In Practice
Dwight Golann
Health Affairs, July 2011, Pages 1343-1350
Abstract:
Most medical malpractice claims are neither settled nor adjudicated. Instead, they are abandoned by the plaintiffs who bring them. This study measured the frequency and cost of abandoned claims and gathered opinions from attorneys and other experts on why plaintiffs drop claims. Plaintiffs in the study abandoned 58.6 percent of claims against defendants, while settling only 26.6 percent and adjudicating 14.8 percent. Claims are not dropped because a large percentage of them are frivolous, but for other reasons. The most important is that as plaintiffs acquire more information in the course of a lawsuit, they often conclude that a claim is weaker than they had first thought. The author recommends that insurers and hospitals adopt new procedures to encourage both plaintiff attorneys and defense representatives to exchange information more efficiently, discuss the merits of malpractice cases more candidly, and resolve cases quickly. Such reforms would greatly reduce both the frequency and the duration of cases that are dropped, and thus the cost of malpractice litigation.
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Carrie Colla, William Dow & Arindrajit Dube
NBER Working Paper, July 2011
Abstract:
A key issue surrounding employer benefit mandates is the incidence on workers through wages and employment. In this paper, we address this question using a pay-or-play policy implemented in San Francisco in 2008 that requires employers to either provide health benefits or contribute to a public option health plan. We estimate the impact on employment and earnings for the private sector overall, as well as for high impact sectors: retail and accommodation and food services. We develop a novel approach for individual case studies by combining both spatial discontinuity in policies and permutation-type inference using other MSAs. We find that, compared to control counties, employment and earnings patterns in San Francisco did not change appreciably following the policy. This was true for industries most affected by the mandate, as well as for overall private sector employment. The results are generally robust to inclusion of different control groups, county-specific time trends, and varying pre-periods. In contrast to the small effects on the labor market, we do find that about 25% of surveyed restaurants imposed customer surcharges, with the median surcharge being 4% of the bill. These results indicate that while little of the burden of the mandate fell on San Francisco workers, approximately half of the incidence of the mandate fell on consumers.
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Samantha Roberts, Jeff Allen & Ellen Sigal
Health Affairs, July 2011, Pages 1375-1381
Abstract:
The US Food and Drug Administration is often criticized as inefficient compared to its European counterpart, the European Medicines Agency. This criticism is especially common in the field of oncology, where severely ill patients have few therapeutic options. We conducted a direct drug-to-drug comparison of the two regulatory agencies' approvals of new oncology drugs. We found that contrary to public assertions, the median time for approval for new cancer medicines in the United States was just six months - and that these new anticancer medicines are typically available in the United States before they are in Europe. Our findings reinforce the need for strong financial and public support of the Food and Drug Administration, so that such medicines can continue to be made available speedily to patients in need.
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The Oregon Health Insurance Experiment: Evidence from the First Year
Amy Finkelstein et al.
NBER Working Paper, July 2011
Abstract:
In 2008, a group of uninsured low-income adults in Oregon was selected by lottery to be given the chance to apply for Medicaid. This lottery provides a unique opportunity to gauge the effects of expanding access to public health insurance on the health care use, financial strain, and health of low-income adults using a randomized controlled design. In the year after random assignment, the treatment group selected by the lottery was about 25 percentage points more likely to have insurance than the control group that was not selected. We find that in this first year, the treatment group had substantively and statistically significantly higher health care utilization (including primary and preventive care as well as hospitalizations), lower out-of-pocket medical expenditures and medical debt (including fewer bills sent to collection), and better self-reported physical and mental health than the control group.
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James Robinson
Health Affairs, July 2011, Pages 1265-1271
Abstract:
The coverage expansions planned under the Affordable Care Act are to be financed in part by slowing Medicare payment updates to hospitals, thereby reigniting the debate over whether low prices paid by public payers cause hospitals to increase prices to private insurers-a practice known as cost shifting. Recently, the Medicare Payment Advisory Commission (MedPAC) proposed an alternative explanation of hospital pricing and profitability that could be used to support policies that pressure hospitals to reduce overall costs rather than to only raise prices. This study evaluated the cost-shift and MedPAC perspectives using 2008 data on hospital margins for 30,514 Medicare and privately insured patients undergoing any of seven major procedures in markets where robust hospital competition exists and in markets where hospital care is concentrated in the hands of a few providers. The study presents empirical evidence that, faced with shortfalls between Medicare payments and projected costs, hospitals in concentrated markets focus on raising prices to private insurers, while hospitals in competitive markets focus on cutting costs. Policy makers need to examine whether efforts to promote clinical coordination through provider integration may interfere with efforts to restrain overall health care cost growth by restraining Medicare payment rates.
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Joshua Williams et al.
Journal of General Internal Medicine, forthcoming
Background: Little is known about how often patients desire and experience discussions with hospital personnel regarding R/S (religion and spirituality) or what effects such discussions have on patient satisfaction.
Objective, Design and Participants: We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center.
Main Measures: Primary outcomes were whether or not patients desired to have their religious or spiritual concerns addressed while hospitalized, whether or not anyone talked to them about religious and spiritual issues, and which member of the health care team spoke with them about these issues. Primary predictors were patients' ratings of their religious attendance, their efforts to carry their religious beliefs over into other dealings in life, and their spirituality.
Key Results: Forty-one percent of inpatients desired a discussion of R/S concerns while hospitalized, but only half of those reported having such a discussion. Overall, 32% of inpatients reported having a discussion of their R/S concerns. Religious patients and those experiencing more severe pain were more likely both to desire and to have discussions of spiritual concerns. Patients who had discussions of R/S concerns were more likely to rate their care at the highest level on four different measures of patient satisfaction, regardless of whether or not they said they had desired such a discussion (odds ratios 1.4-2.2, 95% confidence intervals 1.1-3.0).
Conclusions: These data suggest that many more inpatients desire conversations about R/S than have them. Health care professionals might improve patients' overall experience with being hospitalized and patient satisfaction by addressing this unmet patient need.
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William Hsiao et al.
Health Affairs, July 2011, Pages 1232-1241
Abstract:
Single-payer health care systems consist of publicly financed insurance that provides basic benefits for all citizens. The design is intended to achieve universal coverage and allow greater cost control. Many states have attempted to reform their systems around single-payer principles, but none succeeded until Vermont enacted a law in May 2011. In this article we describe how our team developed a viable single-payer proposal that served as the foundation of Vermont's law. According to our estimates, after the first full year of operation in 2015, our proposed single-payer system is expected to produce an annual savings of 25.3 percent when compared to current state health spending levels; cut employer and household health care spending by $200 million; create 3,800 jobs; and boost the state's overall economic output by $100 million. We describe how this plan was designed, and we discuss lessons for other states considering health system reform.
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Physician-leaders and hospital performance: Is there an association?
Amanda Goodall
Social Science & Medicine, forthcoming
Abstract:
Although it has long been conjectured that having physicians in leadership positions is valuable for hospital performance, there is no published empirical work on the hypothesis. This cross-sectional study reports the first evidence. Data were collected on the top-100 U.S. hospitals in 2009, as identified by a widely-used media-generated ranking of quality, in three specialties: Cancer, Digestive Disorders, and Heart and Heart Surgery. The personal histories of the 300 chief executive officers of these hospitals were then traced by hand. The CEOs are classified into physicians and non-physician managers. The paper finds a strong positive association between the ranked quality of a hospital and whether the CEO is a physician or not (p<0.001). This kind of cross-sectional evidence does not establish that physician-leaders outperform professional managers, but it is consistent with such claims and suggests that this area is now an important one for systematic future research.
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Mary Takach
Health Affairs, July 2011, Pages 1325-1334
Abstract:
This article describes patient-centered medical home initiatives that seventeen states have launched. These initiatives use national recognition or state-based qualification standards along with incentive payments to address soaring costs and lagging health outcomes in state Medicaid programs. Even though these initiatives are in their infancy, early results are encouraging. Modest increases in payment to physicians, aligned with quality improvement standards, have not only resulted in promising trends for costs and quality, but have also greatly improved access to care. Several state programs have already demonstrated declines in per capita costs for patients enrolled in Medicaid; increased participation of physicians in caring for Medicaid patients; and high patient and provider satisfaction. These early results give states good reason to continue developing patient-centered medical homes as part of their Medicaid programs. This article provides a closer look at these innovative models, to inform public and private reform efforts.
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Pierre-Carl Michaud et al.,
Social Science & Medicine, July 2011, Pages 254-263
Abstract:
In 1975, 50 year-old Americans could expect to live slightly longer than most of their Western European counterparts. By 2005, American life expectancy had fallen behind that of most Western European countries. We find that this growing longevity gap is primarily due to real declines in the health of near-elderly Americans, relative to their Western European peers. We use a microsimulation approach to project what US longevity would look like, if US health trends approximated those in Western Europe. The model implies that differences in health can explain most of the growing gap in remaining life expectancy. In addition, we quantify the public finance consequences of this deterioration in health. The model predicts that gradually moving American cohorts to the health status enjoyed by Western Europeans could save up to $1.1 trillion in discounted total health expenditures from 2004 to 2050.
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Quality risk in offshore manufacturing: Evidence from the pharmaceutical industry
John Gray, Aleda Roth & Michael Leiblein
Journal of Operations Management, forthcoming
Abstract:
Does offshore production pose an added quality risk relative to domestic production? If so, what factors influence the quality risk? Progress addressing these deceptively simple questions has been hindered by the challenges associated with 1) difficulties in controlling for a wide range of factors that may potentially affect quality risk in offshore manufacturing and 2) the lack of available measures that are consistent across geographic regions. This paper contributes to the academic discourse by empirically assessing differences in quality risk across domestic and offshore plants in a setting that naturally controls for many confounding factors. Specifically, we employ a sample of 30 pairs of regulated drug manufacturing plants in the U.S. mainland and Puerto Rico matched both by parent firm and by product standard industrial code (SIC). Using a plant-level measure of quality risk that is measurement invariant, our findings indicate that Puerto Rican plants operate with a significantly higher quality risk than matching plants operated by the same firm located in the mainland U.S., on average. This finding persists above and beyond potentially important factors, such as geographic distance and the local population's general and industry-specific skills. Thus, challenges related to the transfer and maintenance of the knowledge required to operate with a low quality risk across non-geographic distance are left as the most plausible explanatory factor. Practically, our research highlights the need for manufacturing firms to carefully consider increased quality risk associated with the offshoring of production, particularly with regard to process-sensitive products like drugs. From a policy standpoint, our study highlights the need for the Food and Drug Administration (FDA) to continue to intensify its inspection focus on international manufacturing.
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Jennifer Rothkopf et al.
Health Affairs, July 2011, Pages 1335-1342
Abstract:
Federally qualified health centers, also known as community health centers, play an essential role in providing health care to millions of Americans. In return for providing primary care to underserved, homeless, and migrant populations, these centers are reimbursed at a higher rate than other providers by public programs such as Medicaid. Under the Affordable Care Act of 2010, the role of the centers is expected to grow. To examine the quality of care that the centers provide, the Colorado Department of Health Care Policy and Financing compared the use of costly hospital-related services by Medicaid clients whose usual source of care was a community health center with the use by clients whose usual source of care was a private, fee-for-service provider. The study found that community health center users were about one-third less likely than the other group to have emergency department visits, inpatient hospitalizations, or preventable hospital admissions. Public funders such as states should work with community health centers to improve the quality and reduce the cost of care even further.
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Scientific Expertise and the Balance of Political Interests: MEDCAC and Medicare Coverage Decisions
Stéphane Lavertu, Daniel Walters & David Weimer
Journal of Public Administration Research and Theory, forthcoming
Abstract:
Federal advisory committees are commonplace in the administrative state and often play a critical informational role in policymaking. Public administration scholars have yet to explore fully the implications of the institutional design and intra-committee dynamics that influence the advice produced by advisory committees. Using the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) as a case, we provide a much needed empirical examination of committee composition, advice, and influence. MEDCAC provides advice to the Centers for Medicare and Medicaid Services (CMS) about what medical treatments to cover under Medicare. Using data from 2005 through 2009, this study compares the voting of different types of committee members and estimates the degree to which CMS coverage decisions correspond to these votes. The results indicate that patient and consumer representatives are generally more optimistic about medical treatments than regular committee members appointed for their expertise, but that these differences are mostly on technical matters. On matters that deal with Medicare benefits more explicitly, and thus come to bear more directly on coverage determinations, the differences in assessments between these representatives and regular committee members are minimal. The results also indicate that the votes of scientific experts correlate with CMS coverage decisions, and they suggest that the votes of guest experts are most influential when there is committee disagreement. Overall, the study yields evidence consistent with the notion that the advice of expert committee members captures the diverse preferences of political stakeholders and that it is influential in CMS's coverage decisions.
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Matthew McHugh et al.
Health Affairs, July 2011, Pages 1299-1306
Abstract:
When California passed a law in 1999 establishing minimum nurse-to-patient staffing ratios for hospitals, it was feared that hospitals might respond by disproportionately hiring lower-skill licensed vocational nurses. This article examines nurse staffing ratios for California hospitals for the period 1997-2008. It compares staffing levels to those in similar hospitals in the United States. We found that California's mandate did not reduce the nurse workforce skill level as feared. Instead, California hospitals on average followed the trend of hospitals nationally by increasing their nursing skill mix, and they primarily used more highly skilled registered nurses to meet the staffing mandate. In addition, we found that the staffing mandate resulted in roughly an additional half-hour of nursing per adjusted patient day beyond what would have been expected in the absence of the policy. Policy makers in other states can look to California's experience when considering similar approaches to improving patient care.