Reading list

Geographic Variation in Commercial Medical-Care Expenditures: A Framework for Decomposing Price and Utilization by Abe Dunn, Adam Shapiro, and Eli Liebman (Journal of Health Economics)

This study introduces a new framework for measuring and analyzing medical-care expenditures. The framework focuses on expenditures at the disease level that are decomposed between price and utilization. We find that both price and utilization differences are important contributors to expenditure differences across commercial markets. Further examination shows that for some diseases utilization drives variation while for others price is more important. Finally, when disease-specific measures are aggregated across diseases, much of the important disease-specific variation is masked, leading to much smaller measures of aggregate variation.

Productivity and the Health Care Workforce by Shannon Brownlee, Joe Colucci, and Thom Walsh (New America Foundation)

Despite a steady stream of medical innovations, productivity growth in the health care sector has been slow. There are several reasons for this poor productivity. Many tests and treatments (both new and old) are routinely put to use with little or no regard for whether they improve patient outcomes. […] There is also evidence that between one-tenth and one-third of tests and treatments are unnecessary or unwanted by patients. […] There is one additional reason for health care’s poor productivity: medical institutions are poorly organized. They waste time, money, labor, and other resources by operating inefficiently. […] Making better use of health care labor force is the key to improving productivity in the sector. This paper looks first at sources of low productivity in health care, and then examines the implications for future health care workforce needs.

The Demand Side: Consumer-Focused Strategies to Improve Health System Outcomes by Rob Cunningham (AcademyHealth Research Insights)

This research brief summarizes the discussion of an expert panel AcademyHealth convened in June 2013 to take stock of recent research on demand-side efforts and inform policy deliberations on demand-side strategies. Among the subjects covered were value-based insurance design, wellness programs, high-deductible insurance plans, price transparency, and shared decision-making.

A systematic review of medical practice variation in OECD countries by Ashley Corallo, Ruth Croxford, David Goodman, Elisabeth Bryan, Divya Srivastava, and Therese A. Stukel (Health Policy)

Major variations in medical practice have been documented internationally. Variations raise questions about the quality, equity, and efficiency of resource allocation and use, and have important implications for health care and health policy. We searched MEDLINE to find publications on medical practice variations in OECD countries published between 2000 and 2011. We present an overview of the characteristics of published studies as well as the magnitude of variations for select high impact conditions. A total of 836 studies were included. Consistent with the gray literature, there were large variations across regions, hospitals and physician practices for almost every condition and procedure studied. Many studies focused on high-impact conditions, but very few looked at the causes or outcomes of medical practice variations. While there were an overwhelming number of publications on medical practice variations the coverage was broad and not often based on a theoretical construct. Future studies should focus on conditions and procedures that are clinically important, policy relevant, resource intensive, and have high levels of public awareness. Further study of the causes and consequences of variations is important.

A Conceptual Framework for Understanding and Reducing Overuse by Primary Care Providers by Adam Powell, Hanna Bloomfield, Diana Burgess, Timothy Wilt, and Melissa Partin (Medical Care Research and Review)

Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.

The State of Overuse Measurement: A Critical Review by Kitty Chan, Eva Chang, Najlla Nassery, Hsien-Yen Chang, and Jodi B. Segal (Medical Care Research and Review)

Health care overuse contributes to unnecessary expenditures and patient exposure to harm. Understanding and addressing this problem requires a comprehensive set of valid metrics. This article describes and critiques the current state of overuse measurement through a review of the published and gray literature, measures clearinghouses and ongoing work by major measure developers. Our review identified 37 fully specified measures and 123 measurement development opportunities. Many services were considered overuse due to the extension of diagnostic or screening services to low-risk populations. There were more diagnostic or therapeutic overuse measures than for screening or monitoring/surveillance. Imaging services is a major focus of current measures, but opportunities exist to expand overuse measurement in medication, laboratory services. Future development of overuse measures would benefit from new empirical research and clinical guidelines focused on identifying indications or populations for which there is likely to be no or low benefit.

Massachusetts Coverage Expansion Associated with Reduction in Primary Care Utilization among Medicare Beneficiaries by Amelia Bond and Chapin White (Health Services Research)

In areas of Massachusetts with the highest uninsurance rates—where insurance expansion had the largest impact—visits per beneficiary fell 6.9 percent (p < .001) relative to areas of Massachusetts with the smallest uninsurance rates. The expansion of coverage for the nonelderly reduced primary care visits, but it did not reduce the percent of beneficiaries with at least one visit. These results could imply restricted access, increased efficiency, or some blend.

How the Pioneer ACO Model Needs to Change: Lessons From Its Best-Performing ACO by John Toussaint, Arnold Milstein, and Stephen Shortell (JAMA)

Weighing In on Opioids for Chronic Pain The Barriers to Change by Daniel Alford (JAMA)

The ACA and High-Deductible Insurance — Strategies for Sharpening a Blunt Instrument by J. Frank Wharam, Deniis Ross-Degnan, and Meredith Rosenthal (New England Journal of Medicine)

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