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)

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