Diagnostic
Can Health Care Information Technology Save Babies?
Amalia Miller & Catherine Tucker
Journal of Political Economy, April 2011, Pages 289-324
Abstract:
Electronic medical records (EMRs) facilitate fast and accurate access to patient records, which could improve diagnosis and patient monitoring. Using a 12-year county-level panel, we find that a 10 percent increase in births that occur in hospitals with EMRs reduces neonatal mortality by 16 deaths per 100,000 live births. This is driven by a reduction of deaths from conditions requiring careful monitoring. We also find a strong decrease in mortality when we instrument for EMR adoption using variation in state medical privacy laws. Rough cost-effectiveness calculations suggest that EMRs are associated with a cost of $531,000 per baby's life saved.
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Are Drugs Substitutes or Complements for Intensive (and Expensive) Medical Treatment
Yuting Zhang, Joseph Newhouse & Katherine Baicker
American Economic Review, May 2011, Pages 393-397
Abstract:
Little is known about the relationship between variation in drug and non-drug medical treatment and how areas may substitute one type of care for the other. Using pharmacy and medical claims data for Medicare beneficiaries, we examine whether areas with more drug use have lower non-drug medical costs and how the quality of prescribing and primary care are associated with medical costs. We find that areas with higher drug spending do not have lower non-drug medical spending; however, poorer-quality prescribing and primary care are associated with higher medical spending in general and inpatient spending in particular.
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Health, Health Insurance, and Decision to Exit from Farming
Kuo-Liang Chang, George Langelett & Andrew Waugh
Journal of Family and Economic Issues, June 2011, Pages 356-372
Abstract:
The purpose of this paper is to study the influence of health and health insurance on farmers' exit decision-making process. Using data from 2000 to 2007 Medical Expenditure Panel Survey, we tested the following three hypotheses: (1) Health condition affects farmers' exit decision; (2) Having health insurance discourages farmers from exiting; (3) Obtaining health insurance helps farmers with physical health problems to continue farming. Empirical results indicated that having health insurance has a positive effect on encouraging farmers to continue farming regardless of health condition. The study results also suggested that farmer's health condition and access to health insurance have noticeably larger marginal impacts on farmer' exit decision than income and other commonly-considered socio-economic and demographic variables.
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Do mobile phones of patients, companions and visitors carry multidrug-resistant hospital pathogens?
Mehmet Sait Tekerekoǧlu et al.
American Journal of Infection Control, June 2011, Pages 379-381
Abstract:
A cross-sectional study was conducted to determine bacterial colonization on the mobile phones (MPs) used by patients, patients' companions, visitors, and health care workers (HCWs). Significantly higher rates of pathogens (39.6% vs 20.6%, respectively; P = .02) were found in MPs of patients' (n = 48) versus the HCWs' (n = 12). There were also more multidrug pathogens in the patents' MPs including methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing Escherichia coli, and Klebsiella spp, high-level aminoglycoside-resistant Enterococcus spp, and carabepenem-resistant Acinetobacter baumanii. Our findings suggest that mobile phones of patients, patients' companions, and visitors represent higher risk for nosocomial pathogen colonization than those of HCWs. Specific infection control measures may be required for this threat.
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How Do Employers React to a Pay-or-Play Mandate? Early Evidence from San Francisco
Carrie Colla, William Dow & Arindrajit Dube
Forum for Health Economics & Policy, 2011
Abstract:
In 2008 San Francisco implemented major health reform, becoming the first city to adopt a pay-or-play employer health spending mandate. It also created Healthy San Francisco, a new "public option" low-cost health access plan for the uninsured. This study evaluates employer-level health benefit offering responses to the pay-or-play mandate in the first year of implementation using the 2008 Bay Area Employer Health Benefits Survey and a difference-in-difference estimator. Although 92% of firms subject to the mandate already offered insurance prior to enactment, we find that 76% of firms had to expand benefits to comply with the minimum hourly spending requirement for each worker. Nevertheless, most surveyed San Francisco employers (61%) were supportive of the law. There is substantial employer demand for the public option, with 18% of firms using Healthy San Francisco for at least some employees, yet there is little evidence of firms dropping or restricting existing insurance offerings in the first year after implementation. A non-trivial portion of firms chose to meet the mandate by paying into health reimbursement accounts (14%). These results confirm that employer mandate details can have crucial effects on employer behavior. While there are important geographic and political characteristics of San Francisco that are important to bear in mind, San Francisco's early experience suggests that implementation of a strong pay-or-play mandate is indeed feasible.
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Yaniv Hanoch et al.
Health Psychology, forthcoming
Objective: The Medicare Modernization Act of 2003 (better known as Medicare Part D) represents the most important change to Medicare since its inception in the mid-1960s. The large number of drug plans being offered has raised concern over the complex design of the program. The purposes of this article are to examine the effect of age and choice set size (3 vs. 9 drug plans) on decision processes, strategy selection, and decision quality within the Medicare Part D program.
Method: One hundred fifty individuals completed a MouselabWeb study, a computer-based program that allowed us to trace the information acquisition process, designed to simulate the official Medicare Web site.
Results: The data reveal that participants identified the lowest cost plan only 46% of the time. As predicted, an increase in choice set size (3 vs. 9) was associated with 0.25 times the odds of correctly selecting the lowest cost plan, representing an average loss of $48.71. Older participants, likewise, tended to make poorer decisions.
Conclusion: The study provides some indication that decision strategy mediates the association between age and choice quality and provides further insight regarding how to better design a choice environment that will improve the performance of older consumers.
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Steven Pizer
Journal of Health Economics, forthcoming
Abstract:
Growth in the number of days between an appointment request and the actual appointment reduces demand. Although such waiting times are relatively low in the US, current policy initiatives could cause them to increase. We estimate multiple-equation models of physician utilization and insurance plan choice for Medicare-eligible veterans. We find that a 10% increase in VA waiting times increases demand for Medigap insurance by 5%, implying that a representative patient would be indifferent between waiting an average of 5 more days for VA appointments and paying $300 more in annual premium.
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Karen Eggleston et al.
American Economic Review, May 2011, Pages 206-211
Abstract:
Although US health care expenditures reached 17.6 percent of GDP in 2009, quality measurement in this important service sector remains limited. Studying quality changes associated with 11 years of health care for patients with diabetes, we find that the value of reduced mortality and avoided treatment spending, net of the increase in annual spending, was $9,094 for the average patient. These results suggest that the unit cost of diabetes treatment, adjusting for the value of health outcomes, has been roughly constant. Since input prices have not been declining, our results are consistent with productivity improvement in health care.
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Does Patient Use of Medical Information Affect Physician Practice Incentives to Provide Care?
Hai Fang & John Rizzo
Forum for Health Economics & Policy, 2011
Abstract:
Patients as consumers are assuming a more active role in their medical care decision-making, which has been prompted by better access to medical information. Patient use of medical information may affect physician practice incentives to provide care, which critically depends on the agency relationship between physician and patient. If patient use of medical information improves communication and understanding, physicians may need to spend less time explaining what treatments are needed and convincing patients about the appropriateness of their recommendations, increasing incentives to provide care. If patients use information to demand treatments and procedures that are at odds with what the physician would recommend, this might lead to a contentious relationship, making it more difficult to agree upon any course of treatment. We use the Community Tracking Study (CTS) physician survey data, a nationally representative sample in the United States, to study the effects of more-informed patients on physician incentives to provide care. We estimate ordinary least squares and ordered probit models, and apply instrumental variables method to correct for the potential endogeneity of the measure of more-informed patients. The empirical results indicate that more-informed patients appear to be reducing physician incentives to provide care. This is consistent with the view that patient use of medical information from alternative sources besides their own physician may be interfering with the physician's ability to provide care.
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Steven Mickelsen et al.
Academic Medicine, June 2011, Pages 726-730
Purpose: Emergency resuscitation or "code blue" is a clinical event through which responding medical residents gain experience and proficiency. A retooling of practice has occurred at academic medical centers since the emergence of quality improvement initiatives and resident duty hours limits. The authors investigated how these changes may impact code blue frequency and resident opportunities to gain clinical experience.
Method: The authors conducted a single-center, retrospective (2002-2009) review of monthly code blue frequency. They compared code blue frequency with corresponding monthly first-year internal medicine resident call schedules (2002-2008 academic years). Using a Monte Carlo simulation they estimated annual code blue experience, and using Poisson regression, they estimated annual trends in resident code blue experience.
Results: The authors detected a 41% overall reduction in code blue events between 2002 and 2008; code blue events decreased by 13% annually (P < .001). These trends persisted, even after accounting for hospital census fluctuations: Rates fell from approximately 12 code blue events/1,000 admissions in 2002 to 3.8 events/1,000 in 2008. Overall, the model of code blue frequency and resident call schedules shows a dramatic reduction in the predicted number of code blue experiences, falling from 29 events (empirical 95% CI 18-40) in academic year 2002 to 5 events (CI 1-9) in 2008.
Conclusions: Physicians-in-training at one facility are seeing far fewer code blue events than their predecessors. Whether current numbers of in-hospital code blue events are sufficient to provide adequate experience without supplemental practice for trainees is unclear.
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The Doctor Might See You Now: The Supply Side Effects of Public Health Insurance Expansions
Craig Garthwaite
NBER Working Paper, May 2011
Abstract:
In the United States, public health insurance programs cover over 90 million individuals. Changes in the scope of these programs, such as the Medicaid expansions under the recently passed Patient Protection and Affordable Care Act, may have large effects on physician behavior. This study finds that following the implementation of the State Children's Health Insurance Program, physicians decreased the number of hours spent with patients, but increased their participation in the expanded program. Suggestive evidence is found that this decrease in hours was a result of shorter office visits. These findings are consistent with the predictions from a mixed-economy model of physician behavior with public and private payers and also provide evidence of crowd out resulting from the creation of SCHIP.
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Medical Spending and the Health of the Elderly
Jack Hadley et al.
Health Services Research, forthcoming
Objective: To estimate the relationship between variations in medical spending and health outcomes of the elderly.
Data Sources: 1992-2002 Medicare Current Beneficiary Surveys.
Study Design: We used instrumental variable (IV) estimation to identify the relationships between alternative measures of elderly Medicare beneficiaries' medical spending over a 3-year observation period and health status, measured by the Health and Activity Limitation Index (HALex) and survival status at the end of the 3 years. We used the Dartmouth Atlas End-of-Life Expenditure Index defined for hospital referral regions in 1996 as the exogenous identifying variable to construct the IVs for medical spending.
Data Collection/Extraction Methods: The analysis sample includes 17,438 elderly (age >64) beneficiaries who entered the Medicare Current Beneficiary Survey in the fall of each year from 1991 to 1999, were not institutionalized at baseline, stayed in fee-for-service Medicare for the entire observation period, and survived for at least 2 years. Measures of baseline health were constructed from information obtained in the fall of the year the person entered the survey, and changes in health were from subsequent interviews over the entire observation period. Medicare and total medical spending were constructed from Medicare claims and self-reports of other spending over the entire observation period.
Principal Findings: IV estimation results in a positive and statistically significant relationship between medical spending and better health: 10 percent greater medical spending over the prior 3 years (mean=U.S.$2,709) is associated with a 1.9 percent larger HALex value (p=.045; range 1.2-2.2 percent depending on medical spending measure) and a 1.5 percent greater survival probability (p=.039; range 1.2-1.7 percent).
Conclusions: On average, greater medical spending is associated with better health status of Medicare beneficiaries, implying that across-the-board reductions in Medicare spending may result in poorer health for some beneficiaries.
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How Do Consumer-Directed Health Plans Affect Vulnerable Populations?
Amelia Haviland et al.
Forum for Health Economics & Policy, 2011
Abstract:
We use health care claims data from 59 large employers to estimate how consumer-directed health plans (CDHPs)-plans that combine a high deductible with personal accounts-affect health care costs and the use of preventive services by vulnerable populations. The vulnerable populations studied are those that will have increased access to health insurance under health care reform: families with high health care needs and low income families. A difference-in-difference framework is used with costs and use available for a full year before and after enrolling in a CDHP and for controls. Our key finding is that in almost all cases, CDHP benefit designs affect lower income populations and the chronically ill to the same extent as non-vulnerable populations. These effects include significant reductions in overall spending that increase with the level of the deductible and greater reductions for high deductible plans when paired with health savings accounts (HSAs) in comparison to health reimbursement arrangements (HRAs). However, enrollment in CDHPs also leads to reductions in care that is considered beneficial for all groups, and this may have greater health consequences for lower income and chronically ill people than for others.
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The welfare gain from replacing the health insurance tax exclusion with lump-sum tax credits
Liqun Liu, Andrew Rettenmaier & Thomas Saving
International Journal of Health Care Finance and Economics, June 2011, Pages 101-113
Abstract:
This paper analyzes the welfare gain from replacing the tax exclusion of employer-provided health insurance with a lump-sum tax credit. It differs from earlier studies in that we look at the welfare cost of health insurance tax exclusion as coming directly from excessive health insurance rather than from overconsumption of medical care and that we account for the labor market effect of the tax exclusion on welfare. Both differences work to produce a smaller tax reform welfare gain. For a set of mid-range parameter values, the welfare gain is about 21% of current health insurance tax expenditures. In addition, government tax expenditures would fall by 38%, and health insurance spending would fall by 77% after the reform.
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A Lockean Argument for Universal Access to Health Care
Daniel Hausman
Social Philosophy and Policy, July 2011, Pages 166-191
Abstract:
This essay defends the controversial and indeed counterintuitive claim that there is a good argument to be made from a Lockean perspective for government action to guarantee access to health care. The essay maintains that this argument is in some regards more robust than the well-known argument in defense of universal health care spelled out by Norman Daniels, which this essay also examines in some detail. Locke's view that government should protect people's lives, property, and freedom-where freedom is understood as independence and self-determination-justifies government action to ensure access to health care, because (roughly), just as individuals cannot protect themselves from crime and foreign invasion, so individuals are unable to provide for their own health care. Defense from disease is as important as defense from crime, and-although this is arguable-government action to guarantee access to health care does not itself undermine freedom.
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Where Would You Go for Your Next Hospitalization?
Kyoungrae Jung, Roger Feldman & Dennis Scanlon
Journal of Health Economics, forthcoming
Abstract:
We examine the effects of diverse dimensions of hospital quality-including consumers' perceptions of unobserved attributes-on future hospital choice. We utilize consumers' stated preference weights to obtain hospital-specific estimates of perceptions about unmeasured attributes such as reputation. We report three findings. First, consumers' perceptions of reputation and medical services contribute substantially to utility for a hospital choice. Second, consumers tend to select hospitals with high clinical quality scores even before the scores are publicized. However, the effect of clinical quality on hospital choice is relatively small. Third, satisfaction with a prior hospital admission has a large impact on future hospital choice. Our findings suggest that including measures of consumers' experience in report cards may increase their responsiveness to publicized information, but other strategies are needed to overcome the large effects of consumers' beliefs about other quality attributes.
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Timothy Page
International Journal of Health Care Finance and Economics, June 2011, Pages 133-144
Abstract:
Between 1993 and 1995 Medicare increased the coverage of immunosuppression medication for kidney transplant recipients from 1 to 3 years following transplantation. The universal Medicare eligibility among kidney transplant patients provides a unique opportunity to explore labor supply responses to public insurance provision among a large number of men and women of prime working age and of all income levels. Although these patients are likely to be less healthy than the general population, upon receiving a kidney transplant, the main health problem of an individual with kidney failure, the lack of functioning kidneys, is removed. The income effects associated with the large transfer payment may discourage labor supply, while the potential health benefits of the coverage extension may promote labor supply. Results indicate that Medicare's increased medication coverage led to decreases in labor force participation among part time workers. These results suggest that potential labor supply reducing income effects should be taken into account when discussing the possibility of expanded public health insurance coverage, particularly for other groups of individuals with high expected medical expenditures, such as the elderly, or those with chronic conditions, such as diabetes. These results are useful considering the forthcoming expansion of government aid to purchase health insurance.
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Bayes' Theorem and the Physical Examination: Probability Assessment and Diagnostic Decision Making
Scott Herrle et al.
Academic Medicine, May 2011, Pages 618-627
Purpose: To determine how examination findings influence the probability assessment and diagnostic decision making of third- and fourth-year medical students, internal medicine residents, and academic general internists.
Method: In a 2008 cross-sectional, Web-based survey, participants from three medical schools were asked questions about their training and eight examination scenarios representing four conditions. Participants were given literature-derived preexamination probabilities for each condition and were asked to (1) estimate postexamination probabilities (post-EPs) and (2) select a diagnostic choice (report that condition is present, order more tests, or report that condition is absent). Participants' inverse transformed logit (ITL) mean post-EPs were compared with corresponding literature-derived post-EPs.
Results: Of 906 individuals invited to participate, 684 (75%) submitted a completed survey. In two of four scenarios with positive findings, the participants' ITL mean post-EPs were significantly less than corresponding literature-derived post-EP point estimates (P < .001 for each). In three of four scenarios with negative findings, ITL mean post-EPs were significantly greater than corresponding literature-derived post-EP point estimates (P < .001 for each). In the four scenarios with positive findings, 17% to 38% of participants ordered more diagnostic tests when the literature indicated a >85% probability that the condition was present. In the four scenarios with largely negative findings, 70% to 85% chose to order diagnostic tests to further reduce diagnostic uncertainty.
Conclusions: All three groups tended to similarly underestimate the impact of examination findings on condition probability assessment, especially negative findings, and often ordered more tests when probabilities indicated that additional testing was unnecessary.