Reading list

Beyond Repeal — The Future of Health Care Reform, by Jonathan Oberlander

Expect the Unexpected? Physicians’ Responses to Payment Changes, by Mireille Jacobson and Joseph P. Newhouse. Sometimes paying less means you get more.

The Pricing Of U.S. Hospital Services: Chaos Behind A Veil Of Secrecy, by Uwe E. Reinhardt

Although Americans and foreigners alike tend to think of the U.S. health care system as being a “market-driven” system, the prices actually paid for health care goods and services in that system have remained remarkably opaque. This paper describes how U.S. hospitals now price their services to the various third-party payers and self-paying patients, and how that system would have to be changed to accommodate the increasingly popular concept of “consumer-directed health care.”

Among Lower-Income Families in High-Deductible Health Plans, by Jeffrey T. Kullgren, Alison A. Galbraith, Virginia L. Hinrichsen, Irina Miroshnik, Robert B. Penfold, Meredith B. Rosenthal, Bruce E. Landon, and Tracy A. Lieu. See also the invited commentary by Victor R. Grann that follows the article.

Background: Lower-income families may face unique challenges in high-deductible health plans (HDHPs).

Methods: We administered a cross-sectional survey to a stratified random sample of families in a New England health plan’s HDHP with at least $500 in annualized outof- pocket expenditures. Lower-income families were defined as having incomes that were less than 300% of the federal poverty level. Primary outcomes were costrelated delayed or foregone care, difficulty understanding plans, unexpected costs, information-seeking, and likelihood of families asking their physician about hypothetical recommended services subject to the plan deductible. Multivariate logistic regression was used to control for potential confounders of associations between income group and primary outcomes.

Results: Lower-income families (n=141) were more likely than higher-income families (n=273) to report costrelated delayed or foregone care (57% vs 42%; adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.15-2.83]). There were no differences in plan understanding, unexpected costs, or information-seeking by income. Lower-income families were more likely than others to say they would ask their physician about a $100 blood test (79% vs 63%; AOR, 1.97; 95% CI, 1.18-3.28) or a $1000 screening colonoscopy (89% vs 80%; AOR, 2.04; 95% CI, 1.06-3.93) subject to the plan deductible.

Conclusions: Lower-income families with out-ofpocket expenditures in an HDHP were more likely than higher-income families to report cost-related delayed or foregone care but did not report more difficulty understanding or using their plans, and might be more likely to question services requiring out-of-pocket expenditures. Policymakers and physicians should consider focused monitoring and benefit design modifications to support lower-income families in HDHPs.

Comparative Risk-Adjusted Mortality Outcomes After Primary Surgery, Radiotherapy, or Androgen-Deprivation Therapy for Localized Prostate Cancer, by Matthew R. Cooperberg, Andrew J. Vickers, Jeanette M. Broering, and Peter R. Carroll,

BACKGROUND: Because no adequate randomized trials have compared active treatment modalities for localized prostate cancer, the authors analyzed risk-adjusted, cancer-specific mortality outcomes among men who underwent radical prostatectomy, men who received external-beam radiation therapy, and men who received primary androgendeprivation therapy.

METHODS: The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry comprises men from 40 urologic practice sites who are followed prospectively under uniform protocols, regardless of treatment. In the current study, 7538 men with localized disease were analyzed. Prostate cancer risk was assessed using the Kattan preoperative nomogram and the Cancer of the Prostate Risk Assessment (CAPRA) score, both well validated instruments that are calculated from clinical data at the time of diagnosis. A parametric survival model was constructed to compare outcomes across treatments adjusting for risk and age.

RESULTS: In total, 266 men died of prostate cancer during follow-up. Adjusting for age and risk, the hazard ratio for cancer-specific mortality relative to prostatectomy was 2.21 (95% confidence interval [CI], 1.50-3.24) for radiation therapy and 3.22 (95% CI, 2.16-4.81) for androgen deprivation. Absolute differences between prostatectomy and radiation therapy were small for men at low risk but increased substantially for men at intermediate and high risk. These results were robust to a variety of different analytic techniques, including competing risks regression analysis, adjustment by CAPRA score rather than Kattan score, and examination of overall survival as the endpoint.

CONCLUSIONS: Prostatectomy for localized prostate cancer was associated with a significant and substantial reduction in mortality relative to radiation therapy and androgen-deprivation monotherapy. Although this was not a randomized study, given the multiple adjustments and sensitivity analyses, it is unlikely that unmeasured confounding would account for the large observed differences in survival.

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