• Reading list

    Moving beyond Parity — Mental Health and Addiction Care under the ACA, by Colleen L. Barry and Haiden A. Huskamp (NEJM)

    The Doctor’s Dilemma — What Is “Appropriate” Care? by Victor R. Fuchs (NEJM)

    Rising Hospital Employment of Physicians: Better Quality, Higher Costs? by Ann S. O’Malley, Amelia M. Bond, Robert A. Berenson (Center for Studying Health System Change)

    In a quest to gain market share, hospital employment of physicians has accelerated in recent years to shore up referral bases and capture admissions, according to the Center for Studying Health System Change’s (HSC) 2010 site visits to 12 nationally representative metropolitan communities. Stagnant reimbursement rates, coupled with the rising costs of private practice, and a desire for a better work-life balance have contributed to physician interest in hospital employment. While greater physician alignment with hospitals may improve quality through better clinical integration and care coordination, hospital employment of physicians does not guarantee clinical integration. The trend of hospital-employed physicians also may increase costs through higher hospital and physician commercial insurance payment rates and hospital pressure on employed physicians to order more expensive care. To date, hospitals’ primary motivation for employing physicians has been to gain market share, typically through lucrative service-line strategies encouraged by a fee-for-service payment system that rewards volume. More recently, hospitals view physician employment as a way to prepare for payment reforms that shift from fee for service to methods that make providers more accountable for the cost and quality of patient care.

    Trends in Care for Uninsured Adults and Disparities in Care by Insurance Status, by Lindsay M. Sabik and Bassam A. Dahman (MCRR)

    The uninsured fare worse than the insured on various measures, yet there is little evidence regarding trends in care for the uninsured and disparities by insurance status. Given changes in the health care system and the safety net, disparities between insured and uninsured populations may be changing over time. This article considers trends in access, chronic disease control, and heart attack care by insurance status and the disparity in these measures between uninsured and insured nonelderly adults, controlling for demographic characteristics to account for potential changes in the composition of these populations. Rates for the uninsured for all outcomes have generally been stable from the mid-1990s to mid-2000s, with fluctuation in some measures over shorter periods. In addition, there is a persistent disparity between the privately insured and uninsured on access measures. The gap between the uninsured and insured has not narrowed, though disparities generally have not worsened either.

    The Association Between Hospital Margins, Quality of Care, and Closure or Other Change in Operating Status, by Dan P. Ly, Ashish K. Jha and Arnold M. Epstein (JGIM)

    BACKGROUND. Hospitals face increased pressure to improve their quality of care in an environment of dwindling hospital payments. It is unclear whether lower hospital margins are associated with worse quality of care or closure.

    OBJECTIVE. To determine the association of hospital margins with quality of care and changes in operating status.

    DESIGN, SUBJECTS, AND MAIN MEASURES. We conducted an observational cross-sectional study analyzing hospitals’ margin, quality of care (process quality, risk-adjusted readmission rates, and risk-adjusted mortality rates), and changes in operating status (rates of closure, merger and acquisition, and conversion to a critical access hospital) for 3,262 non-public U.S. hospitals with data from the Hospital Quality Alliance and Medicare Cost Reports.

    KEY RESULTS. Compared to those in the bottom 10% of operating margin, those in the top 10% had higher process quality (e.g. 95.3 vs. 93.7, p = 0.002 for acute myocardial infarction [AMI]) and lower readmission rates (e.g. 19.7% vs. 22.4%, p < 0.001 for AMI). We found no association between margins and mortality rates. Hospitals in the bottom 10% were more likely than those in the top 10% to close (5.7% vs. 2.0%), merge or become acquired (4.0% vs. 0.3%), or convert to a Critical Access Hospital (5.4% vs. 0.6%). Over 15% of hospitals in the lowest decile of hospital margin changed operating status in the subsequent year.

    CONCLUSIONS. Low hospital margins are associated with worse processes of care and readmission rates and with changes in operating status. We should monitor low-margin hospitals closely for declining quality of care.

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