Reading list

Swiss Experiment Shows Physicians, Consumers Want Significant Compensation To Embrace Coordinated Care, by Peter Zweifel (Health Affairs)

Policy makers in several industrial countries are seeking to limit the rise in health care cost growth by supporting coordinated or integrated care programs, which differ from most prevailing forms of medical organization in how physicians are paid and how they work in groups. However, as long as fee-for-service payment systems remain an option, general practitioners will be reluctant to embrace coordinated care because it would give them less autonomy in how they practice. A study in Switzerland indicates that general practitioners will require a pay increase of up to 40 percent before they are willing to accept coordinated care, and a similar study found that Swiss consumers wanted a substantial reduction in premiums to accept it. These findings suggest that provisions of US health care reform designed to encourage the growth of coordinated care—such as accountable care organizations and medical homes—may face a challenging future.

Assessment of Cost Trends and Price Differences for U.S. Hospitals, M. Guerin-Calvert and G. Israilevich. Provided without endorsement (as I do with all items in “Reading lists”), this report presents AHA’s view of hospital price dynamics. If you read it, keep asking yourself whether causality or correlation is illustrated. Another good question is, how much does R-squared reveal about the “quality” of a model?

Using HMOs to serve the Medicaid population: what are the effects on utilization and does the type of HMO matter? by Bradley Herring and E. Kathleen Adams (Health Economics)

States have increasingly used Health Maintenance Organizations (HMOs) to provide medical services to the Medicaid population. However, the effects of these initiatives on total health-care expenses, the mix of utilization, and access to care remain unclear. We examine the effect of changes in Medicaid HMO penetration between 1996 and 2002 on these outcomes using data for the nonelderly Medicaid population in the Community Tracking Study’s Household Survey. We develop market-level measures of Medicaid HMO penetration from CMS and InterStudy data, distinguish whether the HMOs specialize in serving the Medicaid population, and use a market fixed-effects model to focus on changes in HMO penetration rates over time. Although limited by imprecise estimates, we find some evidence that utilization and access are related to the market penetration rates of commercial and Medicaid-dominant HMOs, but the pattern of results we observe does not appear to be consistent with welfare improvements.

Does leaving welfare improve health? Evidence for Germany, by Martin Huber, Michael Lechner, and Conny Wunsch (Health Economics)

Using exceptionally rich linked administrative and survey information on German welfare recipients we investigate the health effects of transitions from welfare to employment and of assignments to welfare-to-work programmes. Applying semi-parametric propensity score matching estimators we find that employment substantially increases (mental) health. The positive effects are mainly driven by males and individuals with bad initial health conditions and are largest for males with poor health. In contrast, the effects of welfare-to-work programmes, including subsidised jobs, are ambiguous and statistically insignificant for most outcomes.

The Effect of Medicaid Expansions on the Health Insurance Coverage of Pregnant Women: An Analysis Using Deliveries, by Dhaval M. Dave Sandra L. Decker Robert Kaestner Kosali Ilayperuma Simon (Inquiry)

Using data from the National Hospital Discharge Survey, this paper analyzes the effect of Medicaid eligibility expansions from 1985 to 1996 on the health insurance coverage of women giving birth. We find that the eligibility expansions reduced the proportion of pregnant women who were uninsured by approximately 10%, although the magnitude of this decrease is sensitive to specification. The decrease in the proportion of uninsured pregnant women came at the expense of a substantial reduction in private insurance coverage (crowd-out) of at least 55%. Substantial crowd-out and the relatively small change in the proportion uninsured suggest that Medicaid eligibility expansions may have had small effects on infant and maternal health.

Geographic Variation in Diagnosis Frequency and Risk of Death Among Medicare Beneficiaries, by H. Gilbert Welch, Sandra M. Sharp, Dan J. Gottlieb, Jonathan S. Skinner, John E. Wennberg (JAMA)

Context. Because diagnosis is typically thought of as purely a patient attribute, it is considered a critical factor in risk-adjustment policies designed to reward efficient and high-quality care.

Objective. To determine the association between frequency of diagnoses for chronic conditions in geographic areas and case-fatality rate among Medicare beneficiaries.

Design, Setting, and Participants. Cross-sectional analysis of the mean number of 9 serious chronic conditions (cancer, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, peripheral artery disease, severe liver disease, diabetes with end-organ disease, chronic renal failure, and dementia) diagnosed in 306 hospital referral regions (HRRs) in the United States; HRRs were divided into quintiles of diagnosis frequency. Participants were 5 153 877 fee-for-service Medicare beneficiaries in 2007.

Main Outcome Measures. Age/sex/race–adjusted case-fatality rates.

Results. Diagnosis frequency ranged across HRRs from 0.58 chronic conditions in Grand Junction, Colorado, to 1.23 in Miami, Florida (mean, 0.90 [95% confidence interval {CI}, 0.89-0.91]; median, 0.87 [interquartile range, 0.80-0.96]). The number of conditions diagnosed was related to risk of death: among patients diagnosed with 0, 1, 2, and 3 conditions the case-fatality rate was 16, 45, 93, and 154 per 1000, respectively. As regional diagnosis frequency increased, however, the case fatality associated with a chronic condition became progressively less. Among patients diagnosed with 1 condition, the case-fatality rate decreased in a stepwise fashion across quintiles of diagnosis frequency, from 51 per 1000 in the lowest quintile to 38 per 1000 in the highest quintile (relative rate, 0.74 [95% CI, 0.72-0.76]). For patients diagnosed with 3 conditions, the corresponding case-fatality rates were 168 and 137 per 1000 (relative rate, 0.81 [95% CI, 0.79-0.84]).

Conclusion. Among fee-for-service Medicare beneficiaries, there is an inverse relationship between the regional frequency of diagnoses and the case-fatality rate for chronic conditions.

State-Based, Single-Payer Health Care — A Solution for the United States?, by William C. Hsiao (NEJM)

Integrating Care through Bundled Payments — Lessons from the Netherlands, by Jeroen N. Struijs, and Caroline A. Baan (NEJM)

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