with CC screening should be investigated. Future studies should also consider country-specific socioeconomic barriers to screening if communication re-design initiatives aim to improve CC screening participation.
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Affiliation(s)
- P R Cyr
- Department of Global Health and Community Medicine, Institute of Health and Society, University of Oslo, P.O. Box 1039 Blindern, 0318 Oslo, Norway
| | - K Pedersen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, P.O. Box 1039 Blindern, 0318 Oslo, Norway
| | - A L Iyer
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, P.O. Box 1039 Blindern, 0318 Oslo, Norway
| | - M K Bundorf
- Stanford School of Public Policy, Duke University, Durham, NC 27708 and NBER, United States
| | - J D Goldhaber-Fiebert
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford Health Policy, Stanford University, Stanford, CA, United States
| | - D Gyrd-Hansen
- Danish Centre for Health Economic, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9B, 1 Floor, 5000, Odense C, Denmark
| | - I S Kristiansen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, P.O. Box 1039 Blindern, 0318 Oslo, Norway
| | - E A Burger
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, P.O. Box 1039 Blindern, 0318 Oslo, Norway
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Shivakumar V, Bundorf MK, Vezeridis AM, Kothary N. The Role of Physician-Driven Device Preference in the Cost Variation of Common Interventional Radiology Procedures. J Vasc Interv Radiol 2021; 32:672-676. [PMID: 33781687 DOI: 10.1016/j.jvir.2021.01.275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To analyze the impact of physician-specific equipment preference on cost variation for procedures typically performed by interventional radiologists at a tertiary care academic hospital. MATERIALS AND METHODS From October 2017 to October 2019, data on all expendable items used by 9 interventional radiologists for 11 common interventional radiology procedure categories were compiled from the hospital analytics system. This search yielded a final dataset of 44,654 items used in 2,121 procedures of 11 different categories. The mean cost per case for each physician as well as the mean, standard deviation, and coefficient of variation (CV) of the mean cost per case across physicians were calculated. The proportion of spending by item type was compared across physicians for 2 high-variation, high-volume procedures. The relationship between the mean cost per case and case volume was examined using linear regression. RESULTS There was a high variability within each procedure, with the highest and the lowest CV for radioembolization administration (56.6%) and transjugular liver biopsy (4.9%), respectively. Variation in transarterial chemoembolization cost was mainly driven by microcatheters/microwires, while for nephrostomy, the main drivers were catheters/wires and access sets. Mean spending by physician was not significantly correlated with case volume (P =.584). CONCLUSIONS Physicians vary in their item selection even for standard procedures. While the financial impact of these differences vary across procedures, these findings suggest that standardization may offer an opportunity for cost savings.
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Affiliation(s)
- Vinita Shivakumar
- Stanford University School of Medicine, Stanford, California, United States
| | - M Kate Bundorf
- Duke University Sanford School of Health Policy, Durham, North Carolina, United States
| | - Alexander M Vezeridis
- Department of Interventional Radiology, Stanford University School of Medicine, Stanford, California, United States
| | - Nishita Kothary
- Department of Interventional Radiology, Stanford University School of Medicine, Stanford, California, United States.
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Pershing S, Henderson VW, Goldstein MK, Lu Y, Bundorf MK, Rahman M, Stein JD. Cataract Surgery Complexity and Surgical Complication Rates Among Medicare Beneficiaries With and Without Dementia. Am J Ophthalmol 2021; 221:27-38. [PMID: 32828874 PMCID: PMC7736486 DOI: 10.1016/j.ajo.2020.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/03/2020] [Accepted: 08/15/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate cataract surgery complexity and complications among US Medicare beneficiaries with and without dementia. DESIGN Retrospective claims-based cohort study. PARTICIPANTS A 20% representative sample of Medicare beneficiaries, 2006-2015. METHODS Dementia was identified from diagnosis codes on or prior to each beneficiary's first-eye cataract surgery. For each surgery, we identified setting, routine vs complex coding, anesthesia provider type, duration, and any postoperative hospitalization. We evaluated 30- and 90-day complication rates-return to operating room, endophthalmitis, suprachoroidal hemorrhage, retinal detachment, retinal tear, macular edema, glaucoma, or choroidal detachment-and used adjusted regression models to evaluate likelihood of surgical characteristics and complications. Complication analyses were stratified by second-eye cataract surgery within 90 days postoperatively. RESULTS We identified 457,128 beneficiaries undergoing first-eye cataract surgery, 23,332 (5.1%) with dementia. None of the evaluated surgical complications were more likely in dementia-diagnosed beneficiaries. There was also no difference in likelihood of nonambulatory surgery center setting, anesthesiologist provider, or postoperative hospitalization. Dementia-diagnosed beneficiaries were more likely to have surgeries coded as complex (15.6% of cases vs 8.8%, P < .0001), and surgeries exceeding 30 minutes (OR = 1.21, 95% CI = 1.17-1.25). CONCLUSIONS Among US Medicare beneficiaries undergoing cataract surgery, those with dementia are more likely to have "complex" surgery" lasting more than 30 minutes. However, they do not have greater likelihood of surgical complications, higher-acuity setting, advanced anesthesia care, or postoperative hospitalization. This may be influenced by case selection and may suggest missed opportunities to improve vision. Future research is needed to identify dementia patients likely to benefit from cataract surgery.
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Affiliation(s)
- Suzann Pershing
- Byers Eye Institute at Stanford, Palo Alto, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA; Department of Health Research and Policy (Health Services Research), Stanford University, Palo Alto, California, USA.
| | - Victor W Henderson
- Department of Epidemiology and Population Health, Stanford University, Palo Alto, CA, USA; Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA, USA; Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Mary K Goldstein
- VA Palo Alto Health Care System, Palo Alto, California, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Ying Lu
- Department of Biomedical Data Science, Stanford University, Palo Alto, California, USA
| | - M Kate Bundorf
- Department of Health Research and Policy (Health Services Research), Stanford University, Palo Alto, CA, USA
| | - Moshiur Rahman
- Byers Eye Institute at Stanford, Palo Alto, California, USA; Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA;; Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Joshua D Stein
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA;; Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA;; School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
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McInerney M, Winecoff R, Ayyagari P, Simon K, Bundorf MK. ACA Medicaid Expansion Associated With Increased Medicaid Participation and Improved Health Among Near-Elderly: Evidence From the Health and Retirement Study. Inquiry 2020; 57:46958020935229. [PMID: 32720837 PMCID: PMC7388087 DOI: 10.1177/0046958020935229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12% reduction in metabolic syndrome; a 32% reduction in complications from metabolic syndrome; an 18% reduction in the likelihood of gross motor skills difficulties; and a 34% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.
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Abstract
In health care, vertical integration - common ownership of producers of complementary services - may have both pro- and anti-competitive effects. We use data on 40 million commercially-insured individuals from the Health Care Cost Institute to construct price indices for office visits to general-practice and specialist physicians for the years 2008-2012. Controlling for generalist market concentration, we find that generalists charge higher prices when they are integrated with specialists, and that the effect of integration is larger in more concentrated specialist markets. Conversely, controlling for specialist market concentration, specialists charge higher prices when integrated with generalists, with larger effects in more concentrated generalist markets. Our results suggest that multispecialty practice enhances physician market power.
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Glassman JR, Hopkins DSP, Bundorf MK, Kaplan RM, Ragavan MV, Glaseroff A, Milstein A. Association Between HEDIS Performance and Primary Care Physician Age, Group Affiliation, Training, and Participation in ACA Exchanges. J Gen Intern Med 2020; 35:1730-1735. [PMID: 31974901 PMCID: PMC7280418 DOI: 10.1007/s11606-020-05642-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 01/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are a limited number of studies investigating the relationship between primary care physician (PCP) characteristics and the quality of care they deliver. OBJECTIVE To examine the association between PCP performance and physician age, solo versus group affiliation, training, and participation in California's Affordable Care Act (ACA) exchange. DESIGN Observational study of 2013-2014 data from Healthcare Effectiveness Data and Information Set (HEDIS) measures and select physician characteristics. PARTICIPANTS PCPs in California HMO and PPO practices (n = 5053) with part of their patient panel covered by a large commercial health insurance company. MAIN MEASURES Hemoglobin A1c testing; medical attention nephropathy; appropriate treatment hypertension (ACE/ARB); breast cancer screening; proportion days covered by statins; monitoring ACE/ARBs; monitoring diuretics. A composite performance measure also was constructed. KEY RESULTS For the average 35- versus 75-year-old PCP, regression-adjusted mean composite relative performance scores were at the 60th versus 47th percentile (89% vs. 86% composite absolute HEDIS scores; p < .001). For group versus solo PCPs, scores were at the 55th versus 50th percentiles (88% vs. 87% composite absolute HEDIS scores; p < .001). The effect of age on performance was greater for group versus solo PCPs. There was no association between scores and participation in ACA exchanges. CONCLUSIONS The associations between population-based care performance measures and PCP age, solo versus group affiliation, training, and participation in ACA exchanges, while statistically significant in some cases, were small. Understanding how to help older PCPs excel equally well in group practice compared with younger PCPs may be a fruitful avenue of future research.
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Affiliation(s)
- Jill R Glassman
- Clinical Excellence Research Center, School of Medicine, Stanford University, 365 Lasuen Street, Stanford, CA, 94305, USA.
| | - David S P Hopkins
- Clinical Excellence Research Center, School of Medicine, Stanford University, 365 Lasuen Street, Stanford, CA, 94305, USA
| | - M Kate Bundorf
- Health Research and Policy, School of Medicine, Stanford University, Stanford, CA, USA
| | - Robert M Kaplan
- Clinical Excellence Research Center, School of Medicine, Stanford University, 365 Lasuen Street, Stanford, CA, 94305, USA
| | - Meera V Ragavan
- Clinical Excellence Research Center, School of Medicine, Stanford University, 365 Lasuen Street, Stanford, CA, 94305, USA
| | - Alan Glaseroff
- Clinical Excellence Research Center, School of Medicine, Stanford University, 365 Lasuen Street, Stanford, CA, 94305, USA
| | - Arnold Milstein
- Clinical Excellence Research Center, School of Medicine, Stanford University, 365 Lasuen Street, Stanford, CA, 94305, USA
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15
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Baker LC, Bundorf MK, Kessler DP. The effects of medicare advantage on opioid use. J Health Econ 2020; 70:102278. [PMID: 31972536 PMCID: PMC7181702 DOI: 10.1016/j.jhealeco.2019.102278] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 12/10/2019] [Accepted: 12/14/2019] [Indexed: 06/10/2023]
Abstract
Despite a vast literature on the determinants of prescription opioid use, the role of health insurance plans has received little attention. We study how the form of Medicare beneficiaries' drug coverage affects the volume of opioids they consume. We find that enrollment in Medicare Advantage, which integrates drug coverage with other medical benefits, significantly reduces beneficiaries' likelihood of filling an opioid prescription, as compared to enrollment in a stand-alone drug plan. Approximately half of this effect was due to fewer fills from prescribers who write a very large number of opioid prescriptions.
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16
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Patel MI, Sundaram V, Desai M, Periyakoil VS, Kahn JS, Bhattacharya J, Asch SM, Milstein A, Bundorf MK. Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncol 2019; 4:1359-1366. [PMID: 30054634 DOI: 10.1001/jamaoncol.2018.2446] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Although lay health workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited. Objective To determine whether an LHW program can increase documentation of patients' care preferences after cancer diagnosis. Design, Setting, and Participants Randomized clinical trial conducted from August 13, 2013, through February 2, 2015, among 213 patients with stage 3 or 4 or recurrent cancer at the Veterans Affairs Palo Alto Health Care System. Data analysis was by intention to treat and performed from January 15 to August 18, 2017. Interventions Six-month program with an LHW trained to assist patients with establishing end-of-life care preferences vs usual care. Main Outcomes and Measures The primary outcome was documentation of goals of care. Secondary outcomes were patient satisfaction on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (on a scale of 0 [worst] to 10 [best possible]), health care use, and costs. Results Among the 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years, 211 (99.1%) were male, and 165 (77.5%) were of non-Hispanic white race/ethnicity. Within 6 months of enrollment, patients randomized to the intervention had greater documentation of goals of care than the control group (97 [92.4%] vs 19 [17.5%.]; P < .001) and larger increases in satisfaction with care on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (difference-in-difference, 1.53; 95% CI, 0.67-2.41; P < .001). The number of patients who died within 15 months of enrollment did not differ between groups (intervention, 60 of 105 [57.1%] vs control, 60 of 108 [55.6%]; P = .68). In the 30 days before death, patients in the intervention group had greater hospice use (46 [76.7%] vs 29 [48.3%]; P = .002), fewer emergency department visits (mean [SD], 0.05 [0.22] vs 0.60 [0.76]; P < .001), fewer hospitalizations (mean [SD], 0.05 [0.22] vs 0.50 [0.62]; P < .001), and lower costs (median [interquartile range], $1048 [$331-$8522] vs $23 482 [$9708-$55 648]; P < .001) than patients in the control group. Conclusions and Relevance Incorporating an LHW into cancer care increases goals-of-care documentation and patient satisfaction and reduces health care use and costs at the end of life. Trial Registration ClinicalTrials.gov Identifier: NCT02966509.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, California.,Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California.,Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Manisha Desai
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Vyjeyanthi S Periyakoil
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California.,Extended Care Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - James S Kahn
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Steven M Asch
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California.,Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - M Kate Bundorf
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
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Bundorf MK, Polyakova M, Stults C, Meehan A, Klimke R, Pun T, Chan AS, Tai-Seale M. Machine-Based Expert Recommendations And Insurance Choices Among Medicare Part D Enrollees. Health Aff (Millwood) 2019; 38:482-490. [PMID: 30830808 DOI: 10.1377/hlthaff.2018.05017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Choosing a health insurance plan is difficult for many people, and patient-centered decision support may help consumers make these choices. We tested whether providing a patient-centered decision-support tool-with or without machine-based, personalized expert recommendations-influenced decision outcomes for Medicare Part D enrollees. We found that providing an online patient-centered decision-support tool increased older adults' satisfaction with the process of choosing a prescription drug plan and the amount of time they spent choosing a plan. Providing personalized expert recommendations as well increased rates of plan switching. Many people who could have accessed the tool chose not to, and the characteristics of people who used the tool differed from those who did not. We conclude that a patient-centered decision-support tool providing personalized expert recommendations can help people choose a plan, but different approaches may be necessary to encourage more people to periodically reevaluate their options.
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Affiliation(s)
- M Kate Bundorf
- M. Kate Bundorf ( ) is an associate professor of health research and policy at the Stanford University School of Medicine, in California
| | - Maria Polyakova
- Maria Polyakova is an assistant professor of health research and policy at the Stanford University School of Medicine
| | - Cheryl Stults
- Cheryl Stults is a research sociologist at the Palo Alto Medical Foundation Research Institute, in California
| | - Amy Meehan
- Amy Meehan is a research associate at the Palo Alto Medical Foundation Research Institute
| | - Roman Klimke
- Roman Klimke is a graduate student at the John F. Kennedy School of Government, Harvard University, in Cambridge, Massachusetts
| | - Ting Pun
- Ting Pun is an independent consultant in Mountain View, California
| | - Albert Solomon Chan
- Albert Solomon Chan is chief of digital patient experience and an investigator at Sutter Health, in Palo Alto, and an adjunct professor at the Stanford Center for Biomedical Informatics Research, Stanford School of Medicine
| | - Ming Tai-Seale
- Ming Tai-Seale is a professor in the Department of Family Medicine and Public Health, University of California San Diego, director of outcomes analysis and scholarship at UC San Diego Health, and director of research at UCSD Health Sciences International, in La Jolla
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Pershing S, Henderson VW, Bundorf MK, Lu Y, Rahman M, Andrews CA, Goldstein M, Stein JD. Differences in Cataract Surgery Rates Based on Dementia Status. J Alzheimers Dis 2019; 69:423-432. [PMID: 30958371 PMCID: PMC10728498 DOI: 10.3233/jad-181292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cataract surgery substantially improves patient quality of life. Despite the rising prevalence of dementia in the US, little is known about use of cataract surgery among this group. OBJECTIVE To evaluate the relationship between dementia status and cataract surgery. METHODS Using administrative insurance claims for a representative sample of 1,125,387 US Medicare beneficiaries who received eye care between 2006 and 2015, we compared cataract surgery rates between patients with and without dementia via multivariable regression models to adjust for patient characteristics. Main outcome measures were annual rates of cataract surgery and hazard ratio and 95% confidence interval (CI) for receiving cataract surgery. RESULTS Cataract surgery was performed in 457,128 patients, 23,331 with a prior diagnosis of dementia. 16.7% of dementia patients underwent cataract surgery, compared to 43.8% of patients without dementia. 59 cataract surgeries were performed per 1000 dementia patients annually, versus 105 surgeries per 1000 nondementia patients. After adjusting for patient characteristics, dementia patients were approximately half as likely to receive cataract surgery compared to nondementia patients (adjusted HR = 0.53, 95% CI 0.53-0.54). Among the subset of patients who received a first cataract surgery, those with dementia were also less likely to receive second-eye cataract surgery (adjusted HR = 0.87, 95% CI 0.86-0.88). CONCLUSION US Medicare patients with dementia are less likely to undergo cataract surgery than those without dementia. This finding has implications for quality of care and dementia progression. More information is necessary to understand why rates of cataract surgery are lower for these patients, and to identify conditions where benefits of surgery may outweigh risks.
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Affiliation(s)
- Suzann Pershing
- Byers Eye Institute at Stanford, Palo Alto, CA, USA
- VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Victor W. Henderson
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
- Department of Health Research and Policy (Epidemiology), Stanford University, Stanford, CA, USA
| | - M. Kate Bundorf
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Ying Lu
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Moshiur Rahman
- Byers Eye Institute at Stanford, Palo Alto, CA, USA
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
- Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Chris A. Andrews
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
- Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Mary Goldstein
- VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Joshua D. Stein
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI, USA
- Center for Eye Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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McKenzie RB, Sanders L, Bhattacharya J, Bundorf MK. Health Care System Factors Associated with Transition Preparation in Youth with Special Health Care Needs. Popul Health Manag 2018; 22:63-73. [PMID: 29957127 DOI: 10.1089/pop.2018.0027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aim of this study was to assess: (1) the proportion of youth with special health care needs (YSHCN) with adequate transition preparation, (2) whether transition preparation differs by individual, condition-related and health care system-related factors, and (3) whether specific components of the medical home are associated with adequate transition preparation. The authors conducted a cross-sectional analysis of the 2009-2010 National Survey of Children with Special Health Care Needs, which surveyed a nationally representative sample of 17,114 parents of YSHCN ages 12 to 18 years. Adequate transition preparation was based on positive responses to questions about transition to an adult provider, changing health care needs, maintaining insurance coverage, and if providers encouraged YSHCN to take responsibility for health care needs. Weighted descriptive, bivariate and multivariate analyses were conducted to determine the association between patient and health care system factors and adequate transition preparation. Overall, 32.1% of YSHCN had adequate transition preparation. Older age, female sex, income ≤400% of the poverty level, lack of medical complexity, and having shared decision making, family-centered care, and effective care coordination were associated with increased odds of transition preparation. The majority of YSHCN do not receive adequate transition preparation and younger, male adolescents with medical complexity were less likely to receive transition preparation. Different patterns of disparities were identified for each subcomponent measure of transition preparation, which may help target at-risk populations for specific services. Efforts to improve transition preparation should leverage specific components of the medical home including care coordination, shared decision making, and family-centered care.
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Affiliation(s)
| | - Lee Sanders
- 2 Division of General Pediatrics, Stanford University , Stanford, California
| | - Jay Bhattacharya
- 1 Division of Pediatric Gastroenterology, Stanford University , Stanford, California.,3 Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University , Stanford, California
| | - M Kate Bundorf
- 4 Department of Health Research and Policy, Stanford University , Stanford, California
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Zhou M, Liu S, Kate Bundorf M, Eggleston K, Zhou S. Mortality In Rural China Declined As Health Insurance Coverage Increased, But No Evidence The Two Are Linked. Health Aff (Millwood) 2018; 36:1672-1678. [PMID: 28874497 DOI: 10.1377/hlthaff.2017.0135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health insurance holds the promise of improving population health and survival and protecting people from catastrophic health spending. Yet evidence from lower- and middle-income countries on the impact of health insurance is limited. We investigated whether insurance expansion reduced adult mortality in rural China, taking advantage of differences across Chinese counties in the timing of the introduction of the New Cooperative Medical Scheme (NCMS). We assembled and analyzed newly collected data on NCMS implementation, linked to data from the Chinese Center for Disease Control and Prevention on cause-specific, age-standardized death rates and variables specific to county-year combinations for seventy-two counties in the period 2004-12. While mortality rates declined among rural residents during this period, we found little evidence that the expansion of health insurance through the NCMS contributed to this decline. However, our relatively large standard errors leave open the possibility that the NCMS had effects on mortality that we could not detect. Moreover, mortality benefits might arise only after many years of accumulated coverage.
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Affiliation(s)
- Maigeng Zhou
- Maigeng Zhou is deputy director of the National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention (China CDC), in Beijing
| | - Shiwei Liu
- Shiwei Liu is a professor at the National Center for Chronic and Noncommunicable Disease Control and Prevention, China CDC
| | - M Kate Bundorf
- M. Kate Bundorf is a professor of health research and policy at the Stanford School of Medicine, in California, and a research associate at the National Bureau of Economic Research, in Cambridge, Massachusetts
| | - Karen Eggleston
- Karen Eggleston is a senior fellow at the Freeman Spogli Institute for International Studies (FSI) and deputy director of FSI's Shorenstein Asia-Pacific Research Center, at Stanford University, in California; and a faculty research fellow at the National Bureau of Economic Research
| | - Sen Zhou
- Sen Zhou is a postdoctoral researcher at the China Institute for Educational Finance Research at Peking University, in Beijing
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21
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Stults CD, Fattahi S, Meehan A, Bundorf MK, Chan AS, Pun T, Tai-Seale M. Comparative Usability Study of a Newly Created Patient-Centered Tool and Medicare.gov Plan Finder to Help Medicare Beneficiaries Choose Prescription Drug Plans. J Patient Exp 2018; 6:81-86. [PMID: 31236456 PMCID: PMC6572936 DOI: 10.1177/2374373518778343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: In response to reported difficulties in selecting a Medicare Part D prescription drug plan, we designed a patient-centered online Part D plan selection tool (CHOICE1.0) to simplify the selection process and to provide personalized, expert recommendations. Methods: This ethnographic comparative usability study observed 44 patients using the first version of the tool during Medicare 2016 Open Enrollment. Participants were observed as they chose their drug plan using Medicare.gov and 1 of 3 versions of CHOICE1.0 that varied in amount of expert guidance. Descriptive statistics were used to analyze exit survey data. The observations were video-recorded, and field notes were analyzed thematically. Results: Participants were significantly more satisfied with CHOICE1.0 for choosing a plan, understanding information, and ease of use compared to Medicare.gov. Those using expert versions of CHOICE1.0 were more likely to indicate their intention to switch plans than those using Medicare.gov, though they wanted to know the source and content. Conclusion: The more patient-centered prescription drug choice tool improved user experience and enabled users to choose plans more consistent with expert recommendations.
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Affiliation(s)
- Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | | | - Amy Meehan
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | - M Kate Bundorf
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Albert S Chan
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA.,Sutter Health, San Carlos, CA, USA
| | - Ting Pun
- Patient-Centered Outcomes Research Institute Patient Advisory Council, Portola Valley, CA, USA
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA.,University of California San Diego School of Medicine, La Jolla, CA, USA
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22
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Abstract
INTRODUCTION Medicare beneficiaries often report that the process of choosing a prescription drug plan is frustrating and confusing and many do not enroll in the plan that covers their drugs at the lowest cost. METHODS We conducted 4 focus groups to understand beneficiaries' experiences in selecting a drug plan to identify what resources and factors were most important to them. Participants were patients served by a multispecialty delivery system and were primarily affluent and Caucasian. RESULTS While low cost was essential to many, other characteristics like having the same plan as a partner, company reputation, convenience, and anticipation of possible future health problems were sometimes more important. Although some used resources including insurance brokers, counselors, and websites beyond Medicare.gov, many expressed a desire for greater assistance with and greater simplicity in the choice process. CONCLUSION Although older adults would likely benefit from greater assistance in choosing Medicare Part D prescription drug plans, more research is necessary to understand how to help with decision-making in this context.
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Affiliation(s)
- Cheryl D Stults
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | | | - M Kate Bundorf
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Ming Tai-Seale
- Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
- School of Medicine, University of California San Diego, CA, USA
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Pershing S, Glasser D, Han E, Baisiwala S, Jain A, Bundorf MK. An Analysis of Medicare Reimbursement to Ophthalmologists: Years 2012 to 2013. Am J Ophthalmol 2018; 186:176-177. [PMID: 29277399 DOI: 10.1016/j.ajo.2017.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 11/29/2017] [Indexed: 11/29/2022]
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Polyakova M, Bundorf MK, Kessler DP, Baker LC. ACA Marketplace premiums and competition among hospitals and physician practices. Am J Manag Care 2018; 24:85-90. [PMID: 29461855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To examine the association between annual premiums for health plans available in Federally Facilitated Marketplaces (FFMs) and the extent of competition and integration among physicians and hospitals, as well as the number of insurers. STUDY DESIGN We used observational data from the Center for Consumer Information and Insurance Oversight on the annual premiums and other characteristics of plans, matched to measures of physician, hospital, and insurer market competitiveness and other characteristics of 411 rating areas in the 37 FFMs. METHODS We estimated multivariate models of the relationship between annual premiums and Herfindahl-Hirschman indices of hospitals and physician practices, controlling for the number of insurers, the extent of physician-hospital integration, and other plan and rating area characteristics. RESULTS Premiums for Marketplace plans were higher in rating areas in which physician, hospital, and insurance markets were less competitive. An increase from the 10th to the 90th percentile of physician concentration and hospital concentration was associated with increases of $393 and $189, respectively, in annual premiums for the Silver plan with the second lowest cost. A similar increase in the number of insurers was associated with a $421 decrease in premiums. Physician-hospital integration was not significantly associated with premiums. CONCLUSIONS Premiums for FFM plans were higher in markets with greater concentrations of hospitals and physicians but fewer insurers. Higher premiums make health insurance less affordable for people purchasing unsubsidized coverage and raise the cost of Marketplace premium tax credits to the government.
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Affiliation(s)
- Maria Polyakova
- Stanford University, Redwood Bldg, Rm T111, 150 Governor's Ln, Stanford, CA 94305.
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25
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Abstract
There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines.
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Affiliation(s)
- Laurence C Baker
- Laurence C. Baker is a professor of health research and policy at Stanford University, in California, and a research associate at the National Bureau of Economic Research, in Cambridge, Massachusetts
| | - M Kate Bundorf
- M. Kate Bundorf is a professor of health research and policy at Stanford University and a faculty research fellow at the National Bureau of Economic Research
| | - Aileen M Devlin
- Aileen M. Devlin is a research fellow at the Stanford Law School
| | - Daniel P Kessler
- Daniel P. Kessler is a professor in the Law School and the Graduate School of Business, a professor (by courtesy) in the Department of Health Research and Policy, and a senior fellow at the Hoover Institution, all at Stanford University. He is also a research associate at the National Bureau of Economic Research
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Polyakova M, Hua LM, Bundorf MK. Marketplace Plans Provide Risk Protection, But Actuarial Values Overstate Realized Coverage For Most Enrollees. Health Aff (Millwood) 2017; 36:2078-2084. [DOI: 10.1377/hlthaff.2017.0660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Maria Polyakova
- Maria Polyakova is an assistant professor of health research and policy at the Stanford University School of Medicine, in California, and a faculty research fellow at the National Bureau of Economic Research, in Cambridge, Massachusetts
| | - Lynn Mei Hua
- Lynn Mei Hua is a research associate in the Department of Health Research and Policy at the Stanford University School of Medicine
| | - M. Kate Bundorf
- M. Kate Bundorf is an associate professor of health research and policy and chief of the Division of Health Services Research at the Stanford University School of Medicine and a research associate at the National Bureau of Economic Research
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Abstract
IMPORTANCE Noninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain. OBJECTIVE To determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia. EXPOSURES Noninvasive testing or coronary angiography within 2 days or 30 days of presentation. MAIN OUTCOMES AND MEASURES The primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography. RESULTS The patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions. CONCLUSIONS AND RELEVANCE Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.
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Affiliation(s)
- Alexander T Sandhu
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Center for Health Policy and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, California.,Stanford University School of Medicine, Stanford, California
| | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Stanford University School of Medicine, Stanford, California
| | - Jay Bhattacharya
- Center for Health Policy and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, California.,Stanford University School of Medicine, Stanford, California
| | - M Kate Bundorf
- Stanford University School of Medicine, Stanford, California.,Health Research and Policy, Stanford, California
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Baker LC, Bundorf MK, Kessler DP. The effect of hospital/physician integration on hospital choice. J Health Econ 2016; 50:1-8. [PMID: 27639202 DOI: 10.1016/j.jhealeco.2016.08.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 08/19/2016] [Accepted: 08/27/2016] [Indexed: 06/06/2023]
Abstract
In this paper, we estimate how hospital ownership of physicians' practices affects their patients' hospital choices. We match data on the hospital admissions of Medicare beneficiaries, including the identity of their physician, with data on the identity of the owner of their physician's practice. We find that a hospital's ownership of a physician dramatically increases the probability that the physician's patients will choose the owning hospital. We also find that patients are more likely to choose a high-cost, low-quality hospital when their physician is owned by that hospital.
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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.
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Affiliation(s)
- Laurence C Baker
- 1 Stanford University, Stanford, CA, USA.,2 National Bureau of Economic Research, Cambridge, MA, USA
| | - M Kate Bundorf
- 1 Stanford University, Stanford, CA, USA.,2 National Bureau of Economic Research, Cambridge, MA, USA
| | | | - Daniel P Kessler
- 1 Stanford University, Stanford, CA, USA.,2 National Bureau of Economic Research, Cambridge, MA, USA
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Stults CD, Baskin A, Tai-Seale M, Bundorf MK. Patient Experiences in Selecting a Medicare Part D Prescription Drug Plan. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Baisiwala S, Bundorf MK, Pershing S. Physician Utilization Patterns for VEGF-Inhibitor Drugs in the 2012 United States Medicare Population: Bevacizumab, Ranibizumab, and Aflibercept. Ophthalmic Surg Lasers Imaging Retina 2016; 47:555-62. [DOI: 10.3928/23258160-20160601-07] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 04/06/2016] [Indexed: 11/20/2022]
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Baker LC, Bundorf MK, Kessler DP. Does health plan generosity enhance hospital market power? J Health Econ 2015; 44:54-62. [PMID: 26402570 DOI: 10.1016/j.jhealeco.2015.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 08/05/2015] [Accepted: 08/11/2015] [Indexed: 06/05/2023]
Abstract
We test whether the generosity of employer-sponsored health insurance facilitates the exercise of market power by hospitals. We construct indices of health plan generosity and the price and volume of hospital services using data from Truven MarketScan for 601 counties from 2001 to 2007. We use variation in the industry and union status of covered workers within a county over time to identify the causal effects of generosity. Although OLS estimates fail to reject the hypothesis that generosity facilitates the exercise of hospital market power, IV estimates show a statistically significant and economically important positive effect of plan generosity on hospital prices in uncompetitive markets, but not in competitive markets. Our results suggest that most of the aggregate effect of hospital market structure on prices found in previous work may be coming from areas with generous plans.
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Affiliation(s)
- Laurence C Baker
- Stanford University and National Bureau of Economic Research, Stanford, CA, United States
| | - M Kate Bundorf
- Stanford University and National Bureau of Economic Research, Stanford, CA, United States
| | - Daniel P Kessler
- Stanford University, Hoover Institution, and The National Bureau of Economic Research, Stanford, CA, United States.
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Baker LC, Bundorf MK, Kessler DP. Patients' preferences explain a small but significant share of regional variation in medicare spending. Health Aff (Millwood) 2015; 33:957-63. [PMID: 24889944 DOI: 10.1377/hlthaff.2013.1184] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study assessed the extent to which differences in patients' preferences across geographic areas explained differences in traditional fee-for-service Medicare spending across Dartmouth Atlas of Health Care Hospital Referral Regions (HRRs). Preference measures were based on results of a survey that asked patients questions about their physicians, their own health status, and the care they would want in their last six months of life. We found that patients' preferences explained 5 percent of the variation across HRRs in total Medicare spending. In comparison, supply factors, such as the number of physicians, specialists, and hospital beds, explained 23 percent, and patients' health and income explained 12 percent. We also explored the relative importance of preferences in determining three components of total spending: spending at the end of life, inpatient spending, and spending on physician services. Relative to supply factors, health, and income, patients' preferences explained the largest share of variation in end-of-life spending and the smallest share of variation in spending on physician services. We conclude that variation in preferences contributes to differences across areas in Medicare spending. Medicare policy must consider both supply factors and patients' preferences in deciding how much to accommodate area variation in spending and the extent to which that variation should be subsidized by taxpayers.
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Affiliation(s)
- Laurence C Baker
- Laurence C. Baker is a professor of health research and policy at Stanford University, in California, and a research associate at the National Bureau of Economic Research, in Cambridge, Massachusetts
| | - M Kate Bundorf
- M. Kate Bundorf is a professor of health research and policy at Stanford University and a faculty research fellow at the National Bureau of Economic Research
| | - Daniel P Kessler
- Daniel P. Kessler is a professor in the Law School and the Graduate School of Business, a professor (by courtesy) in the Department of Health Research and Policy, and a senior fellow at the Hoover Institution, all at Stanford University. He is also a research associate at the National Bureau of Economic Research
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He XY, Bundorf MK, Gu JJ, Zhou P, Xue D. Compliance with clinical pathways for inpatient care in Chinese public hospitals. BMC Health Serv Res 2015; 15:459. [PMID: 26445427 PMCID: PMC4595105 DOI: 10.1186/s12913-015-1121-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 09/25/2015] [Indexed: 11/25/2022] Open
Abstract
Background The National Health and Family Planning Commission of China has issued more than 400 clinical pathways to improve the effectiveness and efficiency of medical care delivered by public hospitals in China. The aim of our study is to determine whether patient care is compliant with national clinical pathways in public general hospitals of Pudong New Area in Shanghai. Methods We identified the clinical pathways established by the National Health and Family Planning Commission of China for 5 common conditions (community-acquired pneumonia, acute myocardial infarction (AMI), heart failure, cesarean section, type-2 diabetes). We randomly selected patients with each condition admitted to one of 7 public general hospitals in Pudong New Area in China in January, 2013. We identified key process indicators (KPIs) for each pathway and, based on chart review for each patient, determined whether the patient’s care was compliant for each indicator. We calculated the proportion of care which was compliant with clinical pathways for each indicator, the average proportion of indicators that were met for each patient, and the proportion of patients whose care was compliant for all measures. For selected indicators, we compared compliance rates among hospitals in our study with those from other countries. Results Average compliance rates across the KPIs for each condition ranged from 61 % for AMI to 89 % for pneumonia. The percent of patient receiving fully compliant care ranged from 0 for AMI and heart failure to 39 % for pneumonia. Compared to the compliance rate for process indicators in the hospitals of other countries, some rates in the hospitals that we audited were higher, but some were lower. Conclusions Few patients received care that complied with all the pathways for each condition. The reasons for low compliance with national clinical pathways and how to improve clinical quality in public hospitals of China need to be further explored. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1121-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiao Yan He
- Department of Hospital Management, Key Laboratory of Health Technology Assessment (MOH), Collaborative Innovation Center of Social Risks Governance in Health, School of Public Health, Fudan University, No 138, Yi Xue Yuan Road, P.O.Box 197, Shanghai, 200032, P. R. China.
| | - M Kate Bundorf
- School of Medicine, Stanford University, HRP Redwood Building, 259 Campus Drive, Stanford, CA, 94305-5405, USA.
| | - Jian Jun Gu
- Commission of Health and Family Planning of Pudong New Area, No. 990, Chengshan Road, Shanghai, 200125, P. R. China.
| | - Ping Zhou
- Department of Hospital Management, Key Laboratory of Health Technology Assessment (MOH), Collaborative Innovation Center of Social Risks Governance in Health, School of Public Health, Fudan University, No 138, Yi Xue Yuan Road, P.O.Box 197, Shanghai, 200032, P. R. China.
| | - Di Xue
- Department of Hospital Management, Key Laboratory of Health Technology Assessment (MOH), Collaborative Innovation Center of Social Risks Governance in Health, School of Public Health, Fudan University, No 138, Yi Xue Yuan Road, P.O.Box 197, Shanghai, 200032, P. R. China.
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Baker LC, Bundorf MK, Kessler DP. Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff (Millwood) 2015; 33:756-63. [PMID: 24799571 DOI: 10.1377/hlthaff.2013.1279] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We examined the consequences of contractual or ownership relationships between hospitals and physician practices, often described as vertical integration. Such integration can reduce health spending and increase the quality of care by improving communication across care settings, but it can also increase providers' market power and facilitate the payment of what are effectively kickbacks for inappropriate referrals. We investigated the impact of vertical integration on hospital prices, volumes (admissions), and spending for privately insured patients. Using hospital claims from Truven Analytics MarketScan for the nonelderly privately insured in the period 2001-07, we constructed county-level indices of prices, volumes, and spending and adjusted them for enrollees' age and sex. We measured hospital-physician integration using information from the American Hospital Association on the types of relationships hospitals have with physicians. We found that an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians--ownership of physician practices--was associated with higher hospital prices and spending. We found that an increase in contractual integration reduced the frequency of hospital admissions, but this effect was relatively small. Taken together, our results provide a mixed, although somewhat negative, picture of vertical integration from the perspective of the privately insured.
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Pershing S, Pal Chee C, Asch SM, Baker LC, Boothroyd D, Wagner TH, Bundorf MK. Treating Age-Related Macular Degeneration: Comparing The Use Of Two Drugs Among Medicare And Veterans Affairs Populations. Health Aff (Millwood) 2015; 34:229-38. [DOI: 10.1377/hlthaff.2014.1032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Suzann Pershing
- Suzann Pershing is an assistant professor of ophthalmology at the Byers Eye Institute at Stanford, in Palo Alto, California, and chief of ophthalmology and eye care services at the Veterans Affairs (VA) Palo Alto Health Care System
| | - Christine Pal Chee
- Christine Pal Chee is a health economist at the VA Health Economics Resource Center, in Menlo Park, California
| | - Steven M. Asch
- Steven M. Asch is a professor of medicine at Stanford University School of Medicine, in Palo Alto, and chief of health services research and director of the Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Laurence C. Baker
- Laurence C. Baker is a professor in health research and policy at Stanford University and a research associate at the National Bureau of Economic Research in Cambridge, Massachusetts
| | - Derek Boothroyd
- Derek Boothroyd is a senior biostatistician in medicine at Stanford University School of Medicine
| | - Todd H. Wagner
- Todd H. Wagner is a health economist and associate director of the Health Economics Resource Center, VA Palo Alto Health Care System and Stanford University
| | - M. Kate Bundorf
- M. Kate Bundorf is an associate professor in health research and policy at Stanford University School of Medicine and a faculty research fellow at the National Bureau of Economic Research
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Abstract
IMPORTANCE Physician practice consolidation could promote higher-quality care but may also create greater economic market power that could lead to higher prices for physician services. OBJECTIVE To assess the relationship between physician competition and prices paid by private preferred provider organizations (PPOs) for 10 types of office visits in 10 prominent specialties. DESIGN AND SETTING Retrospective study in 1058 US counties in urbanized areas, representing all 50 states, examining the relationship between measured physician competition and prices paid for office visits in 2010 and the relationship between changes in competition and prices between 2003 and 2010, using regression analysis to control for possible confounding factors. EXPOSURES Variation in the mean Hirschman-Herfindahl Index (HHI) of physician practices within a county by specialty (HHIs range from 0, representing maximally competitive markets, to 10,000 in markets served by a single [monopoly] practice). MAIN OUTCOMES AND MEASURES Mean price paid by county to physicians in each specialty by private PPOs for intermediate office visits with established patients (Current Procedural Terminology [CPT] code 99213) and a price index measuring the county-weighted mean price for 10 types of office visits with new and established patients (CPT codes 99201-99205, 99211-99215) relative to national mean prices. RESULTS In 2010, across all specialties studied, HHIs were 3 to 4 times higher in the 90th-percentile county than the 10th-percentile county (eg, for family practice: 10th percentile HHI = 1023 and 90th percentile HHI = 3629). Depending on specialty, mean price for a CPT code 99213 visit was between $70 and $75. After adjustment for potential confounders, depending on specialty, prices at the 90th-percentile HHI were between $5.85 (orthopedics; 95% CI, $3.46-$8.24) and $11.67 (internal medicine; 95% CI, $9.13-$14.21) higher than at the 10th percentile. Including all types of office visits, price indexes at the 90th-percentile HHI were 8.3% (orthopedics; 95% CI, 5.0%-11.6%) to 16.1% (internal medicine; 95% CI, 12.8%-19.5%) higher. Between 2003 and 2010, there were larger price increases in areas that were less competitive in 2002 than in initially more competitive areas. CONCLUSIONS AND RELEVANCE More competition among physicians is related to lower prices paid by private PPOs for office visits. These results may inform work on policies that influence practice competition.
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Affiliation(s)
- Laurence C Baker
- Stanford University School of Medicine, Stanford, California2National Bureau of Economic Research, Cambridge, Massachusetts
| | - M Kate Bundorf
- Stanford University School of Medicine, Stanford, California2National Bureau of Economic Research, Cambridge, Massachusetts
| | - Anne B Royalty
- Indiana University-Purdue University Indianapolis, Indianapolis
| | - Zachary Levin
- Stanford University School of Medicine, Stanford, California
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Baker L, Bundorf MK, Royalty A. Private insurers' payments for routine physician office visits vary substantially across the United States. Health Aff (Millwood) 2014; 32:1583-90. [PMID: 24019363 DOI: 10.1377/hlthaff.2013.0309] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anecdotal reports suggest that substantial variation exists in private insurers' payments for physician services, but systematic evidence is lacking. Using a retrospective analysis of insurance claims for routine office visits, consultations, and preventive visits from more than forty million physician claims in 2007, we examined variations in private payments to physicians and the extent to which variation is explained by patients' and physicians' characteristics and by geographic region. We found much variation in payments for these routine evaluation and management services. Physicians at the high end of the payment distribution were generally paid more than twice what physicians at the low end were paid for the same service. Little variation was explained by patients' age or sex, physicians' specialty, place of service, whether the physician was a "network provider," or type of plan, although about one-third of the variation was associated with the geographic area of the practice. Interventions that promote more price-consciousness on the part of patients could help reduce health care spending, but more data on the specific causes of price variation are needed to determine appropriate policy responses.
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Baker LC, Bundorf MK, Kessler DP. Why Are Medicare and commercial insurance spending weakly correlated? Am J Manag Care 2014; 20:e8-e14. [PMID: 24669412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To investigate the source of the weak correlation across geographic areas between Medicare and private insurance spending. STUDY DESIGN Retrospective, descriptive analysis. METHODS We obtained Medicare spending data at the hospital referral region (HRR) level for 2007 from the Dartmouth Atlas, and commercial claims from large employers for 2007 from the Truven MarketScan Database. We constructed county-level data on hospital market structure from Medicare patient flows and obtained county-level data on the Medicare wage index from the Centers for Medicare & Medicaid Services website. We aggregated these sources to the HRR level. We decomposed Medicare and private spending into 2 components: price and volume. We also decomposed Medicare and private prices into 2 components: a common measure of cost and a sector-specific markup. We computed correlations between Medicare and private prices and volumes, and the correlation of each sector’s price and volume with cost and markup. RESULTS We found that Medicare and private prices are strongly positively correlated, largely because both are keyed off of common costs. Consistent with previous work, we found that Medicare and private volumes are strongly positively correlated as well. CONCLUSIONS The weak correlation between Medicare and private spending is consistent with these 2 empirical regularities. It is mathematically due to negative correlations between each sector’s price and the other sector’s volume. In particular, we found that private prices have important spillover effects on Medicare volume. Future research on the effects of competition should take account of this phenomenon.
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Szrek H, Bundorf MK. Age and the purchase of prescription drug insurance by older adults. Decision 2013. [DOI: 10.1037/2325-9965.1.s.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
OBJECTIVE To determine how choice set size affects decision quality among individuals of different levels of numeracy choosing prescription drug plans. METHOD Members of an Internet-enabled panel age 65 and over were randomly assigned to sets of prescription drug plans varying in size from 2 to 16 plans from which they made a hypothetical choice. They answered questions about enrollment likelihood and the costs and benefits of their choice. The measure of decision quality was enrollment likelihood among those for whom enrollment was beneficial. Enrollment likelihood by numeracy and choice set size was calculated. A model of moderated mediation was analyzed to understand the role of numeracy as a moderator of the relationship between the number of plans and the quality of the enrollment decision and the roles of the costs and benefits in mediating that relationship. RESULTS More numerate adults made better decisions than less numerate adults when choosing among a small number of alternatives but not when choice sets were larger. Choice set size had little effect on decision making of less numerate adults. Differences in decision making costs between more and less numerate adults helped explain the effect of choice set size on decision quality. CONCLUSIONS Interventions to improve decision making in the context of Medicare Part D may differentially affect lower and higher numeracy adults. The conflicting results on choice overload in the psychology literature may be explained in part by differences amongst individuals in how they respond to choice set size.
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Affiliation(s)
- Helena Szrek
- Centre for Economics and Finance, University of Porto
| | - M Kate Bundorf
- Department of Health Research and Policy, Stanford University School of Medicine
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Bundorf MK, Mata R, Schoenbaum M, Bhattacharya J. Are prescription drug insurance choices consistent with expected utility theory? Health Psychol 2013; 32:986-94. [DOI: 10.1037/a0033517] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
The Medicare Part D Prescription Drug Program places an unprecedented degree of choice in the hands of older adults despite concerns over their ability to make effective decisions and desire to have extensive choice in this context. While previous research has compared older adults to younger adults along these dimensions, our study, in contrast, examines how likelihood to delay decision making and preferences for choice differ by age among older age cohorts. Our analysis is based on responses of older adults to a simulation of enrollment in Medicare Part D. We examine how age, numeracy, cognitive reflection, and the interaction between age and performance on these instruments are related to the decision to enroll in a Medicare prescription drug plan and preference for choice in this context. We find that numeracy and cognitive reflection are positively associated with enrollment likelihood and that they are more important determinants of enrollment than age. We also find that greater numeracy is associated with a lower willingness to pay for choice. Hence, our findings raise concern that older adults, and, in particular, those with poorer numerical processing skills, may need extra support in enrolling in the program: they are less likely to enroll than those with stronger numerical processing skills, even though they show greater willingness to pay for choice.
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Affiliation(s)
- Helena Szrek
- Centre for Economics and Finance, University of Porto, Faculty of Economics, Rua Dr. Roberto Frias, 4200-001 Porto, Portugal.
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Abstract
Controlling health care cost growth remains a high priority for policymakers and private decisionmakers, yet little is known about sources of this growth. We examined spending growth among the privately insured between 2001 and 2006, separating the contributions of price changes from those driven by consumption. Most spending growth was driven by outpatient services and pharmaceuticals, with growth in quantities explaining the entire growth in outpatient spending and about three-quarters of growth in spending on prescription drugs. Rising prices played a greater role in growth in spending for brand-name than for generic drugs. These findings can inform efforts to control private- sector spending.
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Affiliation(s)
- M Kate Bundorf
- Stanford University School of Medicine, California, USA.
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Baker LC, Bundorf MK, Kessler DP. HMO coverage reduces variations in the use of health care among patients under age sixty-five. Health Aff (Millwood) 2011; 29:2068-74. [PMID: 21041750 DOI: 10.1377/hlthaff.2009.0810] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Variation in the use of hospital and physician services among Medicare beneficiaries is well documented. However, less is known about the younger, commercially insured population. Using data from the Community Tracking Study to investigate this issue, we found significant variation in the use of both inpatient and outpatient services across twelve metropolitan areas. HMO insurance reduces, but does not eliminate, the extent of this variation. Our results suggest that health plan spending to better organize delivery systems and manage care may be efficient, and regulations that arbitrarily cap plans' spending on administration, such as minimum medical loss ratios, could undermine efforts to achieve better value in health care.
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Banks NK, Norian JM, Bundorf MK, Henne MB. Insurance mandates, embryo transfer, outcomes—the link is tenuous. Fertil Steril 2010; 94:2776-9. [DOI: 10.1016/j.fertnstert.2010.05.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 05/13/2010] [Accepted: 05/16/2010] [Indexed: 11/25/2022]
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Abstract
BACKGROUND The impact of choice on consumer decision making is controversial in US health policy. OBJECTIVE The authors' objective was to determine how choice set size influences decision making among Medicare beneficiaries choosing prescription drug plans. METHODS The authors randomly assigned members of an Internet-enabled panel age 65 and older to sets of prescription drug plans of varying sizes (2, 5, 10, and 16) and asked them to choose a plan. Respondents answered questions about the plan they chose, the choice set, and the decision process. The authors used ordered probit models to estimate the effect of choice set size on the study outcomes. RESULTS Both the benefits of choice, measured by whether the chosen plan is close to the ideal plan, and the costs, measured by whether the respondent found decision making difficult, increased with choice set size. Choice set size was not associated with the probability of enrolling in any plan. CONCLUSIONS Medicare beneficiaries face a tension between not wanting to choose from too many options and feeling happier with an outcome when they have more alternatives. Interventions that reduce cognitive costs when choice sets are large may make this program more attractive to beneficiaries.
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Affiliation(s)
- M Kate Bundorf
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA.
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Bhattacharya J, Bundorf MK. The incidence of the healthcare costs of obesity. J Health Econ 2009; 28:649-58. [PMID: 19433210 PMCID: PMC4224588 DOI: 10.1016/j.jhealeco.2009.02.009] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 02/06/2009] [Accepted: 02/13/2009] [Indexed: 05/15/2023]
Abstract
Who pays the healthcare costs associated with obesity? Among workers, this is largely a question of the incidence of the costs of employer-sponsored coverage. Using data from the National Longitudinal Survey of Youth and the Medical Expenditure Panel Survey, we find that the incremental healthcare costs associated with obesity are passed on to obese workers with employer-sponsored health insurance in the form of lower cash wages. Obese workers without employer-sponsored insurance do not have a wage offset relative to their non-obese counterparts. A substantial part of the lower wages among obese women attributed to labor market discrimination can be explained by their higher health insurance premiums.
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Bundorf MK, Chun N, Goda GS, Kessler DP. Do markets respond to quality information? The case of fertility clinics. J Health Econ 2009; 28:718-727. [PMID: 19328568 DOI: 10.1016/j.jhealeco.2009.01.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2008] [Revised: 12/20/2008] [Accepted: 01/08/2009] [Indexed: 05/27/2023]
Abstract
Although policymakers have increasingly turned to provider report cards as a tool to improve health care quality, existing studies provide mixed evidence on whether they influence consumer choices. We examine the effects of providing consumers with quality information in the context of fertility clinics providing Assisted Reproductive Therapies (ART). We report three main findings. First, clinics with higher birth rates had larger market shares after the adoption of report cards relative to before. Second, clinics with a disproportionate share of young, relatively easy-to-treat patients had lower market shares after adoption versus before. This suggests that consumers take into account information on patient mix when evaluating clinic outcomes. Third, report cards had larger effects on consumers and clinics from states with ART insurance coverage mandates. We conclude that consumers respond to quality report cards when choosing among providers of ART.
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Affiliation(s)
- M Kate Bundorf
- Stanford University and NBER, HRP Redwood Building, Stanford, CA 94305-5405, United States.
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