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Thornhill MH, Gibson TB, Yoon F, Dayer MJ, Prendergast BD, Lockhart PB, O'Gara PT, Baddour LM. Endocarditis, invasive dental procedures, and antibiotic prophylaxis efficacy in US Medicaid patients. Oral Dis 2023. [PMID: 37103475 DOI: 10.1111/odi.14585] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE Antibiotic prophylaxis is recommended before invasive dental procedures to prevent endocarditis in those at high risk, but supporting data are sparse. We therefore investigated any association between invasive dental procedures and endocarditis, and any antibiotic prophylaxis effect on endocarditis incidence. SUBJECTS AND METHODS Cohort and case-crossover studies were performed on 1,678,190 Medicaid patients with linked medical, dental, and prescription data. RESULTS The cohort study identified increased endocarditis incidence within 30 days of invasive dental procedures in those at high risk, particularly after extractions (OR 14.17, 95% CI 5.40-52.11, p < 0.0001) or oral surgery (OR 29.98, 95% CI 9.62-119.34, p < 0.0001). Furthermore, antibiotic prophylaxis significantly reduced endocarditis incidence following invasive dental procedures (OR 0.20, 95% CI 0.06-0.53, p < 0.0001). Case-crossover analysis confirmed the association between invasive dental procedures and endocarditis in those at high risk, particularly following extractions (OR 3.74, 95% CI 2.65-5.27, p < 0.005) and oral surgery (OR 10.66, 95% CI 5.18-21.92, p < 0.0001). The number of invasive procedures, extractions, or surgical procedures needing antibiotic prophylaxis to prevent one endocarditis case was 244, 143 and 71, respectively. CONCLUSIONS Invasive dental procedures (particularly extractions and oral surgery) were significantly associated with endocarditis in high-risk individuals, but AP significantly reduced endocarditis incidence following these procedures, thereby supporting current guideline recommendations.
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Affiliation(s)
- Martin H Thornhill
- Unit of Oral & Maxillofacial Medicine, Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
- Department Oral Medicine/Oral & Maxillofacial Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | | | - Frank Yoon
- IBM Watson Health, Ann Arbor, Michigan, USA
| | - Mark J Dayer
- Department of Cardiology, Somerset Foundation Trust, Taunton, UK
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Peter B Lockhart
- Department Oral Medicine/Oral & Maxillofacial Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Patrick T O'Gara
- Cardiovascular Medicine Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Departments of Medicine and Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Thornhill MH, Gibson TB, Yoon F, Dayer MJ, Prendergast BD, Lockhart PB, O'Gara PT, Baddour LM. RE: Maxillofacial Surgeons Beware: Some AHA 'Moderate Risk' Patients Develop Endocarditis After Exodontia. J Oral Maxillofac Surg 2023; 81:132-133. [PMID: 36737171 DOI: 10.1016/j.joms.2022.11.014] [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: 11/19/2022] [Accepted: 11/20/2022] [Indexed: 02/04/2023]
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Thornhill MH, Gibson TB, Pack C, Rosario BL, Bloemers S, Lockhart PB, Springer B, Baddour LM. Quantifying the risk of prosthetic joint infections after invasive dental procedures and the effect of antibiotic prophylaxis. J Am Dent Assoc 2023; 154:43-52.e12. [PMID: 36470690 DOI: 10.1016/j.adaj.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/02/2022] [Accepted: 10/03/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Dentists face the expectations of orthopedic surgeons and patients with prosthetic joints to provide antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to reduce the risk of late periprosthetic joint infections (LPJIs), despite the lack of evidence associating IDPs with LPJIs, lack of evidence of AP efficacy, risk of AP-related adverse reactions, and potential for promoting antibiotic resistance. The authors aimed to identify any association between IDPs and LPJIs and whether AP reduces LPJI incidence after IDPs. METHOD The authors performed a case-crossover analysis comparing IDP incidence in the 3 months immediately before LPJI hospital admission (case period) with the preceding 12-month control period for all LPJI hospital admissions with commercial or Medicare supplemental or Medicaid health care coverage and linked dental and prescription benefits data. RESULTS Overall, 2,344 LPJI hospital admissions with dental and prescription records (n = 1,160 commercial or Medicare supplemental and n = 1,184 Medicaid) were identified. Patients underwent 4,614 dental procedures in the 15 months before LPJI admission, including 1,821 IDPs (of which 18.3% had AP). Our analysis identified no significant positive association between IDPs and subsequent development of LPJIs and no significant effect of AP in reducing LPJIs. CONCLUSIONS The authors identified no significant association between IDPs and LPJIs and no effect of AP cover of IDPs in reducing the risk of LPJIs. PRACTICAL IMPLICATIONS In the absence of benefit, the continued use of AP poses an unnecessary risk to patients from adverse drug reactions and to society from the potential of AP to promote development of antibiotic resistance. Dental AP use to prevent LPJIs should, therefore, cease.
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Livingston NA, Davenport M, Head M, Henke R, LeBeau LS, Gibson TB, Banducci AN, Sarpong A, Jayanthi S, Roth C, Camacho-Cook J, Meng F, Hyde J, Mulvaney-Day N, White M, Chen DC, Stein MD, Weisberg R. The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): A nationwide Veterans Health Administration cohort study. Drug Alcohol Depend 2022; 241:109678. [PMID: 36368167 PMCID: PMC9624112 DOI: 10.1016/j.drugalcdep.2022.109678] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/16/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD). METHODS Using VHA's nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year. RESULTS Veterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years. We observed important disparities across Veteran demographics. CONCLUSION Receipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions.
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Affiliation(s)
- Nicholas A. Livingston
- National Center for PTSD, Behavioral Sciences Division, VA Boston Healthcare System, Boston, MA, USA,US Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA,Correspondence to: National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
| | - Michael Davenport
- Data Science Core, Boston CSPCC, VA Boston Healthcare System, Boston, MA, USA
| | | | | | | | | | - Anne N. Banducci
- US Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA,National Center for PTSD, Women’s Health Sciences Division, VA Boston Healthcare System, Boston, MA, USA
| | | | | | - Clara Roth
- Boston VA Research Institute, Boston, MA, USA
| | | | - Frank Meng
- Data Science Core, Boston CSPCC, VA Boston Healthcare System, Boston, MA, USA,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Justeen Hyde
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, US Department of Veterans Affairs, Bedford, MA, USA,General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Norah Mulvaney-Day
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | | | - Daniel C. Chen
- Data Science Core, Boston CSPCC, VA Boston Healthcare System, Boston, MA, USA,General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Michael D. Stein
- Health Law, Policy & Management, Boston University School of Public Health, MA, USA
| | - Risa Weisberg
- US Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA,Department of Family Medicine, Alpert Medical School of Brown University, Providence, RI, USA,BehaVR, Inc, Elizabethtown, KY, USA
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Gibson TB. A dynamic analysis of medication adherence. J Manag Care Spec Pharm 2022; 28:1392-1399. [PMID: 36427339 PMCID: PMC10372951 DOI: 10.18553/jmcp.2022.28.12.1392] [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: 11/27/2022]
Abstract
BACKGROUND: Medication adherence is an important factor in maintaining and improving health, although adherence levels are often suboptimal. Previous studies have highlighted the importance of prior adherence behavior in understanding future adherence behaviors. OBJECTIVE: To improve understanding of adherence behavior and analyze the role of previous adherence in estimating the likelihood of future adherence for maintenance medications. METHODS: The adherence behaviors of 53,709 continuously enrolled individuals in employer-sponsored health plans were analyzed using a state-dependence framework (ie, adherence patterns in the past influence adherence in the future). This allowed for the estimation of the extent of carryover in adherence from one quarter to another while adjusting for observed and unobserved heterogeneity and enrollee characteristics. The role of the initial observation of adherence on the likelihood of future adherence was also analyzed. This study focuses on enrollee cohorts who filled prescriptions in 3 maintenance medication classes: lipid-lowering medications, antihypertensive medications, and oral antidiabetes medications. RESULTS: If an enrollee was adherent in the previous quarter, more than 80% of the time they remained adherent in the current quarter. Similarly, if they were nonadherent in the previous quarter, more than 75% of the time they remained nonadherent. Marginal effect estimates for prior adherence (previous quarter and initial quarter) showed increases in predicted adherence when adherent in the previous quarter (8.7 percentage points [pp] [95% CI = 8.0-9.3 pp] for lipid-lowering medications) and when adherent in the initial quarter (14.4 pp [13.8-15.1 pp] for lipid-lowering medications). Adherence in the initial and previous quarter increased predicted adherence considerably (22.7 pp [22.1-23.3 pp]). Similar patterns held for the antihypertensive medication cohort (antihypertensive medications) and the oral antidiabetes medication cohort (oral antidiabetes medications). The area under the curve (AUC) showed considerable improvement when moving from pooled probit models to dynamic random-effects probit models. AUC for the dynamic models exceeded 0.85 in the 3 medication cohorts, whereas the pooled probit models remained under 0.7. CONCLUSIONS: Adherence in the previous quarter is associated with adherence in the current quarter, after accounting for sources of observable and unobservable heterogeneity across enrollees. In addition, the initial value of adherence matters when explaining the likelihood of adherence.
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Affiliation(s)
- Teresa B Gibson
- IBM Watson Health, IBM, Rochester, NY (at the time of study conduct), and School of Mathematical Sciences, Rochester Institute of Technology, NY
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6
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Thornhill MH, Gibson TB, Yoon F, Dayer MJ, Prendergast BD, Lockhart PB, O'Gara PT, Baddour LM. Antibiotic Prophylaxis Against Infective Endocarditis Before Invasive Dental Procedures. J Am Coll Cardiol 2022; 80:1029-1041. [PMID: 35987887 DOI: 10.1016/j.jacc.2022.06.030] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) is recommended to prevent infective endocarditis (IE) in those at high IE risk, but there are sparse data supporting a link between IDPs and IE or AP efficacy in IE prevention. OBJECTIVES The purpose of this study was to investigate any association between IDPs and IE, and the effectiveness of AP in reducing this. METHODS We performed a case-crossover analysis and cohort study of the association between IDPs and IE, and AP efficacy, in 7,951,972 U.S. subjects with employer-provided Commercial/Medicare-Supplemental coverage. RESULTS Time course studies showed that IE was most likely to occur within 4 weeks of an IDP. For those at high IE risk, case-crossover analysis demonstrated a significant temporal association between IE and IDPs in the preceding 4 weeks (OR: 2.00; 95% CI: 1.59-2.52; P = 0.002). This relationship was strongest for dental extractions (OR: 11.08; 95% CI: 7.34-16.74; P < 0.0001) and oral-surgical procedures (OR: 50.77; 95% CI: 20.79-123.98; P < 0.0001). AP was associated with a significant reduction in IE incidence following IDP (OR: 0.49; 95% CI: 0.29-0.85; P = 0.01). The cohort study confirmed the associations between IE and extractions or oral surgical procedures in those at high IE risk and the effect of AP in reducing these associations (extractions: OR: 0.13; 95% CI: 0.03-0.34; P < 0.0001; oral surgical procedures: OR: 0.09; 95% CI: 0.01-0.35; P = 0.002). CONCLUSIONS We demonstrated a significant temporal association between IDPs (particularly extractions and oral-surgical procedures) and subsequent IE in high-IE-risk individuals, and a significant association between AP use and reduced IE incidence following these procedures. These data support the American Heart Association, and other, recommendations that those at high IE risk should receive AP before IDP.
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Affiliation(s)
- Martin H Thornhill
- Unit of Oral and Maxillofacial Medicine Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, United Kingdom; Department of Oral Medicine, Carolinas Medical Center-Atrium Health, Charlotte, North Carolina, USA.
| | | | - Frank Yoon
- IBM Watson Health, Ann Arbor, Michigan, USA
| | - Mark J Dayer
- Department of Cardiology, Somerset Foundation Trust, Taunton, Somerset, United Kingdom
| | | | - Peter B Lockhart
- Department of Oral Medicine, Carolinas Medical Center-Atrium Health, Charlotte, North Carolina, USA
| | - Patrick T O'Gara
- Cardiovascular Medicine Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Henke RM, Fingar KR, Jiang HJ, Liang L, Gibson TB. Access To Obstetric, Behavioral Health, And Surgical Inpatient Services After Hospital Mergers In Rural Areas. Health Aff (Millwood) 2021; 40:1627-1636. [PMID: 34606343 DOI: 10.1377/hlthaff.2021.00160] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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
Despite rural hospitals' central role in their communities, they are increasingly in financial distress and may merge with other hospitals or health systems, potentially reducing service lines that are less profitable or duplicative of services that the acquirer also offers. Using hospital discharge data from thirty-two Healthcare Cost and Utilization Project State Inpatient Databases from the period 2007-18, we examined the influence of rural hospital mergers on changes to inpatient service lines at hospitals and within their catchment areas. We found that merged hospitals were more likely than independent hospitals to eliminate maternal/neonatal and surgical care. Whereas the number of mental/substance use disorder-related stays decreased or remained stable at merged hospitals and within their catchment areas, it increased for unaffiliated hospitals and their catchment areas, indicating a potential unmet need in the communities of rural hospitals postmerger. Although a merger could salvage a hospital's sustainability, it also could reduce service lines and responsiveness to community needs.
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Affiliation(s)
- Rachel Mosher Henke
- Rachel Mosher Henke is a senior director at IBM Watson Health in Cambridge, Massachusetts
| | - Kathryn R Fingar
- Kathryn R. Fingar is a research manager at IBM Watson Health in Sacramento, California
| | - H Joanna Jiang
- H. Joanna Jiang is a senior social scientist in the Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality (AHRQ), in Rockville, Maryland
| | - Lan Liang
- Lan Liang is a senior economist in the Center for Financing, Access, and Cost Trends, AHRQ
| | - Teresa B Gibson
- Teresa B. Gibson is a senior director at IBM Watson Health in Rochester, New York
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Gibson TB, Nguyen MD, Burrell T, Yoon F, Wong J, Dharmarajan S, Ouellet-Hellstrom R, Hua W, Ma Y, Baro E, Bloemers S, Pack C, Kennedy A, Toh S, Ball R. Electronic phenotyping of health outcomes of interest using a linked claims-electronic health record database: Findings from a machine learning pilot project. J Am Med Inform Assoc 2021; 28:1507-1517. [PMID: 33712852 DOI: 10.1093/jamia/ocab036] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 10/20/2020] [Accepted: 02/19/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Claims-based algorithms are used in the Food and Drug Administration Sentinel Active Risk Identification and Analysis System to identify occurrences of health outcomes of interest (HOIs) for medical product safety assessment. This project aimed to apply machine learning classification techniques to demonstrate the feasibility of developing a claims-based algorithm to predict an HOI in structured electronic health record (EHR) data. MATERIALS AND METHODS We used the 2015-2019 IBM MarketScan Explorys Claims-EMR Data Set, linking administrative claims and EHR data at the patient level. We focused on a single HOI, rhabdomyolysis, defined by EHR laboratory test results. Using claims-based predictors, we applied machine learning techniques to predict the HOI: logistic regression, LASSO (least absolute shrinkage and selection operator), random forests, support vector machines, artificial neural nets, and an ensemble method (Super Learner). RESULTS The study cohort included 32 956 patients and 39 499 encounters. Model performance (positive predictive value [PPV], sensitivity, specificity, area under the receiver-operating characteristic curve) varied considerably across techniques. The area under the receiver-operating characteristic curve exceeded 0.80 in most model variations. DISCUSSION For the main Food and Drug Administration use case of assessing risk of rhabdomyolysis after drug use, a model with a high PPV is typically preferred. The Super Learner ensemble model without adjustment for class imbalance achieved a PPV of 75.6%, substantially better than a previously used human expert-developed model (PPV = 44.0%). CONCLUSIONS It is feasible to use machine learning methods to predict an EHR-derived HOI with claims-based predictors. Modeling strategies can be adapted for intended uses, including surveillance, identification of cases for chart review, and outcomes research.
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Affiliation(s)
- Teresa B Gibson
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | | | - Timothy Burrell
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | - Frank Yoon
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | - Jenna Wong
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Sai Dharmarajan
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rita Ouellet-Hellstrom
- Division of Epidemiology II, Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Wei Hua
- Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yong Ma
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elande Baro
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Sarah Bloemers
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | - Cory Pack
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | - Adee Kennedy
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Sengwee Toh
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Ball
- Office of Surveillance and Epidemiology Center for Drug Evaluation and Research U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Young JC, Pack C, Gibson TB, Yoon F, Irwin DE, Shiv S, Cooper T, Dasgupta N. Machine Learning Can Unlock Insights Into Mortality. Am J Public Health 2021; 111:S65-S68. [PMID: 34314195 DOI: 10.2105/ajph.2021.306418] [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] [Indexed: 11/04/2022]
Affiliation(s)
- Jessica C Young
- Jessica C. Young is with the Cecil. G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Cory Pack, Teresa B. Gibson, Frank Yoon, Debra E. Irwin, and Shalu Shiv are with IBM Watson Health, Bethesda, MD. Toska Cooper and Nabarun Dasgupta are with the Injury Prevention Research Center, University of North Carolina, Chapel Hill
| | - Cory Pack
- Jessica C. Young is with the Cecil. G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Cory Pack, Teresa B. Gibson, Frank Yoon, Debra E. Irwin, and Shalu Shiv are with IBM Watson Health, Bethesda, MD. Toska Cooper and Nabarun Dasgupta are with the Injury Prevention Research Center, University of North Carolina, Chapel Hill
| | - Teresa B Gibson
- Jessica C. Young is with the Cecil. G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Cory Pack, Teresa B. Gibson, Frank Yoon, Debra E. Irwin, and Shalu Shiv are with IBM Watson Health, Bethesda, MD. Toska Cooper and Nabarun Dasgupta are with the Injury Prevention Research Center, University of North Carolina, Chapel Hill
| | - Frank Yoon
- Jessica C. Young is with the Cecil. G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Cory Pack, Teresa B. Gibson, Frank Yoon, Debra E. Irwin, and Shalu Shiv are with IBM Watson Health, Bethesda, MD. Toska Cooper and Nabarun Dasgupta are with the Injury Prevention Research Center, University of North Carolina, Chapel Hill
| | - Debra E Irwin
- Jessica C. Young is with the Cecil. G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Cory Pack, Teresa B. Gibson, Frank Yoon, Debra E. Irwin, and Shalu Shiv are with IBM Watson Health, Bethesda, MD. Toska Cooper and Nabarun Dasgupta are with the Injury Prevention Research Center, University of North Carolina, Chapel Hill
| | - Shalu Shiv
- Jessica C. Young is with the Cecil. G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Cory Pack, Teresa B. Gibson, Frank Yoon, Debra E. Irwin, and Shalu Shiv are with IBM Watson Health, Bethesda, MD. Toska Cooper and Nabarun Dasgupta are with the Injury Prevention Research Center, University of North Carolina, Chapel Hill
| | - Toska Cooper
- Jessica C. Young is with the Cecil. G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Cory Pack, Teresa B. Gibson, Frank Yoon, Debra E. Irwin, and Shalu Shiv are with IBM Watson Health, Bethesda, MD. Toska Cooper and Nabarun Dasgupta are with the Injury Prevention Research Center, University of North Carolina, Chapel Hill
| | - Nabarun Dasgupta
- Jessica C. Young is with the Cecil. G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Cory Pack, Teresa B. Gibson, Frank Yoon, Debra E. Irwin, and Shalu Shiv are with IBM Watson Health, Bethesda, MD. Toska Cooper and Nabarun Dasgupta are with the Injury Prevention Research Center, University of North Carolina, Chapel Hill
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Thornhill MH, Gibson TB, Durkin MJ, Dayer MJ, Lockhart PB, O'Gara PT, Baddour LM. Prescribing of antibiotic prophylaxis to prevent infective endocarditis. J Am Dent Assoc 2020; 151:835-845.e31. [PMID: 33121605 DOI: 10.1016/j.adaj.2020.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND In 2007, the American Heart Association recommended that antibiotic prophylaxis (AP) be restricted to those at high risk of developing complications due to infective endocarditis (IE) undergoing invasive dental procedures. The authors aimed to estimate the appropriateness of AP prescribing according to type of dental procedure performed in patients at high risk, moderate risk, or low or unknown risk of developing IE complications. METHODS Eighty patients at high risk, 40 patients at moderate risk, and 40 patients at low or unknown risk of developing IE complications were randomly selected from patients with linked dental care, health care, and prescription benefits data in the IBM MarketScan Databases, one of the largest US health care convenience data samples. Two clinicians independently analyzed prescription and dental procedure data to determine whether AP prescribing was likely, possible, or unlikely for each dental visit. RESULTS In patients at high risk of developing IE complications, 64% were unlikely to have received AP for invasive dental procedures, and in 32 of 80 high-risk patients (40%) there was no evidence of AP for any dental visit. When AP was prescribed, several different strategies were used to provide coverage for multiple dental visits, including multiday courses, multidose prescriptions, and refills, which sometimes led to an oversupply of antibiotics. CONCLUSIONS AP prescribing practices were inconsistent, did not always meet the highest antibiotic stewardship standards, and made retrospective evaluation difficult. For those at high risk of developing IE complications, there appears to be a concerning level of underprescribing of AP for invasive dental procedures. PRACTICAL IMPLICATIONS Some dentists might be failing to fully comply with American Heart Association recommendations to provide AP cover for all invasive dental procedures in those at high risk of developing IE complications.
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11
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Gibson TB. Commentary on "Do physician incentives increase patient medication adherence?". Health Serv Res 2020; 55:500-502. [PMID: 32700384 PMCID: PMC7375994 DOI: 10.1111/1475-6773.13318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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McClellan C, Fingar KR, Ali MM, Olesiuk WJ, Mutter R, Gibson TB. Price elasticity of demand for buprenorphine/naloxone prescriptions. J Subst Abuse Treat 2019; 106:4-11. [PMID: 31540610 DOI: 10.1016/j.jsat.2019.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/17/2019] [Accepted: 08/06/2019] [Indexed: 12/22/2022]
Abstract
Although there have been supply-side efforts in response to the opioid crisis (e.g., prescription drug monitoring programs), little information exists on demand-side approaches related to patient cost sharing that may affect utilization of and adherence to pharmacotherapy by individuals with opioid use disorder. Among individuals who had initiated pharmacotherapy, we estimated the price elasticity of demand of prescription fills of buprenorphine/naloxone, a common pharmacotherapy drug, overall and by patient characteristics. Using the IBM MarketScan® Commercial Claims and Encounters Database for individuals with employer-sponsored private health insurance coverage, we examined the relationship between cost sharing and the number of buprenorphine/naloxone prescription fills using enrollee-level longitudinal fixed effects models. Cost sharing was expressed as a price index for each employer-plan. By including enrollee-level fixed effects, the identification of the effect of interest comes from longitudinal variation in prices across multiple time points for each enrollee. Overall, the demand for buprenorphine/naloxone was price inelastic (p = 0.191). However, some subgroups were responsive to price. A doubling of price was associated with a decrease in fills by 3.0% for enrollees aged 45-64 years (p = 0.029); 5.7% for those in rural areas (p = 0.033); 5.8% for residents of the South (p ≤0.001); and 3.0% for those enrolled in an HMO (p = 0.004). Insurers should consider the effects on these groups before increasing beneficiary out-of-pocket costs for pharmacotherapy and efforts to increase adherence should consider that price may be a barrier for some subgroups with OUD.
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Affiliation(s)
- Chandler McClellan
- Center for Financing, Access and Cost Trends, Agency for Health Care Research & Quality, United States of America
| | | | - Mir M Ali
- Office of the Assistant Secretary for Planning & Evaluation, US Department of Health & Human Services, 200 Independent Avenue SW, Washington DC 20202, United States of America.
| | | | - Ryan Mutter
- Health, Retirement and Long-Term Analysis Division, Congressional Budget Office, United States of America
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13
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Pickens G, Karaca Z, Gibson TB, Cutler E, Dworsky M, Moore B, Wong HS. Changes in hospital service demand, cost, and patient illness severity following health reform. Health Serv Res 2019; 54:739-751. [PMID: 31070263 DOI: 10.1111/1475-6773.13165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 01/11/2023] Open
Abstract
OBJECTIVE To estimate the effects of the health insurance exchange and Medicaid coverage expansions on hospital inpatient and emergency department (ED) utilization rates, cost, and patient illness severity, and also to test the association between changes in outcomes and the size of the uninsured population eligible for coverage in states. DATA SOURCES Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases, 2011-2015, Nielsen Demographic Data, and the American Community Survey. STUDY DESIGN Retrospective study using fixed-effects regression to estimate the effects in expansion and nonexpansion states by age/sex demographic groups. FINDINGS In Medicaid expansion states, rates of uninsured inpatient discharges and ED visits fell sharply in many demographic groups. For example, uninsured inpatient discharge rates across groups, except young females, decreased by ≥39 percent per capita on average in expansion states. In nonexpansion states, uninsured utilization rates remained unchanged or increased slightly (0-9.2 percent). Changes in all-payer and private insurance rates were more muted. Changes in inpatient costs per discharge were negative, and all-payer inpatient costs per discharge declined <6 percent in most age/sex groups. The size of the uninsured population eligible for coverage was strongly associated with changes in outcomes. For example, among males aged 35-54 years in expansion states, there was a 0.793 percent decrease in the uninsured discharge rate per unit increase in the coverage expansion ratio (the ratio of the size of the population eligible for coverage to the size of the previously covered population within an age/sex/payer/geographic group). CONCLUSIONS Significant shifts in cost per discharge and patient severity were consistent with selective take-up of insurance. The "treatment intensity" of expansions may be useful for anticipating future effects.
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Affiliation(s)
| | - Zeynal Karaca
- U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Eli Cutler
- Qventis (Formerly of IBM Watson Health), Mountain View, California
| | | | | | - Herbert S Wong
- U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Maryland
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Abstract
Some states have adopted Accountable Care Organization (ACO) models to transform their Medicaid programs, but little is known about their impact on health care outcomes and costs. Medicaid ACOs are uniquely positioned to improve childbirth outcomes because of the number of births covered by Medicaid. Using Healthcare Cost and Utilization Project hospital data, we examined the relationship between ACO adoption and (a) neonatal and maternal outcomes, and (b) cost per birth. We compared outcomes in states that have adopted ACO models in their Medicaid programs with adjacent states without ACO models. Implementation of Medicaid ACOs was associated with a moderate reduction in hospital costs per birth and decreased cesarean section rates. Results varied by state. We found no association between Medicaid ACOs and several birth outcomes, including infant inpatient mortality, low birthweight, neonatal intensive care unit utilization, and severe maternal morbidity. Improving these outcomes may require more time or targeted interventions.
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Affiliation(s)
| | - Zeynal Karaca
- Agency for Healthcare Research and Quality, Rockville, MD, USA
| | | | | | | | | | - Herb S Wong
- Agency for Healthcare Research and Quality, Rockville, MD, USA
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15
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Thornhill MH, Gibson TB, Cutler E, Dayer MJ, Chu VH, Lockhart PB, O'Gara PT, Baddour LM. Antibiotic Prophylaxis and Incidence of Endocarditis Before and After the 2007 AHA Recommendations. J Am Coll Cardiol 2018; 72:2443-2454. [PMID: 30409564 DOI: 10.1016/j.jacc.2018.08.2178] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The American Heart Association updated its recommendations for antibiotic prophylaxis (AP) to prevent infective endocarditis (IE) in 2007, advising that AP cease for those at moderate risk of IE, but continue for those at high risk. OBJECTIVES The authors sought to quantify any change in AP prescribing and IE incidence. METHODS High-risk, moderate-risk, and unknown/low-risk individuals with linked prescription and Medicare or commercial health care data were identified in the Truven Health MarketScan databases from May 2003 through August 2015 (198,522,665 enrollee-years of data). AP prescribing and IE incidence were evaluated by Poisson model analysis. RESULTS By August 2015, the 2007 recommendation change was associated with a significant 64% (95% confidence interval [CI]: 59% to 68%) estimated fall in AP prescribing for moderate-risk individuals and a 20% (95% CI: 4% to 32%) estimated fall for those at high risk. Over the same period, there was a barely significant 75% (95% CI: 3% to 200%) estimated increase in IE incidence among moderate-risk individuals and a significant 177% estimated increase (95% CI: 66% to 361%) among those at high risk. In unknown/low-risk individuals, there was a significant 52% (95% CI: 46% to 58%) estimated fall in AP prescribing, but no significant increase in IE incidence. CONCLUSIONS AP prescribing fell among all IE risk groups, particularly those at moderate risk. Concurrently, there was a significant increase in IE incidence among high-risk individuals, a borderline significant increase in moderate-risk individuals, and no change for those at low/unknown risk. Although these data do not establish a cause-effect relationship between AP reduction and IE increase, the fall in AP prescribing in those at high risk is of concern and, coupled with the borderline increase in IE incidence among those at moderate risk, warrants further investigation.
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Affiliation(s)
- Martin H Thornhill
- Unit of Oral & Maxillofacial Medicine Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, United Kingdom; Department of Oral Medicine, Carolinas Medical Center, Charlotte, North Carolina.
| | - Teresa B Gibson
- Truven Health Analytics/IBM Watson Health, Ann Arbor, Michigan
| | - Eli Cutler
- Truven Health Analytics/IBM Watson Health, Ann Arbor, Michigan
| | - Mark J Dayer
- Department of Cardiology, Taunton and Somerset NHS Trust, Taunton, Somerset, United Kingdom
| | - Vivian H Chu
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina
| | - Peter B Lockhart
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | - Patrick T O'Gara
- Cardiovascular Medicine Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
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16
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Wong H, Karaca Z, Gibson TB. A Quantitative Observational Study of Physician Influence on Hospital Costs. Inquiry 2018; 55:46958018800906. [PMID: 30264626 PMCID: PMC6166308 DOI: 10.1177/0046958018800906] [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
Physicians serve as the nexus of treatment decision-making in hospitalized
patients; however, little empirical evidence describes the influence of
individual physicians on hospital costs. In this study, we examine the extent to
which hospital costs vary across physicians and physician characteristics. We
used all-payer data from 2 states representing 15 237 physicians and 2.5 million
hospital visits. Regression analysis and propensity score matching were used to
understand the role of observable provider characteristics on hospital costs
controlling for patient demographics, socioeconomic characteristics, clinical
risk, and hospital characteristics. We used hierarchical models to estimate the
amount of variation attributable to physicians. We found that the average cost
of hospital inpatient stays registered to female physicians was consistently
lower across all empirical specifications when compared with male physicians. We
also found a negative association between physicians’ years of experience and
the average costs. The average cost of hospital inpatient stays registered to
foreign-trained physicians was lower than US-trained physicians. We observed
sizable variation in average costs of hospital inpatient stays across medical
specialties. In addition, we used hierarchical methods and estimated the amount
of remaining variation attributable to physicians and found that it was
nonnegligible (intraclass correlation coefficient [ICC]: 0.33 in the full
sample). Historically, most physicians have been reimbursed separately from
hospitals, and our study shows that physicians play a role in influencing
hospital costs. Future policies and practices should acknowledge these important
dependencies. This study lends further support for alignment of physician and
hospital incentives to control costs and improve outcomes.
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Affiliation(s)
- Herbert Wong
- 1 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Zeynal Karaca
- 1 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD, USA
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Huskamp HA, Samples H, Hadland SE, McGinty EE, Gibson TB, Goldman HH, Busch SH, Stuart EA, Barry CL. Mental Health Spending and Intensity of Service Use Among Individuals With Diagnoses of Eating Disorders Following Federal Parity. Psychiatr Serv 2018; 69:217-223. [PMID: 29137561 PMCID: PMC5794569 DOI: 10.1176/appi.ps.201600516] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The Mental Health Parity and Addiction Equity Act (MHPAEA) was intended to eliminate differences in insurance coverage for mental health and substance use disorder services and medical-surgical care. No studies have examined mental health service use after federal parity implementation among individuals with diagnoses of eating disorders, for whom financial access to care has often been limited. This study examined whether MHPAEA implementation was associated with changes in use of mental health services and spending in this population. METHODS Using Truven Health MarketScan data from 2007 to 2012, this study examined trends in mental health spending and intensity of use of specific mental health services (inpatient days, total outpatient visits, psychotherapy visits, and medication management visits) among individuals ages 13-64 with a diagnosis of an eating disorder (N=27,594). RESULTS MHPAEA implementation was associated with a small increase in total mental health spending ($1,271.92; p<.001) and no change in out-of-pocket spending ($112.99; p=.234) in the first year after enforcement of the parity law. The law's implementation was associated with an increased number of outpatient mental health visits among users, corresponding to an additional 5.8 visits on average during the first year (p<.001). This overall increase was driven by an increase in psychotherapy use of 2.9 additional visits annually among users (p<.001). CONCLUSIONS MHPAEA implementation was associated with increased intensity of outpatient mental health service use among individuals with diagnoses of eating disorders but no increase in out-of-pocket expenditures, suggesting improvements in financial protection.
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Affiliation(s)
- Haiden A Huskamp
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - Hillary Samples
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - Scott E Hadland
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - Emma E McGinty
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - Teresa B Gibson
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - Howard H Goldman
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - Susan H Busch
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - Elizabeth A Stuart
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - Colleen L Barry
- Dr. Huskamp is with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Gibson is with Truven Health Analytics Inc., Ann Arbor, Michigan. Dr. Samples is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York. Dr. McGinty, Dr. Stuart, and Dr. Barry are with the Department of Health Policy and Management and with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. Dr. Hadland is with the Department of Pediatrics, Boston University School of Medicine, and the Department of Medicine, Children's Hospital Boston, Boston. Dr. Goldman is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Dr. Busch is with the Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
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18
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McKellar MR, Landrum MB, Gibson TB, Landon BE, Fendrick AM, Chernew ME. Geographic Variation in Quality of Care for Commercially Insured Patients. Health Serv Res 2017; 52:849-862. [PMID: 27140721 PMCID: PMC5346491 DOI: 10.1111/1475-6773.12501] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Extensive evidence documents geographic variation in spending, but limited research assesses geographic variation in quality, particularly among commercially insured enrollees. OBJECTIVE To measure geographic variation in quality measures, correlation among measures, and correlation between measures and spending for commercially insured enrollees. DATA SOURCE Administrative claims from the 2007-2009 Truven MarketScan database. METHODS We calculated variation in, and correlations among, 10 quality measures across 306 Hospital Referral Regions (HRRs), adjusting for beneficiary traits and sample size differences. Further, we created a quality index and correlated it with spending. RESULTS The coefficient of variation of HRR-level performance ranged from 0.04 to 0.38. Correlations among quality measures generally ranged from 0.2 to 0.5. Quality was modestly positively related to spending. CONCLUSION Quality varied across HRRs and there was only a modest geographic "quality footprint."
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Affiliation(s)
| | | | | | - Bruce E. Landon
- Department of Health Care PolicyHarvard Medical SchoolBostonMA
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19
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Henke RM, Karaca Z, Gibson TB, Cutler E, Barrett ML, Levit K, Johann J, Nicholas LH, Wong HS. Medicare Advantage and Traditional Medicare Hospitalization Intensity and Readmissions. Med Care Res Rev 2017; 75:434-453. [PMID: 29148332 DOI: 10.1177/1077558717692103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 11/17/2022]
Abstract
Medicare Advantage plans have incentives and tools to optimize patient care. Therefore, Medicare Advantage hospitalizations may have lower cost and higher quality than similar traditional Medicare hospitalizations. We applied a coarsened matching approach to 2013 Healthcare Cost and Utilization Project hospital discharge data from 22 states to compare hospital cost, length of stay, and readmissions for Traditional Medicare and Medicare Advantage. We found that Medicare Advantage hospitalizations were substantially less expensive and shorter for mental health stays but costlier and longer for injury and surgical stays. We found little difference in the cost and length of medical stays and in readmission rates. One explanation is that Medicare Advantage plans use outpatient settings for many patients with behavioral health conditions and for injury and surgical patients with less complex health needs. Alternatively, the observed differences in behavioral health cost and length of stay may represent skimping on appropriate care.
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Affiliation(s)
| | - Zeynal Karaca
- 2 Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Teresa B Gibson
- 1 Truven Health Analytics, an IBM Company. Cambridge, MA, USA
| | - Eli Cutler
- 1 Truven Health Analytics, an IBM Company. Cambridge, MA, USA
| | | | - Katharine Levit
- 1 Truven Health Analytics, an IBM Company. Cambridge, MA, USA
| | - Jayne Johann
- 1 Truven Health Analytics, an IBM Company. Cambridge, MA, USA
| | | | - Herbert S Wong
- 2 Agency for Healthcare Research and Quality, Rockville, MD, USA
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20
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Stuart EA, McGinty EE, Kalb L, Huskamp HA, Busch SH, Gibson TB, Goldman H, Barry CL. Increased Service Use Among Children With Autism Spectrum Disorder Associated With Mental Health Parity Law. Health Aff (Millwood) 2017; 36:337-345. [PMID: 28167724 PMCID: PMC8320748 DOI: 10.1377/hlthaff.2016.0824] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [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: 11/05/2022]
Abstract
Health care services for children with autism spectrum disorder are often expensive and frequently not covered under private health insurance. The 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was viewed as a possible means of improving access by eliminating differences between behavioral health and medical/surgical benefits. We examined whether the legislation was associated with increased use of and spending on mental health care and functional services for children with autism spectrum disorder compared to the period prior to implementation of the law. We used nationwide health insurance commercial group claims data to examine trends in service use and spending among children with autism spectrum disorder before and after implementation of the law. For such children, implementation was associated with increased use of both mental health and non-mental health services. These increases in use were not associated with higher out-of-pocket spending, which suggests that the law improved financial protection for families.
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Affiliation(s)
- Elizabeth A Stuart
- Elizabeth A. Stuart is associate dean for education, a professor in the Departments of Mental Health, Biostatistics, and Health Policy and Management, and codirector of the Center for Mental Health and Addiction Policy Research, all at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Emma E McGinty
- Emma E. McGinty is an assistant professor in the Departments of Health Policy and Management and Mental Health and Core Faculty of the Center for Mental Health and Addiction Policy Research, Johns Hopkins Bloomberg School of Public Health
| | - Luther Kalb
- Luther Kalb is a doctoral student in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health
| | - Haiden A Huskamp
- Haiden A. Huskamp is a professor of health care policy at Harvard Medical School, in Boston, Massachusetts
| | - Susan H Busch
- Susan H. Busch is a professor of public health and chair of the Department of Health Policy and Management, Yale University School of Public Health, in New Haven, Connecticut
| | - Teresa B Gibson
- Teresa B. Gibson is senior director at Truven Health Analytics in Ann Arbor, Michigan
| | - Howard Goldman
- Howard Goldman is a professor in the Department of Psychiatry, University of Maryland School of Medicine, in Baltimore
| | - Colleen L Barry
- Colleen L. Barry is the Fred and Julie Soper Professor and chair of the Department of Health Policy and Management and codirector of the Center for Mental Health and Addiction Policy Research, Johns Hopkins Bloomberg School of Public Health
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21
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Sherman BW, Gibson TB, Lynch WD, Addy C. Health Care Use And Spending Patterns Vary By Wage Level In Employer-Sponsored Plans. Health Aff (Millwood) 2017; 36:250-257. [DOI: 10.1377/hlthaff.2016.1147] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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)
- Bruce W. Sherman
- Bruce W. Sherman ( ) is the medical director, population health management at Conduent HR Services, and an assistant clinical professor of medicine at the Case Western Reserve University School of Medicine, both in Cleveland, Ohio
| | - Teresa B. Gibson
- Teresa B. Gibson is senior director of Health Outcomes Research at Truven Health Analytics in Ann Arbor, Michigan
| | - Wendy D. Lynch
- Wendy D. Lynch is the founder of Lynch Consulting Ltd., in Steamboat Springs, Colorado
| | - Carol Addy
- Carol Addy is chief medical officer at HMR Weight Management Services Corp. (a subsidiary of Merck and Company), in Boston, Massachusetts
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22
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McGinty EE, Busch SH, Stuart EA, Huskamp HA, Gibson TB, Goldman HH, Barry CL. Federal parity law associated with increased probability of using out-of-network substance use disorder treatment services. Health Aff (Millwood) 2017; 34:1331-9. [PMID: 26240247 DOI: 10.1377/hlthaff.2014.1384] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [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
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires commercial insurers providing group coverage for substance use disorder services to offer benefits for those services at a level equal to those for medical or surgical benefits. Unlike previous parity policies instituted for federal employees and in individual states, the law extends parity to out-of-network services. We conducted an interrupted time-series analysis using insurance claims from large self-insured employers to evaluate whether federal parity was associated with changes in out-of-network treatment for 525,620 users of substance use disorder services. Federal parity was associated with an increased probability of using out-of-network services, an increased average number of out-of-network outpatient visits, and increased average total spending on out-of-network services among users of those services. Our findings were broadly consistent with the contention of federal parity proponents that extending parity to out-of-network services would broaden access to substance use disorder care obtained outside of plan networks.
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Affiliation(s)
- Emma E McGinty
- Emma E. McGinty is an assistant professor of health policy and management and of mental health at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Susan H Busch
- Susan H. Busch is a professor of health policy at Yale School of Public Health, in New Haven, Connecticut
| | - Elizabeth A Stuart
- Elizabeth A. Stuart is a professor of mental health, biostatistics, and health policy and management at the Johns Hopkins Bloomberg School of Public Health
| | - Haiden A Huskamp
- Haiden A. Huskamp is a professor of health care policy at Harvard Medical School, in Boston, Massachusetts
| | - Teresa B Gibson
- Teresa B. Gibson is a faculty research associate of health care policy at Harvard Medical School and a senior research scientist at the Arbor Research Collaborative for Health, in Ann Arbor, Michigan
| | - Howard H Goldman
- Howard H. Goldman is a professor of psychiatry at the University of Maryland School of Medicine, in Baltimore
| | - Colleen L Barry
- Colleen L. Barry is an associate professor of health policy and management and of mental health at the Johns Hopkins Bloomberg School of Public Health
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Hirth RA, Cliff EQ, Gibson TB, McKellar MR, Fendrick AM. Connecticut’s Value-Based Insurance Plan Increased The Use Of Targeted Services And Medication Adherence. Health Aff (Millwood) 2016; 35:637-46. [DOI: 10.1377/hlthaff.2015.1371] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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)
- Richard A. Hirth
- Richard A. Hirth ( ) is a professor in the Department of Health Management and Policy at the University of Michigan, in Ann Arbor
| | - Elizabeth Q. Cliff
- Elizabeth Q. Cliff is a PhD candidate in the Department of Health Management and Policy at the University of Michigan
| | - Teresa B. Gibson
- Teresa B. Gibson is a senior director of health outcomes research at Truven Health Analytics, in Ann Arbor
| | - M. Richard McKellar
- M. Richard McKellar is a research consultant for the Department of Health Management and Policy at the University of Michigan
| | - A. Mark Fendrick
- A. Mark Fendrick is a professor in the Departments of Internal Medicine and Health Management and Policy at the University of Michigan
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Martsolf GR, Gibson TB, Benevent R, Jiang HJ, Stocks C, Ehrlich ED, Kandrack R, Auerbach DI. An Examination of Hospital Nurse Staffing and Patient Experience with Care: Differences between Cross-Sectional and Longitudinal Estimates. Health Serv Res 2016; 51:2221-2241. [PMID: 26898946 DOI: 10.1111/1475-6773.12462] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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: 01/07/2023] Open
Abstract
OBJECTIVE To study the association between hospital nurse staffing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. DATA SOURCES State hospital financial and utilization reports, Healthcare Cost and Utilization Project State Inpatient Databases, HCAHPS survey, and American Hospital Association Annual Survey of Hospitals. STUDY DESIGN Retrospective study using cross-sectional and longitudinal models to estimate the effect of nurse staffing levels and skill mix on seven HCAHPS measures. DATA COLLECTION/EXTRACTION METHODS Hospital-level data measuring nurse staffing, patient experience, and hospital characteristics from 2009 to 2011 for 341 hospitals (977 hospital years) in California, Maryland, and Nevada. PRINCIPAL FINDINGS Nurse staffing level (i.e., number of licensed practical nurses and registered nurses per 1,000 inpatient days) was significantly and positively associated with all seven HCAHPS measures in cross-sectional models and three of seven measures in longitudinal models. Nursing skill mix (i.e., percentage of all staff who are registered nurses) was significantly and negatively associated with scores on one measure in cross-sectional models and none in longitudinal models. CONCLUSIONS After controlling for unobserved hospital characteristics, the positive influences of increased nurse staffing levels and skill mix were relatively small in size and limited to a few measures of patients' inpatient experience.
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Affiliation(s)
| | - Teresa B Gibson
- Health Outcomes Research, Truven Health Analytics, Ann Arbor, MI
| | - Richele Benevent
- Health Outcomes Research, Truven Health Analytics, Santa Barbara, CA
| | - H Joanna Jiang
- Center for Delivery, Organization and Markets, Agency for Healthcare Research and Quality, Rockville, MD
| | - Carol Stocks
- Center for Delivery, Organization and Markets, Agency for Healthcare Research and Quality, Rockville, MD
| | - Emily D Ehrlich
- Health Research Division, Mathematica Policy Research, Ann Arbor, MI
| | | | - David I Auerbach
- Center for Interdisciplinary Health Workforce Studies at Montana State University, Bozeman, MT
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Hirth RA, Gibson TB, Levy HG, Smith JA, Calónico S, Das A. New evidence on the persistence of health spending. Med Care Res Rev 2015; 72:277-97. [PMID: 25701579 DOI: 10.1177/1077558715572387] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 02/19/2014] [Accepted: 01/09/2015] [Indexed: 11/17/2022]
Abstract
Surprisingly little is known about long-term spending patterns in the under-65 population. Such information could inform efforts to improve coverage and control costs. Using the MarketScan claims database, we characterize the persistence of health care spending in the privately insured, under-65 population. Over a 6-year period, 69.8% of enrollees never had annual spending in the top 10% of the distribution and the bottom 50% of spenders accounted for less than 10% of spending. Those in the top 10% in 2003 were almost as likely (34.4%) to be in the top 10% five years later as one year later (43.4%). Many comorbid conditions retained much of their predictive power even 5 years later. The persistence at both ends of the spending distribution indicates the potential for adverse selection and cream skimming and supports the use of disease management, particularly for those with the conditions that remained strong predictors of high spending throughout the follow-up period.
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Affiliation(s)
| | | | | | | | | | - Anup Das
- University of Michigan, Ann Arbor, MI, USA
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Abstract
IMPORTANCE In 2009, Washington State enacted legislation outlining the medical care of children and adolescents with concussion (ie, the Lystedt Law), with all other states and Washington, DC passing legislation by January 2014. OBJECTIVE To evaluate the effect of concussion laws on health care utilization rates from January 1, 2006, through June 30, 2012, in states with and without legislation. DESIGN, SETTING, AND PARTICIPANTS For commercially insured children aged 12 to 18 years from all 50 states and DC from January 1, 2006, through June 30, 2009, we examined the following: (1) prelegislation trends in concussion-related health care utilization from January 1, 2006, through June 30, 2009, (2) postlegislation trends in states without concussion legislation, and (3) the effect of state concussion laws on trends in states with concussion legislation in effect by means of negative binomial multivariable estimation with state and time fixed effects. EXPOSURES Concussion diagnosis. MAIN OUTCOMES AND MEASURES Emergency department and related health care utilization rates for concussion. RESULTS Between academic school years 2008-2009 and 2011-2012, states with legislation experienced a 92% increase in concussion-related health care utilization, while states without legislation had a 75% overall increase in concussion-related health care utilization during the same period. In the multivariable fixed-effects models, controlling for differences across states, rates of treated concussion in states without legislation were 7% higher in the 2009-2010 school year, 20% higher in the 2010-2011 school year, and 34% higher in the 2011-2012 school year compared with the prelegislation trends (2005-2009) (all P < .01). During the same period, states with concussion laws demonstrated a 10% higher concussion-related health care utilization rate compared with states without laws (P < .01). CONCLUSIONS AND RELEVANCE Increased health care utilization rates among children with concussion in the United States are both directly and indirectly related to concussion legislation. A portion of the increased rates (60%) in states without legislation is attributable to an ongoing upward trend demonstrated before enactment of the first state law in 2009. The remaining 40% increase in these states is thought to have resulted from elevated awareness brought about by heightened local and national media attention. Concussion legislation has had a seemingly positive effect on health care utilization, but the overall increase can also be attributed to increased injury awareness.
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Affiliation(s)
- Teresa B Gibson
- Truven Health Analytics and Health Care Policy, Harvard Medical School, Ann Arbor, Michigan
| | - Stanley A Herring
- Department of Rehabilitation Medicine, University of Washington, Seattle3Department of Orthopaedics and Sports Medicine, University of Washington, Seattle4Department of Neurological Surgery, University of Washington, Seattle
| | - Jeffrey S Kutcher
- Department of Neurology, Michigan NeuroSport, University of Michigan, Ann Arbor
| | - Steven P Broglio
- School of Kinesiology, Michigan NeuroSport, Michigan Injury Center, University of Michigan, Ann Arbor
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Gibson TB, Maclean RJ, Chernew ME, Fendrick AM, Baigel C. Value-based insurance design: benefits beyond cost and utilization. Am J Manag Care 2015; 21:32-35. [PMID: 25880148] [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: 06/04/2023]
Abstract
As value-based insurance design (VBID) programs proliferate, evidence is emerging on the impact of VBID. To date, studies have largely measured VBID impact on utilization, and a few studies have assessed its impact on quality, outcomes, and cost. In this commentary we discuss these domains, summarize evidence, and propose the extension of measurement of VBID impact into areas including workplace productivity and quality of life, employee and patient engagement, and talent attraction and retention. We contend that VBID evaluations should consider a broad variety of programmatic dividends on both humanistic and health-related outcomes.
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Affiliation(s)
- Teresa B Gibson
- Harvard Medical School, 180 Longwood Ave, Boston, MA 02135. E-mail:
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Gatwood J, Gibson TB, Chernew ME, Farr AM, Vogtmann E, Fendrick AM. Price elasticity and medication use: cost sharing across multiple clinical conditions. J Manag Care Spec Pharm 2014; 20:1102-7. [PMID: 25351971 PMCID: PMC10441015 DOI: 10.18553/jmcp.2014.20.11.1102] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To address the impact that out-of-pocket prices may have on medication use, it is vital to understand how the demand for medications may be affected when patients are faced with changes in the price to acquire treatment and how price responsiveness differs across medication classes. OBJECTIVE To examine the impact of cost-sharing changes on the demand for 8 classes of prescription medications. METHODS This was a retrospective database analysis of 11,550,363 commercially insured enrollees within the 2005-2009 MarketScan Database. Patient cost sharing, expressed as a price index for each medication class, was the main explanatory variable to examine the price elasticity of demand. Negative binomial fixed effect models were estimated to examine medication fills. The elasticity estimates reflect how use changes over time as a function of changes in copayments. RESULTS Model estimates revealed that price elasticity of demand ranged from -0.015 to -0.157 within the 8 categories of medications (P less than 0.01 for 7 of 8 categories). The price elasticity of demand for smoking deterrents was largest (-0.157, P less than 0.0001), while demand for antiplatelet agents was not responsive to price (P greater than 0.05). CONCLUSIONS The price elasticity of demand varied considerably by medication class, suggesting that the influence of cost sharing on medication use may be related to characteristics inherent to each medication class or underlying condition.
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Affiliation(s)
- Justin Gatwood
- University of Tennessee College of Pharmacy, 881 Madison Ave., Memphis, TN 38103.
| | - Teresa B. Gibson
- University of Tennessee College of Pharmacy, 881 Madison Ave., Memphis, TN 38103.
| | - Michael E. Chernew
- University of Tennessee College of Pharmacy, 881 Madison Ave., Memphis, TN 38103.
| | - Amanda M. Farr
- University of Tennessee College of Pharmacy, 881 Madison Ave., Memphis, TN 38103.
| | - Emily Vogtmann
- University of Tennessee College of Pharmacy, 881 Madison Ave., Memphis, TN 38103.
| | - A. Mark Fendrick
- University of Tennessee College of Pharmacy, 881 Madison Ave., Memphis, TN 38103.
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Martsolf GR, Auerbach D, Benevent R, Stocks C, Jiang HJ, Pearson ML, Ehrlich ED, Gibson TB. Examining the Value of Inpatient Nurse Staffing. Med Care 2014; 52:982-8. [DOI: 10.1097/mlr.0000000000000248] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gibson TB, Ehrlich ED, Graff J, Dubois R, Farr AM, Chernew M, Fendrick AM. Real-world impact of comparative effectiveness research findings on clinical practice. Am J Manag Care 2014; 20:e208-e220. [PMID: 25180504] [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: 06/03/2023]
Abstract
OBJECTIVES Unprecedented funding for comparative effectiveness research (CER) to help provide better evidence for decision making as a way to lower costs and improve quality is under way. Yet how research findings are adopted and applied will impact the nation's return on this investment. We examine the relationship between the publication of findings from 4 seminal CER trials, the release of subsequent clinical practice guidelines (CPGs), and utilization trends for associated surgical interventions, diagnostic interventions, or medications. STUDY DESIGN Retrospective, observational study. METHODS Using a large national administrative claims database, we examined time series utilization trends before and after publication of findings from 4 CER trials published within the last decade. RESULTS We found no clear pattern of utilization in the first 4 quarters after publication. However, we found that results for 2 of the studies were in concert with the release of CPGs and publication of study results. The trend in intensive statin therapy rose rapidly starting at the end of 2007, while the trend in standard therapy remained relatively constant (PROVE-IT). And, 9 months after trial publication, breast magnetic resolution imaging (MRI) utilization rates rose 43.2%, from 0.033 to 0.048 per 100 enrollees (Mammography With MRI). CONCLUSIONS Our analysis of 4 case studies supports the call others have made to translate and disseminate CER findings to improve application of research findings to clinical practice and the need for continued development and dissemination of CPGs that serve to synthesize research findings and guide practitioners in clinical decision making. Further research is needed to determine whether these findings apply to different medical topics.
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Affiliation(s)
- Teresa B Gibson
- Truven Health Analytics, 777 E Eisenhower Parkway, Ann Arbor, MI 48108. E-mail: teresa.
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Seshamani M, Vogtmann E, Gatwood J, Gibson TB, Scanlon D. Prevalence of Complications from Adult Tonsillectomy and Impact on Health Care Expenditures. Otolaryngol Head Neck Surg 2014; 150:574-81. [DOI: 10.1177/0194599813519972] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To provide information on the prevalence of common complications of adult tonsillectomy and associated health care utilization and expenditures. Study Design Retrospective analysis of a large insurance database. Setting Data from the MarketScan Commercial Claims and Encounters Database. Subjects and Methods Treated prevalence rates for post-tonsillectomy complications were calculated for 36,210 patients with employer-sponsored insurance who had an outpatient tonsillectomy between 2002 and 2007. The relationships with various patient characteristics were examined using multivariate logistic regression. Postoperative emergency department (ED) visits and hospitalizations and total per capita health care expenditures were analyzed. Results This analysis suggests that of adult patients who undergo a tonsillectomy, 20% will have a complication, 10% will visit an ED, and approximately 1.5% will be admitted to a hospital within 14 days of the tonsillectomy. Six percent were treated for postoperative hemorrhage, 2% for dehydration, and 11% for ENT pain within 14 days of surgery. Patients with comorbidities, prior peritonsillar abscess, or an increased number of antibiotic prescriptions in the past year were significantly more likely to develop complications. Three out of 4 patients with postoperative hemorrhage went to the ED (4.63% of all patients), and 50% had a procedural intervention (3.09% overall). The average cost associated with a tonsillectomy was $3832 if no complication. If there was a complication within 14 days, hemorrhage was the most expensive ($6388 vs $5753 for dehydration and $4708 for ENT pain). Conclusions Complications of adult outpatient tonsillectomies are common and may be associated with significant morbidity, health care utilization, and expenditures.
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Affiliation(s)
- Meena Seshamani
- Department of Head and Neck Surgery, The Permanente Medical Group, San Francisco, California, USA
| | | | | | | | - Dennis Scanlon
- The Pennsylvania State University, State College, Pennsylvania, USA
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Borah BJ, Carls GS, Moore BJ, Gibson TB, Moriarty JP, Stewart EA. Cost comparison between uterine-sparing fibroid treatments one year following treatment. J Ther Ultrasound 2014; 2:7. [PMID: 25512868 PMCID: PMC4265990 DOI: 10.1186/2050-5736-2-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 10/21/2013] [Accepted: 01/31/2014] [Indexed: 11/29/2022] Open
Abstract
Background To compare one-year all-cause and uterine fibroid (UF)-related direct costs in patients treated with one of the following three uterine-sparing procedures: magnetic resonance-guided focused ultrasound (MRgFUS), uterine artery embolization (UAE) and myomectomy. Methods This retrospective observational cohort study used healthcare claims for several million individuals with healthcare coverage from employers in the MarketScan Database for the period 2003–2010. UF patients aged 25–54 on their first UF procedure (index) date with 366-day baseline experience, 366-day follow-up period, continuous health plan enrollment during baseline and follow-up, and absence of any baseline UF procedures were included in the final sample. Cost outcomes were measured by allowed charges (sum of insurer-paid and patient-paid amounts). UF-related cost was defined as difference in mean cost between study cohorts and propensity-score-matched control cohorts without UF. Multivariate adjustment of cost outcomes was conducted using generalized linear models. Results The study sample comprised 14,426 patients (MRgFUS = 14; UAE = 4,092; myomectomy = 10,320) with a higher percent of older patients in MRgFUS cohort (71% vs. 50% vs. 12% in age-group 45–54, P < 0.001). Adjusted all-cause mean cost was lowest for MRgFUS ($19,763; 95% CI: $10,425-$38,694) followed by myomectomy ($20,407; 95% CI: $19,483-$21,381) and UAE ($25,019; 95% CI: $23,738-$26,376) but without statistical significance. Adjusted UF-related costs were also not significantly different between the three procedures. Conclusions Adjusted all-cause and UF-related costs at one year were not significantly different between patients undergoing MRgFUS, myomectomy and UAE.
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Affiliation(s)
- Bijan J Borah
- Division of Health Care Policy and Research & College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ginger S Carls
- Truven Health Analytics, 777 E. Eisenhower Parkway, Ann Arbor, MI 48108, USA
| | - Brian J Moore
- Truven Health Analytics, 777 E. Eisenhower Parkway, Ann Arbor, MI 48108, USA
| | - Teresa B Gibson
- Truven Health Analytics, 777 E. Eisenhower Parkway, Ann Arbor, MI 48108, USA
| | - James P Moriarty
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth A Stewart
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology and Department of Surgery, Mayo Clinic and Mayo Medical School, Rochester, Minnesota, USA
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Ryu AJ, Gibson TB, McKellar MR, Chernew ME. The slowdown in health care spending in 2009-11 reflected factors other than the weak economy and thus may persist. Health Aff (Millwood) 2014; 32:835-40. [PMID: 23650315 DOI: 10.1377/hlthaff.2012.1297] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [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: 12/13/2022]
Abstract
During and immediately after the recent recession, national health expenditures grew exceptionally slowly. During 2009-11 per capita national health spending grew about 3 percent annually, compared to an average of 5.9 percent annually during the previous ten years. Policy experts disagree about whether the slower health spending growth was temporary or represented a long-term shift. This study examined two factors that might account for the slowdown: job loss and benefit changes that shifted more costs to insured people. Based on an examination of data covering more than ten million enrollees with health care coverage from large firms in 2007-11, we found that these enrollees' out-of-pocket costs increased as the benefit design of their employer-provided coverage became less generous in this period. We conclude that such benefit design changes accounted for about one-fifth of the observed decrease in the rate of growth. However, we also observed a slowdown in spending growth even when we held benefit generosity constant, which suggests that other factors, such as a reduction in the rate of introduction of new technology, were also at work. Our findings suggest cautious optimism that the slowdown in the growth of health spending may persist--a change that, if borne out, could have a major impact on US health spending projections and fiscal challenges facing the country.
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McKellar MR, Naimer S, Landrum MB, Gibson TB, Chandra A, Chernew M. Insurer market structure and variation in commercial health care spending. Health Serv Res 2013; 49:878-92. [PMID: 24303879 DOI: 10.1111/1475-6773.12131] [Citation(s) in RCA: 15] [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] [Accepted: 09/20/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the relationship between insurance market structure and health care prices, utilization, and spending. DATA SOURCES Claims for 37.6 million privately insured employees and their dependents from the Truven Health Market Scan Database in 2009. Measures of insurer market structure derived from Health Leaders Inter study data. METHODS Regression models are used to estimate the association between insurance market concentration and health care spending, utilization, and price, adjusting for differences in patient characteristics and other market-level traits. RESULTS Insurance market concentration is inversely related to prices and spending, but positively related to utilization. Our results imply that, after adjusting for input price differences, a market with two equal size insurers is associated with 3.9 percent lower medical care spending per capita (p = .002) and 5.0 percent lower prices for health care services relative to one with three equal size insurers (p < .001). CONCLUSION Greater fragmentation in the insurance market might lead to higher prices and higher spending for care, suggesting some of the gains from insurer competition may be absorbed by higher prices for health care. Greater attention to prices and utilization in the provider market may need to accompany procompetitive insurance market strategies.
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Gibson TB, Driver VR, Wrobel JS, Christina JR, Bagalman E, DeFrancis R, Garoufalis MG, Carls GS, Gatwood J. Podiatrist care and outcomes for patients with diabetes and foot ulcer. Int Wound J 2013; 11:641-8. [PMID: 23374540 DOI: 10.1111/iwj.12021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 09/20/2012] [Revised: 11/21/2012] [Accepted: 12/03/2012] [Indexed: 12/01/2022] Open
Abstract
We examined whether outcomes of care (amputation and hospitalisation) among patients with diabetes and foot ulcer differ between those who received pre-ulcer care from podiatrists and those who did not. Adult patients with diabetes and a diagnosis of a diabetic foot ulcer were found in the MarketScan Databases, 2005-2008. Multivariate Cox proportional hazard models estimated the hazard of amputation and hospitalisation. Logistic regression estimated the likelihood of these events. Propensity score weighting and regression adjustment were used to adjust for potentially different characteristics of patients who did and did not receive podiatric care. The sample included 27 545 patients aged greater than 65+ years (Medicare-eligible patients with employer-sponsored supplemental insurance) and 20 208 patients aged lesser than 65 years (non Medicare-eligible commercially insured patients). Care by podiatrists in the year prior to a diabetic foot ulcer was associated with a lower hazard of lower extremity amputation, major amputation and hospitalisations in both non Medicare-eligible commercially insured and Medicare-eligible patient populations. Systematic differences between patients with diabetes and foot ulcer, receiving and not receiving care from podiatrists were also observed; specifically, patients with diabetes receiving care from podiatrists tend to be older and sicker.
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Abstract
BACKGROUND Prior to 2010, Medicare payments for consultations (commonly billed by specialists) were substantially higher than for office visits of similar complexity (commonly billed by primary care physicians). In January 2010, Medicare eliminated consultation payments from the Part B Physician Fee Schedule and increased fees for office visits. This change was intended to be budget neutral and to decrease payments to specialists while increasing payments to primary care physicians. We assessed the impact of this policy on spending, volume, and complexity for outpatient office encounters in 2010. METHODS We examined outpatient claims from 2007 through 2010 for 2 247 810 Medicare beneficiaries with Medicare Supplemental (Medigap) coverage through large employers in the Thomson Reuters MarketScan Database. We used segmented regression analysis to study changes in spending, volume, and complexity of office encounters adjusted for age, sex, health status, secular trends, seasonality, and hospital referral region. RESULTS "New" office visits largely replaced consultations in 2010. An average of $10.20 more was spent per beneficiary per quarter on physician encounters after the policy (6.5% increase). The total volume of physician encounters did not change significantly. The increase in spending was largely explained by higher office-visit fees from the policy and a shift toward higher-complexity visits to both specialists and primary care physicians. CONCLUSIONS The elimination of consultations led to a net increase in spending on visits to both primary care physicians and specialists. Higher prices, partially owing to the subjectivity of codes in the physician fee schedule, explained the spending increase, rather than higher volumes.
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Affiliation(s)
- Zirui Song
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
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Jacobson JJ, Epstein JB, Eichmiller FC, Gibson TB, Carls GS, Vogtmann E, Wang S, Murphy B. The cost burden of oral, oral pharyngeal, and salivary gland cancers in three groups: commercial insurance, Medicare, and Medicaid. Head Neck Oncol 2012; 4:15. [PMID: 22537712 PMCID: PMC3503554 DOI: 10.1186/1758-3284-4-15] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 03/30/2012] [Indexed: 11/29/2022]
Abstract
Background Head and neck cancers are of particular interest to health care providers, their patients, and those paying for health care services, because they have a high morbidity, they are extremely expensive to treat, and of the survivors only 48% return to work. Consequently the economic burden of oral cavity, oral pharyngeal, and salivary gland cancer (OC/OP/SG) must be understood. The cost of these cancers in the U.S. has not been investigated. Methods A retrospective analysis of administrative claims data for 6,812 OC/OP/SG cancer patients was undertaken. Total annual health care spending for OC/OP/SG cancer patients was compared to similar patients without OC/OP/SG cancer using propensity score matching for enrollees in commercial insurance, Medicare, and Medicaid. Indirect costs, as measured by short term disability days were compared for employed patients. Results Total annual health care spending for OC/OP/SG patients during the year after the index diagnosis was $79,151 for the Commercial population. Health care costs were higher for OC/OP/SG cancer patients with Commercial Insurance ($71,732, n = 3,918), Medicare ($35,890, n = 2,303) and Medicaid ($44,541, n = 585) than the comparison group (all p < 0.01). Commercially-insured employees with cancer (n = 281) had 44.9 more short-term disability days than comparison employees (p < 0.01). Multimodality treatment was twice the cost of single modality therapy. Those patients receiving all three treatments (surgery, radiation, and chemotherapy) had the highest costs of cost of care, from $96,520 in the Medicare population to $153,892 in the Commercial population. Conclusions In the U.S., the cost of OC/OP/SG cancer is significant and may be the most costly cancer to treat in the U.S. The results of this analysis provide useful information to health care providers and decision makers in understanding the economic burden of head and neck cancer. Additionally, this cost information will greatly assist in determining the cost-effectiveness of new technologies and early detection systems. Earlier identification of cancers by patients and providers may potentially decrease health care costs, morbidity and mortality.
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Affiliation(s)
- Jed J Jacobson
- Delta Dental of Michigan, University of Michigan, 4100 Okemos Road, Okemos, MI 48864, USA.
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Gibson TB, Jing Y, Bagalman JE, Cao Z, Bates JA, Hebden T, Forbes RA, Doshi JA. Impact of cost-sharing on treatment augmentation in patients with depression. Am J Manag Care 2012; 18:e15-e22. [PMID: 22435786] [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: 05/31/2023]
Abstract
OBJECTIVES Many patients with depression do not respond to first-line antidepressant therapy and may require augmentation with another concurrent treatment such as a second antidepressant, a stimulant, a mood stabilizer, or a second-generation antipsychotic (SGA). The objective of this study was to examine the relationship between patient cost-sharing and the use of augmentation among a sample of commercially insured patients. STUDY DESIGN Retrospective observational study of adult patients diagnosed with depression and receiving antidepressant therapy (n = 48,807). METHODS Logistic regression models estimated the likelihood of augmentation as a function of patient cost-sharing amounts. An alternative-specific conditional logit model of the likelihood of each augmentation class, varying the cost-sharing prices faced for each class, was also estimated. All models controlled for sociodemographic characteristics, physical and mental comorbidities, health plan type, and year of index antidepressant therapy initiation. RESULTS The range of mean copayments paid by patients for augmentation therapy was from $27.05 (antidepressant) to $38.81 (SGA). A $10- higher cost-sharing index for all augmentation classes was associated with lower odds of augmentation (adjusted odds ratio = 0.85; 95% confidence interval 0.79-0.91). Doubling the costsharing amount for each augmentation class was associated with a smaller percentage of patients utilizing each class of augmentation therapy. CONCLUSIONS Employers and payers should consider the relationship between cost-sharing and medication utilization patterns of patients with depression.
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Affiliation(s)
- Teresa B Gibson
- Thomson Reuters, 777 E. Eisenhower Pkwy, Ann Arbor, MI 48108.
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Carls GS, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG, Defrancis RR, Wang S, Bagalman JE, Christina JR. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. J Am Podiatr Med Assoc 2011; 101:93-115. [PMID: 21406693 DOI: 10.7547/1010093] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We sought to examine the economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers by evaluating cost outcomes for patients with diabetic foot ulcer who did and did not receive care from a podiatric physician in the year before the onset of a foot ulcer. METHODS We analyzed the economic value among commercially insured patients and Medicare-eligible patients with employer-sponsored supplemental medical benefits using the MarketScan Databases. The analysis consisted of two parts. In part I, we examined cost or savings per patient associated with care by podiatric physicians using propensity score matching and regression techniques; in part II, we extrapolated cost or savings to populations. RESULTS Matched and regression-adjusted results indicated that patients who visited a podiatric physician had $13,474 lower costs in commercial plans and $3,624 lower costs in Medicare plans during 2-year follow-up (P < .01 for both). A positive net present value of increasing the share of patients at risk for diabetic foot ulcer by 1% was found, with a range of $1.2 to $17.7 million for employer-sponsored plans and $1.0 to $12.7 million for Medicare plans. CONCLUSIONS These findings suggest that podiatric medical care can reduce the disease and economic burdens of diabetes.
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Affiliation(s)
- Ginger S Carls
- Health Outcomes, Thomson Reuters, Ann Arbor, MI 48108, USA
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Gibson TB, Wang S, Kelly E, Brown C, Turner C, Frech-Tamas F, Doyle J, Mauceri E. A value-based insurance design program at a large company boosted medication adherence for employees with chronic illnesses. Health Aff (Millwood) 2011; 30:109-17. [PMID: 21209446 DOI: 10.1377/hlthaff.2010.0510] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This paper contributes to a small but growing body of evidence regarding the efficacy of value-based insurance design. In a retrospective, observational study of employees of a large global pharmaceutical firm, we evaluated how reduced patient cost sharing for prescription drugs for asthma, hypertension, and diabetes affected the use of these drugs and related medical services. We estimate that prescription medication use rose 5 percent per enrollee across the entire enrolled population. Increased use was most evident for patients taking cardiovascular medication. By the third year, adherence to cardiovascular medications was 9.4 percent higher, and patients realized cost savings over time. Overall, the program was mostly cost-neutral to the company, and there was no aggregate change in spending. However, we raise the prospect that this program may have saved the company money by reducing other medical costs.
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Gibson TB, Mahoney J, Ranghell K, Cherney BJ, McElwee N. Value-Based Insurance Plus Disease Management Increased Medication Use And Produced Savings. Health Aff (Millwood) 2011; 30:100-8. [DOI: 10.1377/hlthaff.2010.0896] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [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)
- Teresa B. Gibson
- Teresa B. Gibson ( ) is director of health outcomes at Thomson Reuters, in Ann Arbor, Michigan
| | - John Mahoney
- John Mahoney is medical director of the Florida Health Care Coalition, in Orlando
| | - Karlene Ranghell
- Karlene Ranghell is a project director at the Florida Health Care Coalition
| | - Becky J. Cherney
- Becky J. Cherney is president and chief executive officer of the Florida Health Care Coalition
| | - Newell McElwee
- Newell McElwee is executive director of US outcomes research at Merck and Company, in North Wales, Pennsylvania
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Gibson TB, Jing Y, Kim E, Bagalman E, Wang S, Whitehead R, Tran QV, Doshi JA. Cost-sharing effects on adherence and persistence for second-generation antipsychotics in commercially insured patients. Manag Care 2010; 19:40-47. [PMID: 20822071] [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: 05/29/2023]
Abstract
PURPOSE To assess the relationship between patient cost-sharing (e.g., copayments or coinsurance) and adherence and persistence to second-generation (atypical) antipsychotic (SGA) medications. DESIGN AND METHODOLOGY A retrospective, observational study of adults aged 18-64 years with schizophrenia or bipolar disorder (n = 7,910) who initiated SGA medications with employer-sponsored insurance in the 2003-2006 MarketScan Commercial Claims and Encounters Database. Adherence was defined as percent of days covered in each calendar quarter. Persistence was defined as days from initiation of SGA to the first 90-day gap in medication on-hand. Generalized Estimating Equations were used to determine the effects of cost-sharing on adherence to SGA medications based on patient-quarter data. A Cox proportional hazards model with patient cost-sharing as a time-varying covariate estimated the effects on persistence with SGA medication. PRINCIPAL FINDINGS Higher cost-sharing was associated with a lower likelihood of adherence. When compared to plans with cost-sharing below $10, adherence rates were approximately 27% lower for patients in plans with SGA cost-sharing of $50 and above and about 10% lower for patients in plans with cost-sharing between $30 and $50. In both cases, the reduction in adherence was significant. Higher cost-sharing was also associated with a shorter time to discontinuation (HR: 1.028; 95% CI [1.006-1.051]). CONCLUSION High SGA cost-sharing appears to be a financial barrier to SGA medication compliance, especially when cost-sharing levels exceeded $30. Our findings have implications for health plans, employers, and policymakers who have, or are, contemplating establishing cost-sharing tiers for SCA medications for commercially insured patients with serious mental illnesses.
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Gibson TB, Song X, Alemayehu B, Wang SS, Waddell JL, Bouchard JR, Forma F. Cost sharing, adherence, and health outcomes in patients with diabetes. Am J Manag Care 2010; 16:589-600. [PMID: 20712392] [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: 05/29/2023]
Abstract
OBJECTIVES To assess the relationship between cost sharing and adherence to antidiabetic medications in patients with type 2 diabetes and to examine the relationship between medication adherence and outcomes, including complication rates, medical service utilization, and workplace productivity measures. STUDY DESIGN A retrospective, cross-sectional study analyzing the healthcare experience of patients with type 2 diabetes on oral antidiabetic medication (OAD) with or without insulin (n = 96,734) and patients on OAD only (n = 55,356) with employer-sponsored insurance in the 2003-2006 MarketScan Database. METHODS Using a 2-stage residual inclusion model, the first stage estimated the effects of cost sharing on adherence to antidiabetic medications in an 18-month time frame (January 2003 through June 2004). Adherence was determined from the percentage of days covered. The second stage estimated the effects of adherence on complication rates (eg, retinopathy, neuropathy, peripheral vascular disease), medical service utilization rates, and measures of productivity (absence days and short-term disability days) in the subsequent 2 years (July 2004 through June 2006). RESULTS A $10 increase in the patient cost-sharing index resulted in a 5.4% reduction in adherence to antidiabetic medications for patients on OAD only and a 6.2% reduction in adherence for patients on OAD with or without insulin. Adherence was associated with lower rates of complications (eg, amputation/ulcers, retinopathy) and also was associated with fewer emergency department visits and short-term disability days. CONCLUSIONS Medical plans, employers, and policy makers should consider implementing interventions targeted to improve antidiabetic medication adherence, which may translate to better outcomes.
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Gibson TB, Jing Y, Smith Carls G, Kim E, Bagalman JE, Burton WN, Tran QV, Pikalov A, Goetzel RZ. Cost burden of treatment resistance in patients with depression. Am J Manag Care 2010; 16:370-377. [PMID: 20469957] [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: 05/29/2023]
Abstract
OBJECTIVE To develop a claims-based scale for treatment-resistant depression (TRD) and estimate the associated direct cost burden. STUDY DESIGN Retrospective, observational study of patients receiving antidepressant therapy between January 2000 and June 2007 (N = 78,477). METHODS The Massachusetts General Hospital (MGH) clinical staging method for treatment resistance (assigning points for adequate trials of antidepressant medication, upward dose titration, extended duration, augmentation, and electroconvulsive therapy) was applied to claims data from the MarketScan Research Databases over a 24-month time period. Direct expenditures were measured over a subsequent 12-month period. Patients identified as having TRD (MGH score >or=3.5) (n = 22,593) were matched to depressed patients without TRD using propensity score methods. Regression models estimated the relationship between TRD and expenditures, controlling for sociodemographics, health plan type, and health status. Similar regression models estimated costs for an antidepressant-only version of the scale (MGH-AD). RESULTS Treatment resistance among depressed patients was associated with 40% higher medical care costs (P <.001). The MGH-AD score was associated with an increasing gradient in direct costs. Annual costs for patients with mild TRD (MGH-AD 3.5-4) were $1530 higher than those for non-TRD patients, and costs for patients with complex TRD (MGH-AD >or=6.5) were $4425 higher than those for non-TRD patients (all P <.001). A 1-point increase in the MGH-AD score was associated with a $590 increase in annual costs (P <.001). CONCLUSIONS Early identification of TRD patients, using a claims-based algorithm, may support targeted interventions for these patients.
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Chernew M, Gibson TB, Fendrick AM. Trends in patient cost sharing for clinical services used as quality indicators. J Gen Intern Med 2010; 25:243-8. [PMID: 20058193 PMCID: PMC2839339 DOI: 10.1007/s11606-009-1219-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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: 04/20/2009] [Revised: 09/25/2009] [Accepted: 10/22/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patient copayments for all medical services have increased dramatically. There are few data available regarding how copayments have changed for services commonly considered to be quality indicators. OBJECTIVE Describe the relative change in copayments for services used as quality indicators and interventions subject to programs to control utilization. DESIGN A large claims database was used to assess copayment changes from 2001 to 2006 for selected drug and non-drug services in patient cohorts with specific chronic diseases. SUBJECTS Approximately 5 million commercially-insured individuals enrolled in a variety of fee-for-service and capitated health plans. MEASUREMENTS Copayment trends were calculated as the change in the average amount paid per unit service from 2001 to 2006. RESULTS Out-of-pocket payments for services targeted by quality improvement initiatives increased substantially [>50%] and in a similar magnitude to interventions subject to programs to control their use. For prescription drugs, the trend was driven more by copayment increases for branded medications [$10 per prescription] than for generic drugs [$2 per prescription]. Copayments for non-drug preventive services rose modestly. CONCLUSIONS Benefit designers should consider reversing the trend of copayment increases for services considered to be indicators of high quality care.
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Affiliation(s)
- Michael Chernew
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 USA
| | - Teresa B. Gibson
- Health Outcomes, Thomson Reuters (Healthcare), 777 E. Eisenhower Parkway, Ann Arbor, MI 48108 USA
| | - A. Mark Fendrick
- Departments of Internal Medicine and Health Management & Policy, University of Michigan, 300 North Ingalls Building Room 7E06, Ann Arbor, MI 48109-0429 USA
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Chernew ME, Sabik LM, Chandra A, Gibson TB, Newhouse JP. Geographic correlation between large-firm commercial spending and Medicare spending. Am J Manag Care 2010; 16:131-138. [PMID: 20148618 PMCID: PMC3322373] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To investigate the correlation between geographic variation in inpatient days, total spending, and spending growth in traditional Medicare versus the large-firm commercial sector. STUDY DESIGN Retrospective descriptive analysis. METHODS Medicare spending data at the hospital referral region (HRR) level were obtained from the Dartmouth Atlas. Commercial claims data from large employers were obtained from Thomson Reuters MarketScan Database for 1996-2006 and aggregated to the HRR level. County-level data on inpatient days per capita and market characteristics were obtained from the Area Resource File. We computed correlations between Medicare and commercial spending and spending growth, as well as Medicare and non-Medicare inpatient days, and examined traits of high- and low-spending HRRs in both sectors. RESULTS We found a positive correlation between inpatient days per capita across counties, but a small inverse correlation between measures of commercial and Medicare spending across HRRs. Spending growth was weakly positively correlated across HRRs. Markets in the upper third of commercial spending had more concentrated hospital markets than markets in the lower third of commercial spending. The reverse was true for Medicare spending. CONCLUSIONS The positive correlation in utilization and lack of correlation in spending implies an inverse correlation in prices. This is consistent with evidence that the differences appear to be, at least partially, related to aspects of the market structure. If private markets are to work better to reduce cost, stronger efforts are needed to reduce provider market concentration and promote competitive pricing for healthcare services.
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Affiliation(s)
- Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, USA.
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Gibson TB, Lee TA, Vogeli CS, Hidalgo J, Carls GS, Sredl K, DesHarnais S, Marder WD, Weiss KB, Williams TV, Shields AE. A four-system comparison of patients with chronic illness: the Military Health System, Veterans Health Administration, Medicaid, and commercial plans. Mil Med 2009; 174:936-43. [PMID: 19780368 DOI: 10.7205/milmed-d-03-7808] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
We compared chronic care utilization in four major health systems in the U.S.: the military health system (TRICARE), the Department of Veterans Affairs (VA), Medicaid, and employer-sponsored commercial plans. Prevalence rates and key performance indicators were constructed from administrative data in federal fiscal year 2003 for eight chronic conditions: hypertension, major depression, diabetes, tobacco dependence, ischemic heart disease, severe mental illness, persistent asthma, and stroke. Continuously enrolled beneficiaries under 65 years old were studied: TRICARE (N = 2,963,987), VA (N = 2,114,739), Medicaid enrollees in five states (N = 5,554,974), and commercial insurance (N = 5,212,833). Condition-specific adjusted prevalence rates and measures were compared using the standardized rate ratio. For the majority of the conditions, the estimated prevalence rates were highest in the VA and Medicaid populations. Prevalence rates were generally lower in TRICARE and commercial plans. Medicaid beneficiaries had the highest hospitalization rates in four of the six conditions where hospitalization rates were measured. These results provide empirical evidence of differences in chronically ill patient populations in several of the major U.S. health insurance systems.
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Affiliation(s)
- Teresa B Gibson
- Thomson Reuters, 777 E. Eisenhower Parkway, Ann Arbor, MI 48108, USA
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Li T, Carls GS, Panopalis P, Wang S, Gibson TB, Goetzel RZ. Long-term medical costs and resource utilization in systemic lupus erythematosus and lupus nephritis: A five-year analysis of a large medicaid population. ACTA ACUST UNITED AC 2009; 61:755-63. [DOI: 10.1002/art.24545] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Carls GS, Lee DW, Ozminkowski RJ, Wang S, Gibson TB, Stewart E. What are the total costs of surgical treatment for uterine fibroids? J Womens Health (Larchmt) 2009; 17:1119-32. [PMID: 18687032 DOI: 10.1089/jwh.2008.0456] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the direct and indirect costs of uterine fibroid (UF) surgery. METHODS Data were obtained from the MarketScan Commercial Claims and Encounters databases for 1999-2004. Our sample included 22,860 women with insurance coverage who were treated surgically for UF and 14,214 women who were treated nonsurgically for UF. Medical care costs and missed workdays were divided into baseline (1 year prior to surgery) and postoperative (1 year after surgery) periods. For a subsample of women, we calculated average annual costs 3 years before and after their surgery. RESULTS Of patients electing surgery, 85.9% underwent hysterectomy, 7.6% myomectomy, 4.9% endometrial ablation, and 1.6% uterine artery embolization (UAE). Women undergoing UAE incurred the highest medical care costs in the operative year ($16,430 unadjusted, $20,634 adjusted for confounders), followed by hysterectomy ($15,180 unadjusted, $17,390 adjusted), myomectomy ($14,726 unadjusted, $18,674 adjusted), and endometrial ablation ($12,096 unadjusted, $13,019 adjusted). Women treated nonsurgically incurred costs of $7,460 unadjusted and $8,257 adjusted during the year after they were diagnosed with UF. Three years after surgery, patients treated with hysterectomy had the lowest annual costs. Missed workdays in the year after surgery were high, resulting in significant losses to employers in the magnitude of $6,670-$25,229, depending on treatment, values assigned to missed workdays, and whether the analyses adjusted for confounders. CONCLUSIONS UF surgical treatment costs were high. Absenteeism and disability were important components of the cost burden of UF treatment for women, their employers, and the healthcare system.
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Mark TL, Gibson TB, McGuigan KA. The effects of antihypertensive step-therapy protocols on pharmaceutical and medical utilization and expenditures. Am J Manag Care 2009; 15:123-131. [PMID: 19284809] [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: 05/27/2023]
Abstract
OBJECTIVE To examine the effects of antihypertensive step therapy on prescription drug utilization and spending, and other medical care utilization and spending. STUDY DESIGN Pre/post design. METHODS Employers who had implemented step therapy were compared with employers who had not implemented step therapy. Data were drawn from the 2003 through 2006 MarketScan Research Databases. The study sample included employees and dependents who used antihypertensives (11,851 patients whose employer implemented a step-therapy protocol and 30,882 patients in the comparison group without step therapy). Multivariate generalized estimating equation models were used to estimate the immediate and time-varying effects of step therapy on medical and prescription drug spending and utilization, while controlling for important covariates and adjusting for clustering by patient. RESULTS Results showed an initial 7.9% reduction in antihypertensive medication days supplied and an initial 3.1% reduction in medication costs among antihypertensive users in the step-therapy plans. However, these percentages grew in each subsequent quarter. Antihypertensive users in step-therapy programs also experienced an increase in inpatient admissions and emergency room visits. After an initial decline in spending, the step-therapy group incurred $99 more per user in quarterly expenditures than the comparison group. CONCLUSIONS The intended effect of step therapy is to substitute cheaper and equivalently effective medications for more expensive medications. As this study demonstrates, step therapy may create barriers to receiving any medication, resulting in higher medical utilization and costs. Further research is needed to understand why these unintended consequences occur and how they might be avoided.
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Affiliation(s)
- Tami L Mark
- Thomson Reuters, 4301 Connecticut Ave, NW, Ste 330, Washington, DC 20008, USA.
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