BCM HPJC (MEERM 628)

Proposals for expanding Medicare insurance coverage to uninsured Americans approaching the Medicare eligibility age of sixty-five has been the subject of intense debate. We undertook this study to assess cancer survival differences between uninsured patients younger than age sixty-five and older Medicare beneficiaries by using data from the National Cancer Database from the period 2004-16. The main outcomes were survival at one, two, and five years for sixteen cancer types in 1,206,821 patients. We found that uninsured patients ages 60-64 were nearly twice as likely to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy than Medicare beneficiaries ages 66-69, despite lower comorbidity among younger patients...

This article examines how the Affordable Care Act Medicaid expansions affected the sources of health insurance coverage of undergraduate students in the United States. We show that the Affordable Care Act expansions increased the Medicaid coverage of undergraduate students by 5 to 7 percentage points more in expansion states than in nonexpansion states, resulting in 17% of undergraduate students in expansion states being covered by Medicaid postexpansion (up from 9% prior to the expansion). In contrast, the growth in employer and private direct coverage was 1 to 2 percentage points lower postexpansion for students in expansion states compared with nonexpansion states...

The transition among many US physicians from independent practice to hospital employment has raised concerns about whether employed physicians will be more inclined to refer patients for hospital-based services that are unnecessary or inappropriate. Using claims data for 2009-16, we conducted a difference-in-differences analysis to investigate whether this form of hospital-physician integration is associated with inappropriate referrals for magnetic resonance imaging (MRI), a widely used mode of diagnostic imaging, for three common medical conditions: lower back pain, knee pain, and shoulder pain...

Importance: The US Government Accountability Office has changed its estimate of the annual costs of defensive medicine, largely because it has been difficult to objectively measure its impact. Evaluating the association of malpractice claims rates with hospital admission rates and the costs of admitting patients with low-risk conditions would help to document the impact of defensive medicine. Although syncope is a concerning symptom, most patients with syncope have a low risk of adverse outcomes...

Medicare's Merit-based Incentive Payment System (MIPS) includes episode-based cost measures that evaluate Medicare expenditures for specific conditions and procedures. These measures compare clinicians' cost performance and, along with other MIPS category scores, determine Medicare Part B clinician payment adjustments. The measures do not include risk adjustment for social risk factors. We found that adjusting for individual and community social risk did not have a meaningful impact on clinicians' cost measure performance...

OBJECTIVE: To examine which factors are driving improvement in the Dialysis Facility Compare (DFC) star ratings and to test whether nonclinical facility characteristics are associated with observed longitudinal changes in the star ratings. DATA SOURCES: Data were collected from eligible patients in over 6,000 Medicare-certified dialysis facilities from three annual star rating and individual measure updates, publicly released on DFC in October 2015, October 2016, and April 2018...

Private equity firms have increasingly acquired physician practices, and particularly dermatology practices. Analyzing commercial claims from the Health Care Cost Institute (2012-17), we used a difference-in-differences design within an event study framework to estimate the prevalence of private equity acquisitions and their impact on dermatologist prices, spending, utilization, and volume of patients. By 2017 one in eleven dermatologists practiced in a private equity-owned practice, and private equity-owned practices employed four advanced practitioners for every ten dermatologists compared with three for non-private equity practices...

Importance: Rigorous evidence describing the relationship between private equity acquisition and changes in hospital spending and quality is currently lacking. Objective: To examine changes in hospital income, use, and quality measures that may be associated with private equity acquisition. Design, Setting, and Participants: This cohort study identified 204 hospitals acquired by private equity firms from 2005 to 2017 and 532 matched hospitals not acquired by private equity...

CONTEXT: Social distancing is an essential but economically painful measure to flatten the curve of emergent infectious diseases. As the novel coronavirus that causes COVID-19 spread throughout the United States in early 2020, the federal government left to the states the difficult and consequential decisions about when to cancel events, close schools and businesses, and issue stay-at-home orders. METHODS: We present an original, detailed dataset of state-level social distancing policy responses to the epidemic, then apply event history analysis to study the timing of implementation of five social distancing policies across all fifty states...

Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement...

Importance: Health savings accounts (HSAs) can be used by enrollees in high-deductible health plans (HDHPs) to save for health care expenses before taxes. Expansion of and encouraging contributions to HSAs have been centerpieces of recent federal legislation. Little is known about how US residents who may be eligible for HSAs are using them to save for health care. Objective: To determine which patients who may be eligible for an HSA do not have one and what decisions patients with HSAs make about contributing to them...

Importance: The Affordable Care Act expanded access to Medicaid coverage in 2014 for individuals living in participating states. Whether expanded coverage was associated with increases in the use of outpatient surgical care, particularly among underserved populations, remains unknown. Objective: To evaluate the association between state participation in the Affordable Care Act Medicaid expansion reform and the use of outpatient surgical care. Design, Setting, and Participants: This case-control study used a quasi-experimental difference-in-differences design to compare the use of outpatient surgical care at the facility and state levels by patient demographic characteristics and payer categories (Medicaid, private insurance, and no insurance)...

OBJECTIVE: To measure the burden of financing health care costs and quantify redistribution among population groups. DATA SOURCES: A synthetic population using data combined from multiple sources, including the Survey of Income and Program Participation (SIPP), Medical Expenditure Panel Survey (MEPS), Kaiser Family Foundation (KFF)/Health Research Educational Trust (HRET) Employer Health Benefits Survey, American Community Survey (ACS), and National Health Expenditure Accounts (NHEA)...

State policies mandating public or community use of face masks or covers in mitigating the spread of coronavirus disease 2019 (COVID-19) are hotly contested. This study provides evidence from a natural experiment on the effects of state government mandates for face mask use in public issued by fifteen states plus Washington, D.C., between April 8 and May 15, 2020. The research design is an event study examining changes in the daily county-level COVID-19 growth rates between March 31 and May 22, 2020. Mandating face mask use in public is associated with a decline in the daily COVID-19 growth rate by 0...

OBJECTIVE: Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety-net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties. STUDY DESIGN: Retrospective cohort study. DATA SOURCES/STUDY SETTING: Claims data for 2 952 605 fee-for-service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015...

Using commercial claims for 2012-2013 from the Colorado All Payer Claims Database, we examine how medical service prices vary for five hospital-based procedures and the complexity-adjusted inpatient price. We find that prices vary substantially in multiple dimensions. Our analysis indicates that there is significant price variation across payers for the same service in the same hospital. If prices converged to the lowest rate each hospital receives, commercial expenditures would fall by 10% to 20%. Differences across hospitals account for an even more substantial amount of the overall variation...

In 2010 Maryland replaced fee-for-service payment for some rural hospitals with "global budgets" for hospital-provided services called Total Patient Revenue (TPR). A principal goal was to incentivize hospitals to manage resources efficiently. Using a difference-in-differences design, we compared eight TPR hospitals to seven similar non-TPR Maryland hospitals to estimate how TPR affected hospital-provided services. We also compared health care use by "treated" patients in TPR counties to that of patients in counties containing control hospitals...

Many countries use external reference pricing to help determine drug prices. However, external reference pricing has received little attention in the US-perhaps because the US is often the first adopter of drugs. External reference pricing could be used to set prices for drugs that were already established in the market. We compared the price differentials between the US and the UK, Japan, and Ontario (Canada) for single-source brand-name drugs that had been on the market for at least three years. We found that the prices averaged 3...

Because of workforce needs and demographic and chronic disease trends, nurse practitioners (NPs) and physician assistants (PAs) are taking a larger role in the primary care of medically complex patients with chronic conditions. Research shows good quality outcomes, but concerns persist that NPs' and PAs' care of vulnerable populations could increase care costs compared to the traditional physician-dominated system. We used 2012-13 Veterans Affairs data on a cohort of medically complex patients with diabetes to compare health services use and costs depending on whether the primary care provider was a physician, NP, or PA...

OBJECTIVES: To evaluate the impact of value-based insurance design (VBID), which removed patient cost sharing for primary care visits, on healthcare spending in a large, geographically diverse employer. STUDY DESIGN: Quasi-experimental, difference-in-differences (DID) design, administrative claims-based study. METHODS: Healthcare spending during the preintervention period (2008 and 2009) was compared with the postintervention period (2011 through 2014) to measure the impact of removing primary care cost sharing...