Author Interviews, Cost of Health Care, Emergency Care, Primary Care / 09.04.2015

Haichang Xin, PhD Department of Health Care Organization and policy School of Public Health University of Alabama at BirminghamMedicalResearch.com Interview with: Haichang Xin, PhD Department of Health Care Organization and policy School of Public Health University of Alabama at Birmingham MedicalResearch: What is the background for this study? Dr. Xin: Research suggests that nearly half of all emergency department (ED) visits in the United States are for nonurgent conditions, leading to billions of dollars in potentially avoidable spending annually. A well-functioning primary care system has the capacity to provide timely, adequate, and effective care for patients in order to avoid nonurgent emergency department use and care costs. This study examined how deficiencies in ambulatory care were associated with nonurgent emergency department care costs nationwide, and to what extent these costs can be reduced if deficiencies in primary care systems could be improved. MedicalResearch: What are the main findings? Dr. Xin: Patient perceived poor and intermediate levels of primary care quality had higher odds of nonurgent emergency department care costs (OR=2.22, p=0.035, and OR=2.05, p=0.011, respectively) compared to high quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs. These ambulatory care quality deficiency related costs amounted up to $229 million for private plans (95% CI: $100 million, $358 million), $58.5 million for public plans (95% CI: $33.9 million, $83.1 million), and an overall of $379 million (95% CI: $229 million, $529 million) at the national level.
Author Interviews, Cancer Research, Cost of Health Care / 08.04.2015

MedicalResearch.com Interview with: Stacie B. Dusetzina PhD Assistant professor in the Eshelman School of Pharmacy and the Gillings School of Global Public Health University of North Carolina at Chapel Hill Member of the Lineberger Comprehensive Cancer CenterMedicalResearch.com Interview with: Stacie B. Dusetzina PhD Assistant professor in the Eshelman School of Pharmacy and the Gillings School of Global Public Health University of North Carolina at Chapel Hill Member of the Lineberger Comprehensive Cancer Center Medical Research: What is the background for this study? What are the main findings? Dr. Dusetzina: Charges for health services — the amounts providers request before payments are negotiated — have not been widely known for services delivered in physicians’ offices. Charges can be considered the maximum amount that would be paid by a person without insurance who does not or is unable to negotiate for a lower price. In this study we used recently released data from the Medicare Provider Utilization and Payment Public Use File and other sources to measure what physicians charged for chemotherapy drugs delivered intravenously in 2012 and the amounts reimbursed by Medicare and private health plans for the same services. We found that uninsured cancer patients may be asked to pay from 2 to 43 times what Medicare pays for chemotherapy drugs. Medicare and insurers don’t pay the sticker price of health care. They pay a discounted rate. However, uninsured patients don’t have the bargaining power, or they may not try to negotiate for a better price. On average, Medicare paid approximately 40 percent of the charged amounts for chemotherapy drugs. Private insurers paid nearly 57 percent of the charged amounts on average. We also looked at what cancer patients were asked to pay for an office visit. Uninsured patients may be asked to pay from $129 to $391, depending on the complexity of the visit. Medicare paid between $65 and $188 and private insurance paid between $78 and $246 for the same visits.
Author Interviews, Columbia, Cost of Health Care / 27.03.2015

Peter Muennig, MD, MPH Columbia University Mailman School of Public Health NYC 10032MedicalResearch.com Interview with: Peter Muennig, MD, MPH Columbia University Mailman School of Public Health NYC 10032 Medical Research: What is the background for this study? What are the main findings? Dr. Muennig: The Oregon Health Insurance Experiment (OHIE) is one of just two experimental investigations of the health benefits of medical insurance. The first was the Rand Health Insurance Experiment, which was conducted over 3 decades ago. The OHIE randomly assigned participants to receive Medicaid or their usual care. It found that Medicaid protected families from financial ruin caused by medical illness, that it reduced depression, and that it increased preventive screening tests. However, it produced no medical benefits with respect to high blood pressure, diabetes, or high cholesterol. Medicaid opponents suggested that this meant that we should get rid of Medicaid because Medicaid does not improve physical health. But Medicaid proponents suggested that too few participants enrolled to detect a benefit, and, regardless of the study’s flaws, reduced depression, financial protections, and improved screening were reason enough to continue. We found that the Medicaid opponents were right. Medicaid actually didn’t produce any meaningful benefits with respect to blood pressure, diabetes, or cholesterol. But we also found that the Medicaid proponents were right. It’s impacts on depression alone rendered it cost-effective even if one does not account for the benefits of financial protections or medical screening.
AHRQ, Author Interviews, Cost of Health Care, JAMA, Medical Imaging, Pain Research / 17.03.2015

Jeffrey (Jerry) G. Jarvik MD MPH Professor, Radiology, Neurological Surgery and Health Services Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA 98104-2499MedicalResearch.com Interview with: Jeffrey (Jerry) G. Jarvik MD MPH Professor, Radiology, Neurological Surgery and Health Services Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA Medical Research: What is the background for this study? Dr. Jarvik:  When I arrived at the Univ of WA over 20 years ago, my mentor, Rick Deyo, had just finished leading a project that was responsible for developing one of the first set of guidelines for the diagnosis and treatment of acute low back pain. These guidelines, published in a booklet by AHRQ (then called AHCPR), recommended that patients with acute low back pain not undergo imaging for 4-6 weeks unless a red flag was present. One of the exceptions was that patients older than 50 could get imaged immediately, the rationale being that older adults had a higher prevalence of potentially serious conditions such as cancer, infections, etc, that would justify the early imaging. As a practicing neuroradiologist, it was clear that a potential problem with this strategy is that the prevalence of age-related changes, which may or may not be related to back pain, also increases with age. So earlier imaging of older adults would almost certainly reveal findings, and these could easily start a series of unfortunate events leading to potentially poor outcomes and more healthcare resource use. Thus this policy of early imaging of older adults didn’t entirely make sense. About 5 years ago, these guidelines hit home when I developed acute low back pain and since I was over 50 (barely) my doctor recommended that I get an imaging study. Being a knowledgeable patient and having a reasonable doctor, we mutually agreed not to get the study. I improved but that wasn’t the end of it. When we had the chance to apply for one of the CHOICE ARRA awards funded by AHRQ, we made answering this question of early imaging in older adults one of our primary goals.
Author Interviews, Cost of Health Care, Emergency Care / 16.03.2015

MedicalResearch.com Interview with: Asako Moriya Ph.D School of Public and Environmental Affairs Indiana University, Bloomington, IN Center for Financing, Access and Cost Trends Agency for Healthcare Research and Quality Rockville, MD MedicalResearch: What is the background for this study? What are the main findings? Response: Historically, young adults have had the lowest rate of insurance coverage.  They have also frequently sought non-urgent care in emergency departments (EDs). However, ED care, while appropriate for injuries and other true emergencies, is very expensive and inefficient for non-urgent care. The Affordable Care Act (ACA)’s dependent coverage provision requires health plans that offer dependent coverage to allow young adults to stay on their parents’ private health plans until age 26. This insurance expansion had a potential to improve efficiency by reducing inappropriate ED use. We used data from the Agency for Healthcare Research and Quality and found that the quarterly ED-visit rate decreased by a small, but statistically significant amount (1.6 per 1,000 population) among adults age 19-25 after the implementation of the ACA’s dependent coverage provision. The decrease was concentrated among women, weekday visits, non-urgent conditions, and conditions that could be treated in other settings. We found no effect among visits due to injury, weekend visits, and urgent conditions. The findings suggest that the ACA’s dependent coverage provision has increased the efficiency of medical care delivery by reducing non-urgent ED use. Having access to their parents’ health insurance appears to be prompting young adults to use medical care more appropriately.
Author Interviews, Cost of Health Care, Education / 13.03.2015

MedicalResearch.com Interview with: Tyler Winkelman, M.D. Internal Medicine and Pediatrics - PGY 4 University of Minnesota MedicalResearch: What is the background for this study? What are the main findings? Dr. Winkelman: Future physicians will practice after key provisions of the Affordable Care Act (ACA) have been enacted.  Whether medical students support or understand the legislation or are willing to engage in its implementation or modification as part of their professional obligation is unknown.  We surveyed medical students at 8 U.S. medical schools to assess their views and knowledge of the ACA (RR=52%).  We found that the majority of students support the ACA and indicate a professional obligation to assist with its implementation. There are, however, gaps in knowledge with regards to Medicaid expansion and insurance plans available within the health exchanges.  Students anticipating a surgical or procedural specialty, compared to those anticipating a medical specialty, were less likely to support the ACA, less likely to indicate a professional obligation to implement the ACA, and more likely to have negative expectation of the ACA.  Moderates, liberals, and those with above average knowledge scores were more likely to support the ACA and indicate a professional obligation to assist with its implementation.
Author Interviews, Cost of Health Care, JAMA, Medical Imaging, NYU/NYMC / 12.03.2015

Danil Makarov, MD Lead Investigator Assistant Professor, Departments of Urology, Population Health and Health Policy Member, Laura and Isaac Perlmutter Cancer Center NYU Langone Medical Center, New York, NYMedicalResearch.com Interview with: Danil Makarov, MD Lead Investigator Assistant Professor, Departments of Urology, Population Health and Health Policy Member, Laura and Isaac Perlmutter Cancer Center NYU Langone Medical Center, New York, NY Medical Research: What is the background for this study? Dr. Makarov: The background for this study is that regional variation in patterns of care and healthcare spending is widely known.  The drivers of this regional variation, though, are poorly understood.  Certain policy groups like the IOM have suggested that policy efforts be focused on individual providers and patients. Programs such as Choosing Wisely, which encourage a dialogue between physicians and patients, are a great example of such efforts.  However, some of our prior research suggests that regional variation is not random and that there might be are regional-level factors which drive variation. To test out our hypothesis, we wanted to see whether inappropriate imaging for two unrelated cancers was associated at a regional level (it should not be). Medical Research: What are the main findings? Dr. Makarov: We found that, at a regional level, inappropriate breast cancer imaging was associated with inappropriate prostate cancer imaging.
Author Interviews, Cost of Health Care, Critical Care - Intensive Care - ICUs, Mayo Clinic, Outcomes & Safety, Pediatrics, Pediatrics / 11.03.2015

Marc Ellsworth, M.D Neonatology fellow at the Mayo Clinic Children’s CenterMedicalResearch.com Interview with: Marc Ellsworth, M.D Neonatology fellow at the Mayo Clinic Children’s Center MedicalResearch: What is the background for this study? Dr. Ellsworth: Inhaled Nitric Oxide (iNO) is a drug that has FDA approval for use in neonates >34 weeks gestational age. It is used for severe respiratory failure secondary to pulmonary hypertension. However, it has been previously shown that neonatologists have been using this medication off-label and especially in the most premature neonates. Over the last 10 years there have been multiple large studies trying to determine a clinical use (ie long term benefit) for iNO in preterm neonates (patients where there is no FDA approval for iNO use currently). Despite evidence of short term benefit (improved clinical stability) use of this drug has not been shown to improve long-term outcomes (death and chronic lung disease) in premature neonates. As a result of these findings the National Institute of Child Health and Human Development (NICHD) released a consensus guideline in 2011 indicated that available evidence did not support the routine use of iNO in preterm neonates and discouraged this use of this expensive therapy in preterm neonates. Similarly, in 2014 the American Academy of Pediatrics issued a similar statement with similar recommendations. In 2014 a group of NICUs (collectively called the Neonatal Research Network) associated with the NICHD published a report showing that the use of Inhaled Nitric Oxide in preterm infants (ie off-label) decreased following the report in 2011. However, I did not feel that these NICUs were representative of the United States alone as the Neonatal Research Network consists of only a handful of NICUs (~15) and is directly associated with the NICHD. As a result I wanted to get a better idea of Inhaled Nitric Oxide use in a population based study to see if the trends were similar (ie use of iNO has been decreasing) on a much larger, more representative scale. (Editorial comment: My anecdotal experience was that rates of iNO use off-label have not decreased in preterm neonates since the 2011 report).
Author Interviews, Cost of Health Care, Health Care Systems / 04.03.2015

MedicalResearch.com Interview with: Sophie Coronini-Cronberg Honorary research Fellow Department of Primary Care and Public Health, Imperial College London Consultant in public health Centre Medical Directorate with Bupa, United Kingdom. Medical Research: What is the background for this study? What are the main findings? Dr. Coronini-Cronberg: From April 2011, England’s National Health Service (NHS) was challenged to find £20 billion of efficiency savings over four years, in part by reducing the use of ineffective, overused or inappropriate procedures. However, there was no clear instruction as to which procedures are of 'limited clinical value' and also under which circumstances they should be reduced. We looked at hospital admissions statistics for six procedures that appear on local and/or unofficial lists to see which had been affected and whether cuts were applied consistently across commissioners in the first year of the savings programme. We found a significant drop in three procedures considered potentially ‘low value’ compared to the underlying time trend: removal of cataracts, hysterectomy for heavy menstrual bleeding, and myringotomy to relieve eardrum pressure. There was no significant change in three other ‘low-value’ procedures: spinal surgery for lower back pain, inguinal hernia repair, and primary hip replacement, or in two ‘benchmark’ procedures (coronary revascularisation, gall bladder removal). Myringotomy, a procedure to relieve pressure in the ear which is considered relatively ineffective, declined by 11.4 per cent overall. Two procedures considered only effective in certain circumstances also fell overall. Hysterectomy for heavy menstrual bleeding declined by 10.7 per cent overall, and cataract removal declined by 4.8 per cent.ý ýWe also found the reductions were inconsistently applied by commissioning groups (so-called Primary Care Trusts).
Author Interviews, Baylor College of Medicine Houston, Cost of Health Care, Erectile Dysfunction, Heart Disease / 03.03.2015

Alexander W. Pastuszak, MD, PhD Male Reproductive Medicine and Surgery Scott Department of Urology Baylor College of Medicine Houston, TX MedicalResearch.com Interview with: Alexander W. Pastuszak, MD, PhD Male Reproductive Medicine and Surgery Scott Department of Urology Baylor College of Medicine Houston, TX   Medical Research: What is the background for this study? Dr. Pastuszak: The link between erectile dysfunction (ED) and cardiovascular disease (CVD) has been growing stronger in recent years, and recommendations have recently been made to screen men with ED for CVD risk factors.  The arteries in the penis are much smaller than those in the heart, and if vascular disease contributes to ED, which we know it does, then ED should be detected before CVD in affected men.  We also know that treating men with CVD risk factors results in improvement in their risk of having acute cardiovascular events (i.e. heart attack, stroke, etc.).  Because of these relationships, we wanted to assess the economic impact of screening men with erectile dysfunction for CVD, identifying men with CVD risk factors, and treating these men on the incidence of cardiovascular events and new cases of ED.  Specifically, we wanted to look at the costs associated with screening and treatment of CVD and erectile dysfunction, and the cost savings resulting from screening and treating men with CVD risk factors and ED when preventing acute cardiovascular events. Medical Research: What are the main findings? Dr. Pastuszak: We modeled the reduction in acute cardiovascular events and the associated cost savings over 20 years.  We predicted that approximately 5.8 million men with both CVD and ED would be identified over 20 years if we screened men with ED for CVD risk factors, and the cost of this screening would be $2.7 billion.  We assumed that if we treated these at-risk men, there would be an approximately 20% decrease in cardiovascular events, which would prevent 1.1 million cardiovascular events over 20 years, saving $21.3 billion that would otherwise be put to treatment of these acute events.  Since ED and CVD arise from the same pathology, we predicted that in treating the CVD risk factors, a similar decrease in ED cases would be seen as well, which would save $9.7 billion that would otherwise be put to ED treatment.  In screening these men, a combined $28.5 billion would be saved over 20 years.
Author Interviews, Cost of Health Care, Pharmacology / 03.03.2015

Eili Y. Klein Ph.D. Assistant Professor Department of Emergency Medicine Johns Hopkins University Baltimore, MD 21209MedicalResearch.com Interview with: Eili Y. Klein Ph.D. Assistant Professor Department of Emergency Medicine Johns Hopkins University Baltimore, MD 21209 Medical Research: What is the background for this study? What are the main findings? Dr. Klein: Antibiotic prescriptions rates vary widely across the country. We saw this at the state level, where rates in the highest prescribing states were as high as 1,200 prescriptions per 1,000 people to the lowest rates which were around 500 prescriptions per 1,000 people (see resistancemap.org). Europe has similar variation in prescribing rates across countries, and research there has documented a number of potential reasons for this such as education, access to health insurance, use of childcare centers, and cultural differences. However, the healthcare system in the US is structured differently than in Europe, so we set out to see if similar factors underlay differences in antibiotic prescribing in the US. Understanding the drivers of differences in prescribing is important because it can help predict how future changes in demographics and socioeconomic characteristics will affect future antibiotic consumption. It also enables predictions in consumption as a result of interventions that target the healthcare delivery system, and also enables better targeting of information campaigns, such as the CDC's Get Smart Program, on appropriate antibiotic prescribing to specific sub-populations. Finally, it allows providers to better understand how their practice is driven by external factors. The results of the study found that a primary factor driving differences in prescribing was the density of physicians. In other words, the more physicians there are per capita, the more prescriptions per capita. This result could just be due to more physicians making it easier to access a doctor and thus people go to visit a physician more. However, it could also suggest that physicians are competing to attract or retain patients in some manner and this is driving up prescriptions. To try to understand which of these effects was dominating the change, we examined the role of retail and urgent care clinics. Stand-alone urgent care clinics and clinics incorporated into the retail arm of a store (e.g., CVS minute clinic) are truly an American-style invention, and bear little similarity to how most Europeans receive healthcare. Over the last decade these establishments have exploded in popularity and greatly expanded their reach. Surprisingly what we found was that in low-income areas, a clinic increased the prescribing rate, but didn't affect the rate that physicians were prescribing antibiotics. Thus, in these areas the story is all about access. Improving access to healthcare increases the likelihood that people will go to the doctor when they are sick and that increases the rate that people get prescribed antibiotics. This contrasted with wealthier areas, where we found that a clinic increased the rate of prescribing by physicians, which is likely due to competition. This competition can take multiple forms, from increasing the probability of getting an antibiotic as a physician is worried you won't come back otherwise, to changes in how physician offices work so that it is easier to walk-in to your doctor or get a same-day appointment. Though we were not able to quantify which of these effects was dominant in this research.
Author Interviews, Health Care Systems, Medicare / 02.03.2015

Ann M. Sheehy, M.D., M.S. Associate Professor Division Head, Hospital Medicine University of Wisconsin Department of MedicineMedicalResearch.com Interview with: Ann M. Sheehy, M.D., M.S. Associate Professor Division Head, Hospital Medicine University of Wisconsin Department of Medicine MedicalResearch: What is the background for this study? What are the main findings? Dr. Sheehy: Outpatient (observation) and inpatient status determinations are important for hospitalized Medicare beneficiaries. The Recovery Audit program, more commonly known as the RACs (Recovery Audit Contractors), is charged with surveillance and enforcement of such status determinations. Surveillance in the Medicare program is necessary, and Medicare fraud and abuse should not be tolerated. However, there are increasing concerns regarding RAC accuracy, auditor financial incentives, and the volume of audits and overpayment determinations auditors allege. We therefore studied Complex Medicare Part A RAC audits at 3 academic medical centers, the University of Wisconsin, the University of Utah, and Johns Hopkins, to determine the impact and trends of such audits. There was a nearly 300% increase in RAC overpayment determinations in just 2 years at the study hospitals. Each year, the hospitals won a greater percent of contested cases, winning 68.0% of cases with decisions in 2013. Two-thirds of all favorable decisions for the hospitals occurred in the discussion period. Because discussion is not considered part of the formal appeals process, this is omitted from reports of RAC accuracy. None of the overpayment determinations contested the need for the care delivered, rather contested the billing location, outpatient or inpatient. The hospitals averaged 5 FTE each to manage the audit and appeals process. Claims still in appeals had been in process for a mean of 555 days without decisions.
AHRQ, Author Interviews, Cost of Health Care / 26.02.2015

Steven B. Cohen, Ph.D. Director, Center for Financing, Access and Cost Trends Agency for Healthcare Research and Quality Rockville, Maryland 20850MedicalResearch.com Interview with: Steven B. Cohen, Ph.D. Director, Center for Financing, Access and Cost Trends Agency for Healthcare Research and Quality Rockville, Maryland 20850 MedicalResearch: What is the background for this study? Dr. Cohen: Health care expenditures represent more than one-sixth of the U.S. gross domestic product, exhibit a rate of growth that exceeds other sectors of the economy, and constitute one of the largest components of the federal budget and states’ budgets. Although the rate of growth in health care spending has slowed in the past few years, costs continue to rise. As a result, an evaluation of the current health care system requires an understanding of the patterns and trends in the use of health care services and their associated costs and sources of payment. Studies that examine the concentration and persistence of high levels of expenditures over time are essential to help discern the factors most likely to drive health care spending and the characteristics of the individuals who incur them. MedicalResearch: What are the main findings? Dr. Cohen: Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) sponsored by the Agency for Healthcare Research and Quality (AHRQ), this study provides detailed estimates of the concentration and persistence in the level of health care expenditures in the United States. Attention is given to identifying the characteristics of individuals with the highest levels of medical expenditures, in addition to those factors that are associated with low medical expense profiles. In 2011, 1 percent of the population accounted for 21.5 percent of total health care expenditures, and in 2012, the top 1 percent accounted for 22.7 percent of total expenditures with an annual mean expenditure of $97,956. The lower 50 percent of the population ranked by their expenditures accounted for only 2.8 percent and 2.7 percent of the total for 2011 and 2012 respectively. Of those individuals ranked at the top 1 percent of the health care expenditure distribution in 2011 (with a mean expenditure of $92,825), 19.6 percent maintained this ranking with respect to their 2012 health care expenditures. In both 2011 and 2012, the top 10 percent of the population accounted for 65.3 percent of overall health care expenditures in 2011 (with a mean expenditure of $27,927), and 41.5 percent of this subgroup retained this top decile ranking with respect to their 2012 health care expenditures. Those who were in the top decile of spenders in both 2011 and 2012 differed by age, race/ethnicity, sex, health status, and insurance coverage (for those under 65) from those who were in the lower half in both years.
Author Interviews, Cost of Health Care, Duke, JAMA, Radiation Therapy, Thyroid / 19.02.2015

Sanziana Roman MD FACS Professor of Surgery Duke University Section of Endocrine Surgery Director of the Endocrine Surgery Fellows and Scholars Program Duke University School of Medicine Chief, General Surgery and Associate Chief of Surgery for Clinical Affairs, DVAMCMedicalResearch.com Interview with: Sanziana Roman MD FACS Professor of Surgery Duke University Section of Endocrine Surgery Director of the Endocrine Surgery Fellows and Scholars Program Duke University School of Medicine Chief, General Surgery and Associate Chief of Surgery for Clinical Affairs, DVAMC Medical Research: What is the background for this study? Dr. Roman: Adjuvant radioactive iodine (RAI) is commonly used in the management of differentiated thyroid cancer. The main goals of adjuvant RAI therapy are to ablate remnant thyroid tissue in order to facilitate long-term follow-up of patients, decrease the risk of recurrence, or treat persistent and metastatic lesions. On the other hand, Adjuvant radioactive iodine ( therapy is expensive, with an average cost per patient ranging between $5,429.58 and $9,105.67. It also carries the burden of several potential complications, including loss of taste, nausea, stomatitis with ulcers, acute and/or chronic sialoadenitis, salivary duct obstruction, dental caries, tooth loss, epiphora, anemia, neutropenia, thrombocytopenia, acute radiation pneumonitis, pulmonary fibrosis, male infertility, and radiation-induced malignancies. Therefore, Adjuvant radioactive iodine ( should be used only for appropriately selected patients, for whom the benefits would outweigh the risks. Based on current guidelines, adjuvant RAI is not recommended for patients with papillary thyroid cancers confined to the thyroid gland when all foci are ≤1 cm (papillary thyroid microcarcinoma, or PTMC). Similarly, Adjuvant radioactive iodine ( does not have a role in the treatment of medullary and anaplastic thyroid cancer. Given the fact that variation in treatments exist, our goal was to analyze patterns of inappropriate adjuvant RAI use in the U.S. in order to identify potential misuses leading to an increase of costs for the healthcare system and unnecessary patients’ exposure to risks of complications.
Author Interviews, Cost of Health Care / 13.02.2015

John Romley Ph.D Economist at the Leonard D. Schaeffer Center for Health Policy and Economics Research Assistant Professor Sol Price School of Public Policy University of Southern California, Los Angeles.MedicalResearch.com Interview with: John Romley Ph.D Economist at the Leonard D. Schaeffer Center for Health Policy and Economics Research Assistant Professor Sol Price School of Public Policy University of Southern California, Los Angeles. MedicalResearch: What is the background for this study? What are the main findings? Dr. Romley: The need for better value in US health care is widely recognized. Existing evidence suggests that improvement in the productivity of American hospitals—that is, the output that hospitals produce from inputs such as labor and capital—has lagged behind that of other industries. However, previous studies have not adequately addressed quality of care or severity of patient illness. Our study, by contrast, adjusts for trends in the severity of patients’ conditions and health outcomes. We studied productivity growth among US hospitals in treating Medicare patients with heart attack, heart failure, and pneumonia during 2002–11. We found that the rates of annual productivity growth were 0.78 percent for heart attack, 0.62 percent for heart failure, and 1.90 percent for pneumonia.
Author Interviews, Cancer Research, Cost of Health Care, JAMA, University of Pennsylvania / 13.02.2015

Ezekiel Jonathan Emanuel MD PhD Department of Medical Ethics and Health Policy Perelman School of Medicine and Department of Health Care Management The Wharton School University of Pennsylvania Philadelphia, PAMedicalResearch.com Interview with: Ezekiel Jonathan Emanuel MD PhD Department of Medical Ethics and Health Policy Perelman School of Medicine and Department of Health Care Management The Wharton School University of Pennsylvania Philadelphia, PA Editor’s note: Dr. Emanuel is a medical oncologist as well as director of the department of Medical Ethics and Health Policy at the University of Pennsylvania. Dr. Emanuel was kind enough to answer several questions regarding his most recent study, published in the new JAMA Oncology journal, Patient Demands and Requests for Cancer Tests and Treatments. Medical Research: What is the background for this study? What are the main findings? Dr. Emanuel: The genesis for this study is twofold. One, the first referenced article, by John Tilbert1 discussed how physicians explain US health care costs. In this study, physicians felt patients, insurance companies, drug companies, government regulations and malpractice lawyers...all were more to blame than doctors themselves for the high cost of US health care. Secondly, I give lots of presentations to doctors who offer two explanations for escalating health care costs: fear of malpractice litigation, and demanding patients, who request extensive testing and drugs. We decided to see whether the impression doctors frequently held of patients’ demands driving up health care costs, had been previously investigated. We could find no article to substantiate this belief. In addition, demanding patients were not common in my medical experience. In our study we included 5050 patient encounters. We asked the clinician coming out of the encounter, did the patient make a demand or request? (By asking immediately after the doctor left the examination room, there was little risk of inaccurate recall of the specifics of visit). In 8.7% there was a patient request and of these, over 70% were deemed clinically appropriate as determined by the physician (i.e. a request for pain medication, palliative care or imaging to address a new symptom or finding). In only 1% of all encounters (50/5050) was a clinically inappropriate request made as determined by the doctor, and the doctors hardly filled any of these inappropriate requests (total of 7 of 5050 encounters). We concluded that it is pretty rare for patients to make demands or requests, at least in this oncology setting, and even less common for the demands to be complied with by the doctor. Therefore it seems unlikely to us that health care costs are significantly driven by inappropriate patient requests. It is possible that there are more or different patient demands in other health care settings but we were very surprised to find no difference in patient requests based on patient-income, i.e. wealthier, more educated patients made no more demands than patients of lesser means.
Author Interviews, CDC, Cost of Health Care, HIV / 05.02.2015

MedicalResearch.com Interview with: Ya-lin (Aileen) Huang, PhD. Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention Atlanta, GA, 30329 Medical Research: What is the background for this study? What are the main findings? Dr. Huang: With an estimated 50,000 new HIV infections each year in this country, and no vaccine or cure available yet, prevention is critical. Maximizing the impact of all available prevention strategies could significantly reduce new infections in this country. The purpose of this study is to provide evidence for the cost effectiveness of the interventions recommended under the funding announcement and to highlight where more cost-effectiveness studies may be needed. We limited our scope to the four interventions required under the health department funding announcement, including HIV testing, prevention with HIV-positives and their partners, condom distribution and efforts to align policies with optimal HIV prevention, care and treatment. Our review provides an updated summary of the published evidence of cost-effectiveness of four key HIV prevention interventions recommended by CDC: HIV testing, prevention with HIV-positives and their partners, condom distribution and policy initiatives. Models suggest that more than 350,000 HIV infections have been avoided because of the nation’s HIV prevention efforts. In addition to lives saved, HIV prevention has also generated substantial economic benefits. For every HIV infection that is prevented, an estimated $402,000 (http://www.ncbi.nlm.nih.gov/pubmed/23615000) is saved in the cost of providing lifetime HIV treatment. It is estimated that HIV prevention efforts have averted more than $125 billion in medical costs since the beginning of the epidemic.
Accidents & Violence, Author Interviews, CDC, Cost of Health Care / 04.02.2015

Judy A. Stevens PhD National Center for Injury Prevention and Control Centers for Disease Control and Prevention Atlanta GA 30341MedicalResearch.com Interview with: Dr. Judy Stevens PhD National Center for Injury Prevention and Control Centers for Disease Control and Prevention, Atlanta, GA 30341, USA Medical Research: What is the background for this study? What are the main findings? Dr. Stevens: Falls among people aged 65 and older are a serious, costly, and growing public health problem. As our population ages, falls will continue to increase unless we implement effective prevention strategies that are also cost-effective. This study found that three evidence-based fall prevention programs, the Otago Exercise Program, Tai Chi: Moving for Better Balance, and Stepping On, were not only practical and effective but also provided a positive return on investment (ROI) or net benefit.  An ROI of 150% means for each $1 spent on implementing the program, you can expect a net benefit of $1.50. The analysis found that the cost of implementing each of these fall prevention programs was considerably less than the potential medical costs needed to care for someone injured from a fall. These research findings can help community organizations and policymakers identify and use programs that can both save lives and reduce costs.
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, HIV, NEJM / 30.01.2015

Douglas B. Jacobs B.S., MD/MPH Candidate Harvard T.H. Chan School of Public HealthMedicalResearch.com Interview with: Douglas B. Jacobs B.S., MD/MPH Candidate Harvard T.H. Chan School of Public Health Medical Research: What is the background for this study? Response: In May 2014, a formal complaint submitted to the Department of Health and Human Services contended that four Florida insurers were structuring their formularies in a way that discouraged enrollment from HIV positive beneficiaries. These insurers placed all HIV drugs, including generics, on the highest cost-sharing tiers. This formal complaint served as the impetus for this research. We wanted to discover if this was a phenomenon that was isolated to Florida, or if it was national in scope, and what the implications would be for HIV positive beneficiaries. As such, we analyzed what we called “adverse tiering”—in which all drugs for certain conditions are placed in the highest cost sharing tiers—in 12 states in the federal marketplace. We compared cost-sharing for a commonly prescribed class of HIV medication, called Nucleoside Reverse Transcriptase Inhibitors, or NRTIs.
Author Interviews, CDC, Cost of Health Care / 30.01.2015

MedicalResearch.com Interview with: Robin A. Cohen, Ph.D Medical Research: What is the background for this study? Dr. Cohen: Estimates are based on data collected from the 2013 National Health Interview Survey (NHIS). The NHIS is a survey conducted by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics. NHIS collects information about health and health care of the civilian noninstitutionalized population of the United States. In 2013, questions about strategies used to reduce prescription drug cost were asked of more than 34,000 adults aged 18 and over. Medical Research: What are the main findings? Dr. Cohen: To save money, almost 8% of U.S. adults (7.8%) did not take their medication as prescribed, 15.1% asked a doctor for a lower-cost medication, 1.6% bought prescription drugs from another country, and 4.2% used alternative therapies. Adults aged 18–64 (8.5%) were nearly twice as likely as adults aged 65 and over (4.4%) to have not taken their medication as prescribed to save money. Among adults aged 18–64, uninsured adults (14.0%) were more likely than those with Medicaid (10.4%) or private coverage (6.1%) to have not taken their medication as prescribed to save money. The poorest adults—those with incomes below 139% of the federal poverty level—were the most likely to not take medication as prescribed to save money. Among adults aged 65 and over, those living with incomes in the 139-400% FPL range were more likely than adults living in lower or higher income thresholds to have asked their provider for a lower cost prescription to save money.
Author Interviews, Blood Pressure - Hypertension, Cost of Health Care, NEJM / 29.01.2015

Andrew Moran, MD, MPH Herbert Irving Assistant Professor of Medicine Columbia University Division of General Medicine Presbyterian Hospital 9th floor East room 105 New York, NY 10032MedicalResearch.com Interview with: Andrew Moran, MD, MPH Herbert Irving Assistant Professor of Medicine Columbia University Division of General Medicine Presbyterian Hospital  New York, NY 10032 Medical Research: What is the background for this study? What are the main findings? Response: In 2014, a panel appointed by the Eighth Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure (JNC 8) recommended new guidelines for high blood pressure (hypertension ) treatment in U.S. adults.  The guidelines made sweeping changes to the prior guidelines and stirred up controversy among hypertension and public health experts.  Essentially, the panel recommended more conservative treatment targets that narrowed the population eligible for treatment with blood pressure-lowering medications.  Nonetheless, about 28 million U.S. adults have uncontrolled hypertension even under the new more conservative guidelines.  We asked the question:  are the new guidelines cost-effective? That is, does treating this common condition with the available medicines add more health and reduce medical costs?  It is surprising that this question has rarely been answered before.
Author Interviews, Cost of Health Care, Heart Disease / 28.01.2015

Andre Lamy MD MHSc COMPASS (CABG sub-group PI) CORONARY Principal Investigator Professor, Dept Surgery, Division Cardiac Surgery Associate Member, Dept Clinical Epidemiology & Biostatistics McMaster University Hamilton General Hospital Hamilton, ON, CanadaMedicalResearch.com Interview with: Andre Lamy MD MHSc COMPASS (CABG sub-group PI) CORONARY Principal Investigator Professor, Dept Surgery, Division Cardiac Surgery Associate Member, Dept Clinical Epidemiology & Biostatistics McMaster University Hamilton General Hospital Hamilton, ON, Canada Medical Research: What is the background for this study? Dr. Lamy: The Canadian healthcare system operates in an environment that must constantly find new ways to make healthcare delivery more efficient. In the TIMACS clinical led by Dr. Shamir Mehta, it was found that the primary outcome was similar for an early invasive procedure within 24 hours and a delayed approach of after 36 hours in outcomes. However, because of the inherent shorter length of stay associated with early invasive procedures within 24 hours there will be definite cost-savings from an early invasive strategy. Dr. Andre Lamy et al looked at the cost implications of this shorter length of stay in the TIMACS trial and explored the impact of the use of a catheterization lab on days when they are normally not in use (i.e. weekends), which may negate the savings of early intervention. Medical Research: What are the main findings? Dr. Lamy: The main findings of our study were that early invasive strategy was cost-saving for Canadian NTSE-ACS patients due to significant savings from the shorter length of stay. These savings were present even if as many as 50% of TIMACS patients were assumed to be weekend cases. Given many high-risk NSTE-ACS patients receive delayed intervention due to weekend catheterization lab status, these findings support operating catheterization labs on weekends to facilitate the use of early invasive intervention.
AHRQ, Author Interviews, Cost of Health Care / 28.01.2015

Raynard E. Washington, PhD, MPH Center for Delivery, Organization, and Markets Agency for Healthcare Research and Quality Rockville, MD 20850MedicalResearch.com Interview with: Raynard E. Washington, PhD, MPH Center for Delivery, Organization, and Markets Agency for Healthcare Research and Quality Rockville, MD 20850 Medical Research: What is the background for this study? What are the main findings? Dr. Washington: Many individuals with low income who require a hospital stay are uninsured or covered by Medicaid, a joint Federal-State health insurance program for eligible individuals and families with low income. The difference in hospital utilization among patients covered by Medicaid and those who are uninsured may reflect differences in the characteristics of these populations and their level of access to health care. This HCUP Statistical Brief describes 2012 hospital stays with a primary expected payer of Medicaid and stays that were uninsured. Of the 36.5 million total hospital inpatient stays in 2012, 20.9 percent had an expected primary payer of Medicaid and 5.6 percent were uninsured; 30.6 percent were covered by private insurance. Patients covered by Medicaid were on average younger and more likely to live in low-income areas than were patients with private insurance. Patients who were uninsured were more likely to be male and to live in low-income communities than were patients with private insurance. The majority of the top 10 diagnoses for Medicaid hospitalizations were ambulatory care sensitive conditions. Cholecystectomy (gall bladder removal) was the most common operating room procedure for Medicaid and uninsured stays.
Author Interviews, Cost of Health Care, NEJM, University of Pennsylvania / 26.01.2015

Daniel Polsky PhD Executive Director, Leonard Davis Institute of Health Economics Professor of Medicine and Health Care Management Perelman School of Medicine and the Wharton School University of PennsylvaniaMedicalResearch.com Interview with: Daniel Polsky PhD Executive Director, Leonard Davis Institute of Health Economics Professor of Medicine and Health Care Management Perelman School of Medicine and the Wharton School University of Pennsylvania Medical Research: What is the background for this study? What are the main findings? Dr. Polsky: The Medicaid Fee bump, a provision of the Affordable Care Act (ACA), raised Medicaid payments to Medicare levels in 2013 and 2014 for selected services and providers expired on January 1, 2015 before policymakers had much empirical evidence about its effects.   The federally funded increase in reimbursements was aimed at expanding access to primary care for the growing number of Medicaid enrollees. The reimbursement increase expired at the end of 2014 in most states.  We found that this policy worked to increase the number of providers offering primary care appointments to Medicaid patients.  The Medicaid pay bump was associated with a 7.7 percentage points increase in new patient appointment availability without longer wait times.   This increase in availability was largest in the states where primary care physicians received the largest increase in their Medicaid reimbursements.
Author Interviews, Cost of Health Care, Heart Disease, JACC, Outcomes & Safety / 19.01.2015

Dr. P. Michael Ho, MD PhD Denver Veteran Affairs Medical Center, University of Colorado, Denver, Section of Cardiology Denver, Colorado 80220.MedicalResearch.com Interview with: Dr. P. Michael Ho, MD PhD Denver Veteran Affairs Medical Center, University of Colorado, Denver, Section of Cardiology Denver, Colorado 80220. Medical Research: What is the background for this study? What are the main findings? Dr. Ho: There is increasing interest in measuring health care value, particularly as the healthcare system moves towards accountable care. Value in health care focuses on measuring outcomes achieved relative to costs for a cycle of care. Attaining high value care - good clinical outcomes at low costs - is of interest to patients, providers, health systems, and payers. To date, value assessments have not been operationalized and applied to specific patient populations. We focused on percutaneous coronary intervention (PCI) because it is an important aspect of care for patients with ischemic heart disease, is commonly performed and is a costly procedure. In this study, we evaluated 1-year risk-adjusted mortality and 1-year risk-standardized costs of care for all patients who underwent PCI in the VA healthcare system from 2008 to 2010. We found that median one-year unadjusted hospital mortality rate was 6.13% (interquartile range 4.51% to 7.34% across hospitals). Four hospitals were significantly above the one-year risk standardized median mortality rate, with median mortality ratios ranging from 1.23 to 1.28; no hospitals were significantly below median mortality. Median 1-year total unadjusted hospital costs were $46,302 (IQR of $37,291 to $57,886) per patient. There were 16 hospitals above and 19 hospitals below the risk standardized average cost, with risk standardized ratios ranging from 0.45 to 2.09 reflecting much larger magnitude of variability in costs compared to mortality. These findings suggest that there are opportunities to improve PCI healthcare by reducing costs without compromising outcomes. This approach of evaluating outcomes and costs together may be a model for other health systems and accountable care organizations interested in operationalizing value measurement.
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, JAMA, Medicare, Mental Health Research, Pharmacology / 16.01.2015

Dr. Jeanne Madden PhD Instructor, Department of Population Medicine Harvard Medical SchoolMedicalResearch.com Interview with: Dr. Jeanne Madden PhD Instructor, Department of Population Medicine Harvard Medical School   Medical Research: What is the background for this study? What are the main findings? Dr. Madden: When Medicare Prescription Drug Coverage started in 2006, many experts voiced concerns about disabled patients with serious mental illness making the transition from state Medicaid coverage to Medicare.  Our study is one of the first to examine the impact of the transition in mentally ill populations.  People living with schizophrenia and bipolar disorder are at high risk of relapse and hospitalization and are especially vulnerable to disruptions in access to their treatments. We found that the effects of transitioning from Medicaid to Medicare Part D depended on where patients lived.  Transition to Part D in states that put limits on Medicaid drug coverage resulted in fewer patients going without treatment. By contrast, in states with more generous drug coverage, we saw reductions in use, of antipsychotics in particular, after patients shifted to Medicare Part D.  This may have been due to new cost controls used within many private Medicare drug plans.  Given that most states in the US are in this latter category, with the relatively generous Medicaid drug coverage, we also found reductions in antipsychotic use nation-wide. Although a very large group of people made that transition from Medicaid to Medicare in 2006, thousands more still transition every year because when disabled people qualify for Medicare, they must wait 2 years for their benefits kick in.  Also, many other disabled patients are on Medicaid only and don’t qualify for Medicare.  They are of course affected by restrictions on Medicaid coverage, which vary from state to state.
Author Interviews, Cost of Health Care, JAMA, Pediatrics / 24.12.2014

Dr. Ricardo Mosquera MD Assistant professor of Pediatrics at The University of Texas Health Science Center at Houston Medical School Clinic Director, UT Physicians, of the UTHealth Medical School.MedicalResearch.com Interview with: Dr. Ricardo Mosquera MD Assistant professor of Pediatrics at The University of Texas Health Science Center at Houston Medical School Clinic Director, UT Physicians, of the UTHealth Medical School. Medical Research: What is the background for this study? What are the main findings? Dr. Mosquera: There is not strong scientific evidence to support the use of medical homes.  Medical homes have not been demonstrated to decrease adverse outcomes or costs in children. Such benefits are most likely for high-risk children with chronic illness.  We conducted a rigorous and well designed, randomized controlled trial to determine if an enhanced medical home providing comprehensive care decreases serious illness  (death, prolonged hospitalization>7 days, or intensive care unit admissions) and/or cost among high-risk chronically ill children. An enhanced medical home decreased both adverse outcomes (decreased serious illness, hospitalizations, PICU admissions, and serious illness by ~50%) and cost (~$10.000 less per child/year).