Reading list

More Evidence of the Association Between Hospital Market Concentration and Higher Prices and Profits, by James C. Robinson (NIHCM)

In this essay, Dr. James Robinson presents results from his latest work showing that the prices hospitals charge to private insurers for 6 common procedures are 30 to 50 percent higher when the hospital is located in a market where it faces less competition from other hospitals. These findings add to the already substantial body of research showing that consolidation in hospital markets confers market power that enables hospitals to secure higher prices. When seen in the context of current policies encouraging additional provider consolidation through accountable care organizations, this work serves as an important reminder that ongoing vigilance of the potential anti-competitive effects of these new delivery systems is needed along with other measures to counteract growing market power of providers.

Promoting Healthy Competition in Health Insurance Exchanges: Options and Trade-offs, by Chapin White (NIHCR Policy Analysis)

Under national health reform, new federal rules will govern the nongroup and small-group health insurance markets, including a requirement for state-based health insurance exchanges, or marketplaces, to be operational by Jan. 1, 2014. Between now and then, both the federal government and states must make key decisions about the design and operation of the exchanges. This Policy Analysis examines five design decisions that federal and state governments will face related to the degree of benefit and premium standardization of health insurance products sold in the exchanges. Within broad federal guidelines, states inevitably will make different policy decisions, but all states will face a similar set of trade-offs. The most basic trade-off is between simplicity and flexibility—a highly standardized health insurance market simplifies the consumer shopping experience and intensifies insurer competition but limits insurers’ flexibility to develop innovative products. While these policy decisions involve fairly arcane concepts—such as quantifying the actuarial value, or comprehensiveness—of coverage—the overarching question for federal and state policy makers is straightforward: How can the exchanges promote healthy competition among insurers to provide better health care at lower total cost?

Use of UpToDate and outcomes in US hospitals, by Thomas Isaac, Jie Zheng and Ashish Jha. (Journal of Hospital Medicine)

BACKGROUND:  Computerized clinical knowledge mana-gement systems hold enormous potential for improving quality and efficiency. However, their impact on clinical practice is not well known.

OBJECTIVE:  To examine the impact of UpToDate on outcomes of care.

DESIGN:  Retrospective study.

SETTING:  National sample of US inpatient hospitals.

PATIENTS:  Fee-for-service Medicare beneficiaries.

INTERVENTION:  Adoption of UpToDate in US hospitals.

MEASUREMENT:  Risk-adjusted lengths of stay, mortality rates, and quality performance.

RESULTS:  We found that patients admitted to hospitals using UpToDate had shorter lengths of stay than patients admitted to non-UpToDate hospitals overall (5.6 days vs 5.7 days; P < 0.001) and among 6 prespecified conditions (range, −0.1 to −0.3 days; P < 0.001 for each). Further, patients admitted to UpToDate hospitals had lower risk-adjusted mortality rate for 3 of the 6 conditions (range, −0.1% to −0.6% mortality reduction; P < 0.05). Finally, hospitals with UpToDate had better quality performance for every condition on the Hospital Quality Alliance metrics. In subgroup analyses, we found that it was the smaller hospitals and the non-teaching hospitals where the benefits of the UpToDate seemed most pronounced, compared to the larger, teaching institutions where the benefits of UpToDate seemed small or nonexistent.

CONCLUSIONS:  We found a very small but consistent association between use of UpToDate and reduced length of stay, lower risk-adjusted mortality rates, and better quality performance, at least in the smaller, non-teaching institutions. These findings may suggest that computerized tools such as UpToDate could be helpful in improving care.

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