Reading list

The Trade-Off Among Quality, Quantity, And Cost: How To Make It—If We Must, by Mark V. Pauly (Health Affairs)

The Affordable Care Act, with its subsidies, demonstrations, commissions, and study groups, embodies a considerable amount of regulatory and policy pressure on markets to improve the quality of health care. However, it is possible that this government-led movement will lead to a lot of talk about quality but not necessarily much improvement. A better strategy may be found through “disruptive innovation,” a market-driven approach that has balanced cost and quality in other industries. An example would be to provide lower-cost substitutes for some aspects of primary physician care, in the form of care at a retail clinic. Consumers might not perceive a clinic as a perfect substitute for physician care, but they might prefer the greater convenience and lower cost. Perhaps a little less quality for a lot less money might be acceptable to consumers and taxpayers, as we work to keep medical spending from siphoning off funds required for other needs.

Variations In Efficiency And The Relationship To Quality Of Care In The Veterans Health System, by Jian Gao, Eileen Moran, Peter L. Almenoff, Marta L. Render, James Campbell and Ashish K. Jha (Health Affairs)

There is widespread belief that the US health care system could realize significant improvements in efficiency, savings, and patient outcomes if care were provided in a more integrated and accountable way. We examined efficiency and its relationship to quality of care for medical centers run by the Veterans Health Administration of the Department of Veterans Affairs (VA), a national, vertically integrated health care system that is accountable for a large patient population. After devising a statistical model to indicate efficiency, we found that VA medical centers were highly efficient. We also found only modest variation in the level of efficiency and cost across VA medical centers, and a positive correlation overall between greater efficiency and higher inpatient quality. These findings for VA medical centers suggest that efforts to drive integration and accountability in other parts of the US health care system might have important payoffs in reducing variations in cost without sacrificing quality. Policy makers should focus on what aspects of certain VA medical centers allow them to provide better care at lower costs and consider policies that incentivize other providers, both within and outside the VA, to adopt these practices.

The Case For Measuring Quality In Mental Health And Substance Abuse Care, by Harold Alan Pincus, Brigitta Spaeth-Rublee, and Katherine E. Watkins (Health Affairs)

Over the past decade, efforts to measure and improve quality have permeated health policy and health care generally but have barely penetrated mental health and substance abuse care. We review barriers and recent activities in these areas and propose a short list of quality measures to engage the policy and practice community in a discussion about how best to evaluate the care of people with these conditions. Quality measures could include, for example, screening, brief intervention, and referral for alcohol abuse. Because proposing a list is only a first step, we suggest other elements of a broader strategy to bring mental health and substance use care into the mainstream of health care quality improvement.

Playing Fair: Fairness Beliefs and Health Policy Preferences in the United States, by Julia Lynch and Sarah E. Gollust (JHPPL)

Conventional wisdom suggests that the best way to persuade Americans to support changes in health care policy is to appeal to their self-interest — particularly to concerns about their economic and health security. An alternative strategy, framing problems in the health care system to emphasize inequalities, could also, however, mobilize public support for policy change by activating underlying attitudes about the unfairness or injustice of these inequalities. In this article, we draw on original data from a nationally representative survey to describe Americans’ beliefs about fairness in the health domain, including their perceptions of the fairness of particular inequalities in health and health care. We then assess the influence of these fairness considerations on opinions about the appropriate role of private actors versus government in providing health insurance. Respondents believe inequalities in access to and quality of health care are more unfair than unequal health outcomes. Even after taking into account self-interest considerations and the other usual suspects driving policy opinions, perceptions of the unfairness of inequalities in health care strongly influence respondents’ preferences for government provision of health insurance.

How Not to Reform Medicare, by Henry J. Aaron (NEJM)

Listening to Provenge — What a Costly Cancer Treatment Says about Future Medicare Policy, by James D. Chambers and Peter J. Neumann (NEJM)

Women and Children Last — The Predictable Effects of Proposed Federal Funding Cuts, by George J. Annas and Wendy K. Mariner (NEJM)

Medicaid at a Crossroads, by John K. Iglehart

The History and Politics of Health Care in America: From the Progressive Era to the Patient Protection and Affordable Care Act, by Max J. Skidmore (Poverty and Public Policy)

Max J. Skidmore surveys the history and politics of the development of health care delivery in the United States, and reviews Health Care Reform and American Politics: What Everyone Needs to Know, by Lawrence R. Jacobs and Theda Skocpol. This study, by two prominent scholars of health care in America, is a detailed analysis of the process that led to adoption of the Patient Protection and Affordable Care Act of 2010, and of the details of the Act.

Does doctors’ experience matter in LASIK surgeries? by Juan M. Contreras, Beomsoo Kim, and Ignez M. Tristao (Health Economics)

In this article, we use a longitudinal census of laser in situ keratomileusis (LASIK) eye surgeries collected directly from patient charts to examine the learning-by-doing hypothesis in medicine. LASIK surgery has precise measures of presurgical condition and postsurgical outcomes. Unlike other types of surgery, the impact of unobservable underlying patient conditions on outcomes is minimal. Individual learning by doing is identified through observations of surgical outcomes over time, based on the cumulative number of surgeries performed. Collective learning is identified separately, through changes in a group adjustment rule determined jointly by all the surgeons in a structured internal review process. Our unique data set overcomes some of the measurement problems in patient outcomes encountered in other studies and improves the possibility of identifying and separating the impact of learning by doing from other effects. We cannot conclude that the outcome of LASIK surgery improves as an individual surgeon’s experience increases, but we find strong evidence that experience accumulated by surgeons as a group in a clinic significantly improves outcomes.

Health plan enrollment and mortality in the Medicare program, by Bryan Dowd, Matthew L. Maciejewski, Heidi O’Connor, Gerald Riley, and Yisong Geng

Prior studies have found that Medicare health maintenance organization (HMO) enrollees have lower mortality (over a fixed observation period) than beneficiaries in traditional fee-for-service (FFS) Medicare. We use Medicare Current Beneficiary Survey (MCBS) data to compare 2-year predicted mortality for Medicare enrollees in the HMO and FFS sectors using a sample selection model to control for observed beneficiaries characteristics and unobserved confounders. The difference in raw, unadjusted mortality probabilities was 0.5% (HMO lower). Correcting for numerous observed confounders resulted in a difference of −0.6% (HMO higher). Further adjustment for unobserved confounders resulted in an estimated difference of 3.7 and 4.2% (HMO lower), depending on the specification of geographic-fixed effects. The latter result (4.2%) was statistically significant and consistent with prior studies that did not adjust for unobserved confounding. Our findings suggest there may be unobserved confounders associated with adverse selection in the HMO sector, which had a large effect on our mortality estimates among HMO enrollees. An important topic for further research is to identify such confounders and explore their relationship to mortality. The methods presented in this paper represent a promising approach to comparing outcomes between the HMO and FFS sectors, but further research is warranted.

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