MedicalResearch.com Interview with:
Sam P. Most, M.D., F.A.C.S.
Professor, Departments of Otolaryngology-Head & Neck Surgery and Surgery (Division of Plastic Surgery, by courtesy)
Chief, Division of Facial Plastic & Reconstructive Surgery
Stanford University School of Medicine
Stanford, CAMedical Research: What is the background for this study? What are the main findings?
Dr. Most: Insurance companies often require patients to try a 6 or more week treatment with nasal steroids prior to allowing nasal surgery to proceed. This is true even in cases of physician-documented severe or extreme anatomic nasal obstruction that we know will not respond to medical therapy. We sought to examine this from a cost and quality-of-life perspective.
We found that while the up-front cost of surgery is obviously much higher than medical therapy, when viewed from an effect on improvement of quality of life (or lack thereof, in the case of medical therapy), the surgical therapy became more cost effective as years passed by.
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MedicalResearch.com Interview with: Sapna Kaul, Ph.D
Huntsman Cancer Institute
2000 Circle of Hope
Salt Lake City, UT 84112
Medical Research: What is the background for this study? What are the main findings?
Dr. Kaul: The United States has the highest healthcare expenditures in the world, and close to one-third of these expenditures are believed to be unnecessary. One potential reason for these unnecessary expenditures is that patients may ask for medical services that are unnecessary. At the same time, primary care physicians (PCP) could find it difficult to refuse to prescribe unnecessary medical services as they may worry that it may compromise patient satisfaction. Also, there is a shortage of primary care workforce in the U.S. and PCPs may have insufficient time to effectively address patient requests.
We investigated 2 types of unnecessary medical practices initiated by patient requests:
(1) providing unnecessary specialty referrals, and
(2) prescribing brand-name drugs when generic alternatives were available.
To explore these practices, we used data on 840 U.S. PCPs from a national survey of physicians conducted in 2009. Over 50% of primary care physicians reported providing unnecessary specialty referrals and 39% prescribed brand-name drugs at patient requests. Several provider and organizational factors, such as physician specialty and solo/2-person practice, were related to reporting unnecessary practices.
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MedicalResearch.com Interview with:
Asako Moriya, Ph.D.
Service economist
Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality (AHRQ).
Rockville, MarylandMedical Research: What is the background for this study?
Dr. Moriya: While the Affordable Care Act (ACA) has increased insurance coverage and improved access to care among millions of Americans, the law’s potential impacts on the labor market are also important policy considerations. There was speculation that employers would reduce work hours to avoid the ACA employer mandate and also that ACA coverage expansion through Medicaid and the Health Insurance Marketplace would create work disincentives. We wanted to test these speculations using data from a nationally representative sample of approximately 60,000 households interviewed monthly up until June 2015.
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MedicalResearch.com Interview with: Dr. Sarah Elizabeth Little, MD
Obstetrics/Gynecology
Department of Obstetrics and Gynecology
Brigham and Women's Hospital
Medical Research: What is the background for this study? What are the main findings?
Dr. Little: This study investigates the variation in cesarean delivery rates across hospital services areas (a geographic unit designed by the Dartmouth Atlas to represent local markets for primarily hospital-based medical services). We looked at whether variation in cesarean delivery rates was related to broader variation in overall medical spending and utilization in that area, which we measured with Medicare spending and hospital use at the end-of-life. We found that an area’s cesarean delivery rate was correlated with these other measures; in other words, the hospital services areas that are doing the most cesarean deliveries are the same ones that are spending more and doing more to non-obstetric patients as well.(more…)
MedicalResearch.com Interview with:
Christine Veenstra MD
Clinical Lecturer, Internal Medicine
Medical Oncology
University of Michigan
Ann Arbor, MI 48109-5343
MedicalResearch: What is the background for this study? What are the main findings?Dr. Veenstra: Patients with cancer face many costs and incur financial burden as they go through diagnosis and treatment. For working patients, cancer diagnosis and treatment may come with the additional burden of time away from work, lost income, and even long-term job loss. Although 40% of US workers do not have access to paid sick leave, we hypothesized that availability of paid sick leave could reduce the need to take unpaid time away from work during cancer treatment and might therefore be associated with job retention and reduced personal financial burden.
In a survey of over 1300 patients with Stage III colorectal cancer, we found that only 55% of those who were employed at the time of their cancer diagnosis retained their jobs. Working patients with paid sick leave were nearly twice as likely to retain their jobs compared with working patients who did not have paid sick leave. This held true even when controlling for income, education and health insurance. Furthermore, working patients without paid sick reported significantly higher personal financial burden than those who had paid sick leave available.
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MedicalResearch.com Interview with:
Thomas Selden, Ph.D.
Director of the Division of Research and Modeling
Center for Financing, Access, and Cost Trends
Agency for Healthcare Research and Quality (AHRQ), in Rockville, Maryland.Medical Research: What is the background for this study? What are the main findings?
Dr. Selden: Spending on hospital care is expected to exceed $1 trillion for the first time in 2015, and it is important to understand the differences between public and private payment rates if we want to achieve the goals of better care, smarter spending, and healthier people – the triple aims found in HHS’ National Quality Strategy. Our study examined data on inpatient hospital stays between 1996 and 2012, finding that payments to hospitals from private insurers in 2012 were 75 percent greater than Medicare’s – a sharp increase from the approximate 10 percent difference between 1996 and 2001.(more…)
MedicalResearch.com Interview Questions
Carlos del Rio, MD
Chair, HIV Medicine Association Department of MedicineHubert Professor and Chair of the Department of Global Health at the Rollins School of Public Health Professor of Medicine in the Division of Infectious Diseases
Emory University School of Medicine
MedicalResearch.com Editor's note: Dr. Carlos del Rio discusses the statement from the Infectious Diseases Society of America (IDSA), HIV Medicine Association (HIVMA) and the Pediatric Infectious Diseases Society (PIDS) regarding the news that Express Scripts is taking steps to improve access to obtaining pyrimethamine for patients with toxoplasmosis.Medical Research: What is the background for this Express Scripts announcement?Dr. del Rio: The HIV Medicine Association (HIVMA) and the Infectious Diseases Society of America initially heard from our members (ID and HIV clinicians) in August about the 5000% price increase in Daraprim® (from $13.50 to $750 per tablet) following Turing Pharmaceuticals’ acquisition of the rights to distribute Daraprim® from Impax Laboratories, Inc.[1] ID and HIV clinicians told us they had been having difficulties obtaining pyrimethamine since earlier in the summer when Impax implemented a controlled distribution system making the drug available only through Walgreen’s Specialty Pharmacy.
Despite HIVMA, IDSA and others urging Turing to reverse the price hike, no action was taken and providers continued to report the scarcity of the drug due to the cost and issues with the distribution system. [2] Due to these ongoing challenges, HIVMA and IDSA thought it was important to provide information to our members and other providers regarding the new lower cost option so they could evaluate this option in consultation with their patients. Initially Turing agreed to reconsider the price increase and to lower it; however, on Nov. 24th Turing announced that they would not lower the list price of Daraprim but instead planned to offer discounts of up to 50% to some hospitals. [3] The announcement reinforced the urgent need for affordable treatment options and failed to address that a majority of the eight to twelve month treatment course occurs on an outpatient basis.
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MedicalResearch.com Interview with:
Lorette A. Stammen, MD
Department of Educational Development and Research
Faculty of Health, Medicine, and Life Sciences
Maastricht University, Maastricht
The Netherlands
Medical Research: What is the background for this study? What are the main findings?Dr. Stammen: Research indicated that we can improve the quality of care and reduce the health care costs by eliminating health care waste. Health care waste are health care services that are not beneficial to patients. There are many ways to reduce health care waste, like through insurance and government policies modification, but we were especially interested in how the medical expertise of physicians could improve high-value, cost-conscious care. We conducted a systematic review with the aim of understanding how training programs cause learning among physicians, residents and medical students. We analyzed 79 articles using realist review method and found three important factors that facilitate the learning of physicians (in training).
First, educational programs should focus on knowledge transmission. Knowledge that is essential entails knowledge regarding prices and general health economics, scientific evidence, and patient preferences.
Besides knowledge, the second factor of training for high-value, cost-conscious care is reflective practice. Reflective practice for example using feedback and asking reflective questions, by peers, colleagues and supervisors to reflect on decisions made in daily practice.
The third element of training programs should address an supportive environment in which physicians, residents and medical students learn. A supportive environment is important to cultivate the importance of high-value, cost-conscious care on multiple levels in the health care system. Since physicians are a part of a health care team their training programs should incorporate the training of health care professionals.
Furthermore, it is important that role models demonstrate high-value cost-conscious care.
MedicalResearch.com Interview with:
Dr. Eric W. Christensen, PhD
Health Economist
Children’s Hospitals and Clinics of Minnesota
Minneapolis, MN
Medical Research: What is the background for this study?Dr. Christensen: National healthcare expenditures are up from 5.0% of gross domestic product in 1960 to 17.4% in 2013. We must find ways to control cost while maintaining quality. Accountable care organizations (ACOs) were designed to control a population’s health care cost while maintaining or improving quality. This study was an examination of one ACO exclusively covering a pediatric Medicaid population.
Medical Research: What are the main findings?Dr. Christensen: We found that health care utilization and cost patterns were associated with the length of time patients were attributed to this ACO, where attribution length can be thought of as a proxy for consistent primary care from ACO providers. Specifically, attribution length of 2 or more years was associated with a 40.6% decrease in inpatient days. This decrease was partially offset by increases in outpatient visits (as one would expect with a primary care focus), emergency department visits, and use of pharmaceuticals. Combined these utilization changes resulted in a cost reduction 15.7% for those attributed 2 or more years. These changes were achieved while meeting quality benchmarks.
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MedicalResearch.com Interview with:
Dr. Stacie B. Dusetzina, PhD
Assistant professor in the Division of Pharmaceutical Outcomes and Policy
Eshelman School of Pharmacy
University of North CarolinaMedical Research: What is the background for this study? What are the main findings?
Dr. Dusetzina: As part of the Affordable Care Act the Medicare Part D “doughnut hole” is closing – reducing Medicare beneficiaries out-of-pocket expenses during this phase of coverage from 100% of drug costs to 25% between 2010 and 2020. In this study we analyzed 3,344 Medicare formularies that spell out how insurers cover prescription drugs. We found that in 2010, a typical course of oral chemotherapy drugs costs patients on average up to $8,100 per year. When the doughnut hole closes in 2020, patients will still have to pay on average $5,600 out of pocket per year, more than what the average Medicare beneficiary’s household spends on food each year. Even after the doughnut hold is closed oral chemotherapy drugs will still be out of reach for millions of Americans.
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MedicalResearch.com Interview with:
Rozalina G. McCoy, M.D.
Senior Associate Consultant
Division of Primary Care Internal Medicine
Assistant Professor of Medicine
Mayo Clinic
Medical Research: What is the background for this study? What are the main findings?
Dr. McCoy:Blood glucose monitoring is an integral component of managing diabetes. Glycosylated hemoglobin (HbA1c) is a measure of average glycemia over approximately 3 months, and is used in routine clinical practice to monitor and adjust treatment with glucose-lowering medications. However, monitoring and treatment protocols are not well defined by professional societies and regulatory bodies; while lower thresholds of testing frequencies are often discussed, the upper boundaries are rarely mentioned. Most agree that for adult patients who are not using insulin, have stable glycemic control within the recommended targets, and have no history of severe hypoglycemia or hyperglycemia, checking once or twice a year should suffice. Yet in practice, there is a much higher prevalence of excess testing. We believe that such over-testing results in redundancy and waste, adding unnecessary costs and burdens for patients and the health care system.
We therefore conducted a large retrospective study among 31,545 adults across the U.S. with stable and controlled type 2 diabetes who had HbA1c less than 7% without use of insulin and without documented severe hypoglycemia or hyperglycemia. We found that 55% of patients had their HbA1c checked 3-4 times per year, and 6% had it checked 5 times a year or more. Such excessive testing had additional harms as well – we found that excessive testing was associated with greater risk of treatment intensification despite the fact that all patients in the study already met glycemic targets by having HbA1c under 7%. Indeed, treatment was intensified by addition of more glucose lowering drugs or insulin in 8.4% of patients (comprising 13%, 9%, and 7% of those tested 5 or more times per year; 3-4 times per year; and 1-2 times per year, respectively).
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MedicalResearch.com Interview with: Johannes Govaert MD
Department of Surgery
Leiden University Medical Center
Leiden, The Netherlands
Medical Research: What is the background for this study?
Dr. Govaert: The Value Based Health Care agenda ofPprof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined.
Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing.
Medical Research: What are the main findings?
Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction.
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MedicalResearch.com Interview with:
Anup Das
Medical Scientist Training Program
Department of Health Management and Policy
University of Michigan, Ann Arbor
Medical Research: What is the background for this study? What are the main findings?Response: The Centers for Medicare & Medicaid Services (CMS) recently added a new measure of episode spending to the Hospital Value Based Purchasing program. Participation in this program allows hospitals to receive a financial bonus if they perform well on the included measures. This is the first spending measure in the program, and this change now incentivizes hospitals to improve their quality as well as their spending. The measure evaluates spending from three days before a hospitalization through 30 days post-discharge.
In this study, we find that while high-cost hospitals had higher spending levels in each of the three components of an episode of care (pre-admission, index admission, and post-discharge), differences in post-discharge spending were the main determinants of hospital performance on this measure. High-cost hospitals spent on average $4,691 more than low-cost hospitals in post-discharge care. The majority of post-discharge spending comes from skilled nursing facility or readmission costs. Similarly, hospitals that did worse on this new measure of spending over time did so because of increases in their post-discharge spending.
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MedicalResearch.com Interview with:Xuesong Han, PhD
Director, Surveillance and Health Services Research
American Cancer Society, Inc.
Atlanta, GA 3030
Medical Research: What is the background for this study? What are the main findings?
Dr. Han: People with private insurance are more likely to be screened and more likely to be diagnosed at an early stage of cancer. An early provision of the Affordable Care Act implemented in September 2010 allows young adults to remain on their parents’ health insurance plan until age 26 years, following which there has been an increase in private insurance coverage among young adults aged 19-25 years. For young adults, the uterine cervix is the only cancer site for which screening is recommended with a starting age of 21 years, and diagnosis of cervical cancer at early stages allows use of fertility-sparing treatment.
Using data before and after the dependent coverage expansion provision of ACA, we found that compared with 26-34 year-olds who were not affected by the policy change, women 21-25 years of age experienced a net increase of 9 percentage points in early stage disease and 11.9 percentage points in receipt of fertility-sparing treatment.
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MedicalResearch.com Interview with:
Dr. Jonathan L. Silverberg MD PhD MPH
Assistant Professor in Dermatology
Medical Social Sciences and Preventive Medicine
Northwestern University, Chicago, Illinois
Medical Research: What is the background for this study? What are the main findings?
Dr. Silverberg: We previously showed that adults with eczema are more likely to smoke cigarettes, drink alcohol and have sedentary lifestyle. We wondered whether chronic eczema might negatively impact upon other health behaviors, such as seeking preventive care and vaccinations. On the other hand, previous studies from our group and others found that both children and adults with eczema have a number of comorbid medical and mental health conditions. One potential reason for this is detection bias from since eczema patients are “plugged into” the healthcare system because of their skin disease, which allows them to be diagnosed more frequently with other health problems.
We sought to understand the routine and preventive healthcare behaviors of children and adults with eczema. We found that adults with eczema were more likely to be vaccinated for tetanus, influenza, hepatitis A and B viruses, human papilloma virus and pneumonia. Moreover, they were more likely to undergo age-appropriate health screenings, such as blood pressure and cholesterol checks, but not cancer screening. Adults with eczema were more likely to interact with a variety of general doctors and specialists.
Similarly, childhood eczema was associated with higher rates of vaccination for influenza, well child checkups and interaction with most types of healthcare providers.
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MedicalResearch.com Interview with: Dr. Elizabeth D. Kantor PhD MPH
Assistant Attending Epidemiologist
Memorial Sloan Kettering Cancer Center
Medical Research: What is the background for this study? What are the main findings?
Dr. Kantor: We know that use of prescription drugs represents a major expenditure in the United States and research suggests that use of prescriptions has increased. However, much of what we know is derived from information on expenditures, is outdated, or is limited to certain populations, such as older adults or those with a given clinical condition. For example, a number of studies have looked at things like use of drugs used to control condition x among persons with condition x, but that doesn't tell us about use of that class of drugs in the population.
It’s important that we continue to monitor use of prescription drugs in the population, as practice patterns are continually evolving as the population ages, the health needs of the population change, drugs enter/exit the market, scientific knowledge advances, and policies change. We therefore sought to create an updated comprehensive reference on prescription drug use among US adults using nationally representative data from the National Health And Nutrition Examination Survey, a continuous survey conducted by the Centers for Disease Control and Prevention. We examined trends in use of prescription drugs over 7 cycles, ranging from 1999-2000 to 2011-2012 (the sample size per cycle ranged from 4,861 to 6,212).Participants were asked about use of prescription medications over the prior 30 days, from which we were able to estimate the prevalence of use within each survey cycle. We then looked at trends in prescription drug use, both overall and within drug classes.
In our study, we observed that use of any prescription medications increased over the study period, with 51% of adults reporting any prescription medication use in 1999-2000 and 59% reporting any use in 2011-2012. We also observed an increase in polypharmacy (or use of 5 or more prescription drugs) over the study period, with approximately 8% of adults reporting use of 5 or more drugs in 1999-2000, as compared to 15% in 2011-2012. Polypharmacy was much more common among older adults: 24% of adults ages 65 and older reported use of 5 or more drugs in 1999-2000 and 39% reported use of 5 or more drugs in 2011-2012. At first glance, one might take a look at these results and think that this is probably because the US population is aging and people tend to take more drugs as they age. But we found that the increase in overall prescription drug use and polypharmacy persisted even after accounting for the aging of the US population. This means that something else is driving the observed increase in use of prescription drugs.
We also found that use of the majority of drug classes increased over the study period. For example, among commonly used drug classes, we observed marked increases in use of drugs taken to control high cholesterol, high blood pressure, and diabetes. We also observed marked increases in some less commonly used drug classes, such as muscle relaxants. Interestingly, if we look at the ten most commonly used drugs in 2011-2012, we can see that most are taken for conditions associated with cardiometabolic disease This raises the question of how much of this increase in prescription drug use may be attributable to overweight/obesity, as we know that the prevalence of obesity has increased among US adults.
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MedicalResearch.com Interview with:
Shannon Stokley, MPH
Epidemiologist in the
CDC Immunization Services Division
Medical Research: What is the background for this study? What are the main findings?
Response: To determine whether the recommended HPV vaccination series is currently being administered to adolescents with health insurance, CDC and the National Committee for Quality Assurance (NCQA) assessed 2013 data from the Healthcare Effectiveness Data and Information Set (HEDIS). The HEDIS HPV Vaccine for Female Adolescents performance measure evaluates the proportion of female adolescent members in commercial and Medicaid health plans who complete the recommended HPV vaccination series by age 13 years. In 2013, in the United States, the median HPV vaccination coverage level for female adolescents among commercial and Medicaid plans was 12% and 19%, respectively (ranges = 0%–34% for commercial plans, 5%–52% for Medicaid plans). The results of this study indicate that there are significant opportunities for improvement as HPV vaccination coverage among female adolescents was low for both commercial and Medicaid plans.
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MedicalResearch.com Interview with:
Amy S. Kelley, MD, MSHS
Department of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount Sinai
New York, NY
Medical Research: Why is it so important to understand the financial burdens families may face in providing end-of-life care for a loved one and why do you think the burdens may be greater for dementia than for other medical conditions?
Dr. Kelley: Understanding the financial risks that older adults face in the last years of life is important for individuals and families, in order to plan and save, if possible. It is also important for our policy makers, in particular, to know about these costs so that this information can help shape health and social policy that will best serve our society. Households of those with dementia face the greatest burden of costs, on average, particularly with regard to out-of-pocket expenses and the costs of caregiving. Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs, including everything from supervision, to bathing and feeding, may span several years.
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MedicalResearch.com Interview with:
Joseph M Carrington DO, MHA
Department of Medicine - PGY3
Johns Hopkins University/Sinai Hospital
Medical Research: What is the background for this study? What are the main findings?
Dr. Carrington: This study looked at a total of 886 patients at a community hospital. We were faced with the dilemma that our ICU beds were frequently over utilized with severely ill patients for whom our interventions had minimal impact. This prevented patients who were less ill from coming to the ICU who may have benefited from our services. We made a hospital wide culture change to lower ICU admission thresholds. Any patient felt to be "borderline" received an automatic ICU evaluation without any push-back. The result of these earlier interventions was a decrease in complications from patients decompensating in the ED and floors. In turn, the overall ICU length of stay, mortality, and ICU transfers all decreased. By decreasing these overall complications and mortality, our number of ICU over-utilizes decreased. This saved our hospital an annualized amount of over $2 million and freed up ICU beds and resources.
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MedicalResearch.com Interview with:
Sue Dong, DrPH
Data Center Director
CPWR-The Center for Construction Research and Training
Silver Spring, MD, 20910
Medical Research: What is the background for this study? What are the main findings?
Response: The Center for Construction Research and Training (CPWR) is a nonprofit organization funded by NIOSH and several other federal government agencies. The aging workforce study is part of our NIOSH projects. According to our surveillance data (using the Current Population Survey), more than 30% of US workers were baby boomers in 2014, and about 63% of those baby boomers were aged 55 and up. Overall, the baby boomer generation is composed of 75 million Americans who have reached or will soon reach their retirement years. Despite the impending magnitude of societal disruption, information on health status among baby boomers and the potential burden faced by this cohort is still scarce. We hope this study can provide some needed information on the aging population in the US.
To address this concern, we used data from the Health and Retirement Study (HRS). HRS is a national longitudinal survey of Americans aged 50 and over, which started in 1992. The baby boomer cohort (including Early Baby Boomers and Mid Baby Boomers who were born between 1948 and 1959) was added to the survey in recent years. HRS collects information on demographics, employment, health, health expenditures, etc. The rich information and relatively consistent survey instruments used over time allowed us to conduct this study.
Medical Research: What are the main findings?
Response: We estimated medical conditions and expenditures among the baby boomer cohort and compared them with the original HRS cohort (born between 1931 and 1941). We found that the baby boomers were more likely to report chronic conditions than the previous generation (HRS cohort) at similar ages. For example, at age 51-61, about 70% of the baby boomer cohort had at least one chronic condition, while 60% of the HRS cohort had at least one chronic condition. By detailed condition, 42.2% of baby boomers had high blood pressure, compared to 32.1% of the HRS cohort; 14.4% of the baby boomers had diabetes, nearly twice the proportion for the HRS cohort (7.8%). Overall, baby boomers had higher prevalence of chronic conditions for the nine conditions we measured compared to the HRS cohort at the same age.
We also found that the baby boomers were more likely to be overweight compared to the previous generation. The prevalence of obesity was 37% among baby boomers, but it was 21.9% among the HRS cohort when they were at similar ages
In terms of medical expenditures, the average out-of-pocket expenditure (OOPE) for the past two years for those aged 51-61 was $2,156 for the HRS cohort, but $3,118 for the baby boomers. Dollar value was adjusted to 2012 dollars for even comparison. The findings will be presented at the recent APHA annual conference in Chicago.
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[wysija_form id="5"]MedicalResearch.com Interview with:
Salman Nusrat M.D.
Assistant Professor, Section of Digestive Diseases and Nutrition
University of Oklahoma Health Sciences Center
Medical Research: What is the background for this study? What are the main findings?
Dr.Nusrat: Obesity is a global epidemic and is one of the most taxing issues affecting healthcare in the United States. It is a well-established risk factor for increased morbidity and mortality. We looked at how morbid obesity (BMI>40) affected inpatient health care utilization over the last two decades. We found that:
From 1997 to 2012, the number of patients discharged with a diagnosis of morbid obesity increased 11 folds from 10,883 to 124,650
The majority of these patients were female (~80%) and aged between 18-44 years.
Southern States accounted for majority of these admissions (37%). Majority of these patients were insured (~90%) and about three quarters of these admissions were in area with mean income above the 25 percentile.
The number of hospitalizations for patients aged >45 years increased from 33% to 50%.
-Even though the length of stay decreased from 5 days (1997) to 2.1 days (2012), the aggregate charges increased from $198 Million (1997) to $5.9 Billion (2012).
MedicalResearch.com Interview with:
Hannah Neprash PhD student
Health Policy program
Harvard University.
Medical Research: What is the background for this study?
Response: Hospitals are increasingly employing or purchasing physician practices. This trend started before the Affordable Care Act, as our study documents, but there is a concern that these trends may accelerate as providers reorganize to meet the challenges of new payment models that hold providers accountable for the entire spectrum of patient care, spanning inpatient and outpatient settings. It’s not clear how this change in provider market structure should affect spending. It could lead to lower spending, if care is better coordinated, reducing waste and unnecessary utilization. But, it could also lead to higher spending if larger provider groups have more market power and can negotiate higher prices with insurers.
Medical Research: What are the main findings?
Response: We used Medicare claims to quantify the share of physicians in major metropolitan markets that were owned or employed by a hospital. Most markets saw an increase in physician-hospital integration from 2008 to 2012. The average market saw a 3% increase in physician-hospital integration; the 75th percentile market saw a 5% increase; and the 95th percentile market saw a 15% increase. An increase in physician-hospital integration equivalent to the 75th percentile was associated with a $75 per person (or 3%) increase in annual outpatient spending among a non-elderly commercially insured population. This was driven by price increases – as we found no change in utilization.
We did not find a similar association between physician-hospital integration and inpatient hospital spending. This is likely because hospital markets were already less competitive than physician markets at the beginning of our study period. When a hospital system buys a physician practice, the hospitals might not gain much bargaining power against an insurer in negotiating prices for inpatient care, but the hospital’s bargaining power could be used to negotiate higher fees for the outpatient physician practice. That is, an insurer may not be persuaded by the threat of excluding the physician practice from its network, but the threat of excluding the entire hospital system from the insurer’s network is likely to carry more weight.
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MedicalResearch.com Interview with:
James Galipeau PhD
Ottawa Hospital Research Institute
Ottawa, Ontario, CanadaMedical Research: What is the background for this study?
Dr. Galipeau: Overcrowding in emergency departments (EDs) is becoming more and more commonplace in Canada. The issue of overcrowding is complex and multidimensional with three distinct but interdependent components: input, throughput (processing), and output. At the processing level, one solution to overcrowding that has emerged is the establishment of observation/short stay units.
A short-stay unit is a physical location in a hospital, usually in close proximity to the ED. Patients needing treatments or observation that may take several hours to resolve (e.g., blood transfusions, diagnostic testing, arranging social services) can be accommodated in a short-stay unit without occupying ED beds or needing to be admitted. In theory, ED-based short-stay units can lessen ED overcrowding by influencing outcomes such as ED wait times and hospital costs (if patients are moved from the ED to inpatient care).
Although a recent report by the American College of Emergency Physicians recommends pursuing the use of short-stay units to alleviate ED overcrowding, there is a lack of evidence syntheses summarizing their effectiveness, safety, and value for money. Our objective was to conduct a systematic review to evaluate the effectiveness and safety of ED short-stay units compared with care not involving short-stay units.
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MedicalResearch.com Interview with:
Richard S. Hoehn, MD
Division of Transplant Surgery
Department of Surgery
University of Cincinnati School of Medicine
Cincinnati, OH
Medical Research: What is the background for this study? What are the main findings?
Dr. Hoehn: Safety-net hospitals are hospitals that either have a stated purpose of maintaining an “open door policy” to all patients, regardless of their ability to pay, or simply have a significantly high burden of patients with Medicaid or no insurance. As healthcare policy and reimbursement change to focus on both “quality” metrics as well as cost containment, these hospitals may find themselves in a precarious situation. Current literature suggests that increased safety-net burden corresponds to inferior surgical outcomes. If this is true, safety-net hospitals will have inferior outcomes and suffer more financial penalties than other centers. This decrease in resources may adversely affect patient care, leading to even worse outcomes and further financial penalties, potentially creating a downward spiral that exacerbates disparities in surgical care that already exist in our country.
Medical Research: What are the main findings?Dr. Hoehn: Our study analyzed 9 major surgical operations using the University HealthSystem Consortium clinical database, which represents 95% of academic medical centers in the United States. We sought to determine the effect of patient and hospital characteristics on the inferior outcomes at safety-net hospitals. As expected, we found that safety-net hospitals had higher rates of patients who were of black race, of lowest socioeconomic status, had government insurance, had extreme severity of illness, and needed emergent operations. They also had the highest rates of post-operative mortality, 30-day readmissions, and highest costs associated with care.
Next we performed a multivariate analysis controlling for patient age, race, socioeconomic status, and severity of illness, as well as hospital procedure-specific volume. Using this model, we found that the increased mortality and readmission rates at safety-net hospitals were somewhat reduced, but the increased costs were not affected. Safety-net hospitals still provided surgical care that was 23-35% more expensive, despite controlling for patient characteristics. This suggests that intrinsic hospital characteristics may be responsible for the increased costs at safety-net hospitals.
To further investigate this finding, we analyzed Medicare Hospital Compare data and found that safety-net hospitals performed worse on Surgical Care Improvement Project (SCIP) measures, had higher rates of reported surgical complications, and also had much slower measures of emergency department throughput (time from arrival to evaluation, treatment, admission, etc). This corresponded with our finding that hospital characteristics may be driving increased costs at safety-net hospitals.
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MedicalResearch.com Interview with:
James E. Stahl, MD
Senior Scientist
Assistant Professor of Medicine,
Harvard Medical School
MGH Institute for Technology Assessment
Medical Research: What is the background for this study? What are the main findings?
Dr. Stahl: Poor psychological and physical resilience in response to stress drives a great deal of health care utilization. Mind-body interventions can reduce stress and build resiliency. Over the last few decades we have seen substantial evidence that evoking the relaxation response helps the heart, blood pressure, reduces inflammation and creates changes all the way down to the epigenetic level. We have not until now had a broad look at the effect at the health systems level. The rationale for this study is therefore to estimate the effect of mind-body interventions on healthcare utilization.
The main findings are that looking at a broad population these tools, and specifically the relaxation response and resiliency training offered at the BHI, results in real world reductions in health care utilization.
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MedicalResearch.com Interview with:
Jeffrey Rhoades, Ph.D.
Agency for Healthcare Research and Quality
Medical Research: What is the background for this study?
Dr. Rhoades: The Medical Expenditure Panel Survey (MEPS) – Household Component (HC) which began in 1996 and is administered annually collects data from a sample of families and individuals in selected communities across the United States, drawn from a nationally representative subsample of households that participated in the prior year's National Health Interview Survey (conducted by the National Center for Health Statistics).
During the household interviews, MEPS collects detailed information for each person in the household on the following: demographic characteristics, health conditions, health status, use of medical services, charges and source of payments, access to care, satisfaction with care, health insurance coverage, income, and employment.
The panel design of the survey, which features several rounds of interviewing covering two full calendar years, makes it possible to determine how changes in respondents' health status, income, employment, eligibility for public and private insurance coverage, use of services, and payment for care are related.
Medical Research: What are the main findings?
Dr. Rhoades: In 2013, Hispanics were more likely to be uninsured for the entire year or sometime during the year than other racial/ethnic groups.
In 2013, persons living in the South and West regions were more likely to be uninsured for the entire year or sometime during the year than people living in the Northeast or Midwest.
Approximately 50 percent of individuals with the lowest hourly wage (less than $10 per hour) were uninsured sometime during the year in 2013. This fraction decreased with increasing wages.
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MedicalResearch.com Interview with:
Kathleen Carey, Ph.D.
Professor
Department of Health Law, Policy and Management
Boston University School of Public Health
Boston MA 02118
Medical Research: What is the background for this study?
Dr. Carey: Ambulatory surgery centers (ASCs) are a growing alternative to hospital outpatient departments (HOPDs) for patients undergoing surgeries that do not require an overnight stay. The number of ASCs increased 49% between 2002 and 2012 and now exceeds the number of acute care hospitals.
Most Ambulatory surgery centers are specialized in the areas of gastroenterology, ophthalmology or orthopedic surgery. Because of specialization and limitations on the services they provide, it generally is assumed that ASCs can perform the same procedures at a lower cost than HOPDs. In fact, Medicare reimburses ASCs at a rate of roughly 60% of what they reimburse HOPDs. Yet since Medicare doesn’t require ASCs to submit cost reports, this policy is based on little information about the relative costs of ASCs and HOPDs.
The cost advantage may offer an explanation for rapid ASC growth. But financial margins are explained by both costs and revenues, and high returns on investment might also be explained by high prices. Here there is even less information, as prices negotiated between commercial health insurers and providers are ordinarily considered highly confidential. In this study, I took advantage of MarketScan Commercial Claims and Encounters, a large national database distributed by Truven Health Analytics that contains information on actual prices paid to ASCs and HOPDs to explore the revenue side of ASC expansion.
Medical Research: What are the main findings?
Dr. Carey: For this study, I examined six common surgical procedures that are high volume, provided in both ASCs and in HOPDs, and represent the three main ASC specialties: colonoscopy, upper GI endoscopy, cataract surgery, post cataract surgery (capsulotomy), and two knee arthroscopy procedures. Over the period 2007-2012, the ratio of what insurers paid ASCs compared to HOPDs differed considerably across specialty: For colonoscopy and endoscopy, ASCs received 22% less than HOPDS. But for cataract surgery, the payments were relatively comparable, and for knee arthroscopy payments to ASCs exceeded payments to HOPDs by 28% to 30%. Private insurers paid ASCs considerably more than Medicare did – anywhere from 25% more to over twice as much for post cataract surgery.
The other interesting finding was that HOPD prices grew much faster than ASC prices between 2007 and 2012. While some Ambulatory surgery centers prices grew more than others, ASC prices on the whole rose roughly in line with medical care prices generally. HOPD prices for these services, however, rose from 32% to 76% during the same time period.
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MedicalResearch.com Interview with:
Pinar Karaca-Mandic, PhD on behalf of the authors
Associate Professor
Division of Health Policy and Management
University of MinnesotaMedical Research: What is the background for this study? What are the main findings?
Dr. Pinar Karaca-Mandic: Lymphedema is a common disease affecting several million people in the U.S, in particular cancer patients. The disease is associated with edema, recurrent cellulitis, loss of physical function, stress, and of course diminished quality of life. It is also associated with high health care costs. While there is no cure for lymphedema currently, it can be managed well with proper care. Pneumatic compression devices offer a valuable lymphedema self-management option. However, there is limited information on the effectiveness of these devices using data from real world settings. In this paper, we used administrative and claims-based data from a major national insurer to examine the effectiveness of an advanced pneumatic compression device. We examined health economics costs as well as clinical health utilization outcomes associated with the use of the device.
We found that the receipt of the device is associated with large declines in cellulitis rates.
For example, among the cancer patients, cellulitis infection rates by 79% (from 21% to 4.5%). We saw similar reductions for patients without cancer (75%). We also observed large reductions in the use of manual therapy and in lymphedema related outpatient hospital visits. Finally, lymphedema related outpatient costs decreased substantially – for example for the cancer patients, they halved reducing from about $1,500 to $700 among cancer patients, and they declined by 65% from about $1,700 to $600 for patients without cancer. Among cancer patients, total lymphedema-related costs per patient, excluding medical equipment, declined by 37% and declined by 36% in patients without cancer.
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MedicalResearch.com Interview with:
Andrew P. Loehrer, MD
David Torchiana Fellow in Health Policy and Management
Massachusetts General Physicians Organization
Research Fellow
Codman Center for Clinical Effectiveness in Surgery
Department of Surgery
Massachusetts General Hospital
Medical Research: What is the background for this study? What are the main findings?
Dr. Loehrer: The incidence of pancreatic cancer is increasing and is on pace to become the second leading cause of cancer mortality by the year 2020. While surgery remains the only chance for long-term survival, significant and persistent disparities in evaluation for and receipt of surgery remain for underinsured patients across the United States. The Affordable Care Act aims to increase access to care through expansion of health insurance coverage and was modeled on previous reform in the Commonwealth of Massachusetts.
We evaluated the impact of the 2006 Massachusetts health reform on rates of surgery for pancreatic cancer. We found the insurance expansion to be independently associated with a 67% increased rate of resection for pancreatic cancer. While disparities in resection rates by insurance status decreased after the health reform, significant gaps remain between privately-insured patients and government-subsidized/self-pay patients.
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