• Reading list

    Physician communication styles in initial consultations for hematological cancer by Karan Chhabra et al. (Patient Education and Counseling) [Full disclosure: The lead author is a personal friend and colleague.]

    Physicians frequently “broadcasted” information about the disease, treatment options, relevant research, and prognostic information in extended, often-uninterrupted monologs. Their communicative styles had one of two implications: conveying options without offering specific recommendations, or recommending one without incorporating patients’ goals and values into the decision. Some physicians, however, used techniques that encouraged patient participation. […] Broadcasting may be a suboptimal method of conveying complex treatment information in order to support shared decision-making. Interventions could teach techniques that encourage patient participation. […] Techniques such as open-ended questions, affirmations of patients’ expressions, and pauses to check for patient understanding can mitigate the effects of broadcasting and could be used to promote shared decision-making in information-dense subspecialist consultations.

    Physicians May Need More Than Higher Reimbursements To Expand Medicaid Participation: Findings From Washington State by Sharon Long (Health Affairs)

    The expansion of insurance coverage under the Affordable Care Act is expected to put considerable pressure on the capacity of the primary care workforce to meet the needs of the Medicaid population beginning in 2014. The results from a 2011 survey and focus-group sessions with Washington State primary care physicians suggest that doctors welcome planned increases in Medicaid reimbursement rates. However, the data also show that other approaches could be even more effective in increasing physicians’ willingness to see Medicaid patients. Those approaches include lowering the costs of participating in Medicaid by simplifying administrative processes, speeding up reimbursement, and reducing the costs associated with caring for those patients. In focus groups, physicians were cautiously optimistic about the potential of the Affordable Care Act to make a difference in each of these areas, with electronic health records, medical homes, and accountable care organizations all seen as promising developments.

    Impact of Medical Loss Regulation On The Financial Performance Of Health Insurers by Michael McCue , Mark Hall, and Xinliang Liu (Health Affairs)

    The Affordable Care Act’s regulation of medical loss ratios requires health insurers to use at least 80–85 percent of the premiums they collect for direct medical expenses (care delivery) or for efforts to improve the quality of care. To gauge this rule’s effect on insurers’ financial performance, we measured changes between 2010 and 2011 in key financial ratios reflecting insurers’ operating profits, administrative costs, and medical claims. We found that the largest changes occurred in the individual market, where for-profit insurers reduced their median administrative cost ratio and operating margin by more than two percentage points each, resulting in a seven-percentage-point increase in their median medical loss ratio. Financial ratios changed much less for insurers in the small- and large-group markets.

    Emergency Department Visits After Surgery Are Common For Medicare Patients, Suggesting Opportunities To Improve Care by Keith Kocher, Brahmajee Nallamothu, John Birkmeyer, and Justin Dimick (Health Affairs)

     Considerable attention is being paid to hospital readmission as a marker of poor postdischarge care coordination. However, little is known about another potential marker: emergency department (ED) use. We examined ED visits for Medicare patients within thirty days of discharge for six common inpatient surgeries. We found that these visits were widespread and showed extensive variation across facilities. For example, 17.3 percent of these patients experienced at least one ED visit within the postdischarge period, and 4.4 percent of patients had multiple ED visits. Among those patients who were readmitted, 56.5 percent were readmitted from the ED. There was substantial variation—as much as fourfold—in hospital-level ED use for these patients across all six procedures. The variation might signify a failure in upstream coordination of care and therefore might represent a novel hospital quality indicator. In addition, the postdischarge ED visit is an opportunity to ensure that care is properly coordinated and is the last best chance to avoid preventable readmissions.

    Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With Electronic Health Records: A Randomized Trial by Naomi Bardach et al. (JAMA)

     Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied. […] Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100 000/clinic). Quality reports were given quarterly to both the intervention and control groups. […] Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time.

    Current Challenges to Academic Health Centers by Victor Fuchs (JAMA)

     Academic health centers (AHCs) have long been the exemplars of medicine in the United States. They produce “breakthrough” research, pioneer new diagnostic and therapeutic interventions, and train the best and brightest future physicians with emphasis on specialists and subspecialists. Today, they face a perilous future because the health care economic system that supports this enterprise is fading away; what Enthoven has called “cost unconscious” third-party payment for care is being transformed into “value purchasing.”

    Insurer Competition and Negotiated Hospital Prices by Kate Ho and Robin Lee (National Bureau of Economic Research)

    We examine the impact of increased health insurer competition on negotiated hospital prices. Insurer competition can lead to lower premiums and reduced industry surplus, thereby depressing hospital prices; however, hospitals may also leverage fiercer insurer competition when bargaining in order to negotiate higher prices. We rely on a theoretical bargaining model to derive a regression equation relating negotiated prices to the degree of insurer competition, and use the presence of Kaiser Permanente in a hospital’s market as a measure of insurer competition. We estimate a model of consumer demand for hospitals and use it to derive many of the other independent variables specified in the regression equation. Leveraging a unique dataset on negotiated prices between hospitals and commercial insurers in California in 2004, we find that increased insurer competition reduces hospital prices on average, but has a positive and empirically meaningful effect on the prices of attractive and high utility generating hospitals. This heterogeneous effect across hospitals—which has not been emphasized in the recent literature on hospital-insurer bargaining—provides incentives for hospital investment and consolidation, and implies that hospital market power can lead to high input prices even in markets where many insurers are present.

    Adrianna (@onceuponA)

    • Adrianna (or Austin)
      On last paper, NBER–

      Translation? Because of heterogeneous effects, how does a marketplace balance out? Seems like damned if you do, damned if you dont . If constituents tilt too much in one direction prices rise, and vice versa.

      Does the paper allude to policy in getting to a sweet spot? How do we interpret results?


      • The authors don’t offer much by way of policy recommendations. At the very end of the paper, they say, “policy promoting competition between insurers should take into account the potential impact on negotiated prices with providers and, in particular, exercise caution in markets with highly concentrated or extremely desirable providers.

        Austin has written on the balance of insurer/provider market concentration before (see this paper). It does seem kind of a damned if you do, damed if you don’t, with a sweet spot in the middle. What the new NBER paper adds is that hospitals don’t all react the same way—more “desirable” hospitals have more bargaining power, so they can extract higher prices.

    • I take in information much better in written form and struggle to remember all the details a doctor said five minutes after they said it. When presented with entirely new information I do particularly poorly and doctors, when delivering large chunks of information, tend to speak faster than I can write notes.

      I have a masters and was successful at very competitive schools, but discussing and taking notes on a lecture that’s presenting a topic you were expected to study up on is a lot easier than walking in to an office with a vague idea of what, say, my gall bladder is and then being told it’s dysfunctional and being presented with options for handling its dysfunction.

      I can’t imagine a good conversation about treatment options without the patient having the time to go home, think, study and come back to ask questions. And the best way to present it is a powerpoint. I’d think that once the powerpoints were made, doctors would mostly just cobble together the right slides pretty quickly.

      • Thanks for the comment. I’m actually Adrianna’s mysterious friend, colleague, and author of that study. You’d be pleased to know that in most cases, physicians asked patients to go home and sleep on their decisions. They often went to their primary oncologists to discuss the overall plan as well. I didn’t see any cases of Powerpoints being used, though some drew out survival curves (which I have my doubts about, in terms of comprehensibility for the general population). There is a great body of literature on decision aids that you may find interesting: http://informedmedicaldecisions.org/shared-decision-making-in-practice/decision-aids/

    • I found doctor/patient very challenging. This was brought home to me when I was on the receiving end. A close family member needed some high risk surgery, and I sat in the family waiting area without identifying myself as a physician. I overheard a surgeon talk to a family and tell them that things had gone well, but they were very upset by the news which they did not voice to the doctor but expressed to one another after the doctor had gone. Another family was told that things were iffy, but they expressed great happiness and confidence. The surgeon speaking to my family was rather snooty and self-important which made me want to slap him. In all cases the doctor spoke in perfectly intelligible medical jargon with little awareness that other people are not steeped in the same jargon, and the patients’ families did not ask for clarification because they did not wish to appear stupid or be a nuisance for the great surgeon.
      Communication is not talking to people. It is talking WITH people. It took me a long time to learn this, and I made many mistakes along the way for which I hope to be forgiven. The first step is to care about people and show them that you care and respect them.
      Of course, good grades in organic chemistry will count more toward admission to med school than people skills.