The effects of dental hygienist autonomy on dental care utilization.

We investigate the effects of regulations governing the practice autonomy of dental hygienists on dental care use with the 2001-2014 Medical Expenditure Panel Survey. We measure the strength of autonomy regulations by extending the Dental Hygiene Professional Practice Index to the years 2001-2014, allowing us to capture changes in regulations within states over time. Using a difference-in-differences framework applied to selected states, we find that relaxing supervision requirements to provide dental hygienists moderate autonomy results in an increase in total dental visits due to greater use of preventive dental care. However, the use of dental treatment decreases when states adopt the highest level of autonomy. Both sets of estimates increase in magnitude when we subset the sample to dental care provider shortage areas. In support of these findings, we show that dental visits shift to dental hygienists in shortage areas when states expand the scope of practice of hygienists, and that there is an increase in tasks performed by hygienists, such as cleanings and dental exams.

Do elections make you sick? Evidence from first-time voters.

Elections permit the continuance of democracy and enable economic development, but may have unintended effects on health. By applying a two-part model with regression discontinuity design to administrative health care claims, we determine that elections increased health care use during legally specified campaign periods by as much as 19% for first-time voters. Contrary to earlier studies focusing on mental health, we find higher spending on the treatment of physical health conditions, such as acute respiratory infections, gastrointestinal conditions and injuries. Levels of medical spending during campaign periods were highest in rural areas and among low-to-middle-income men. Using data on campaign spending from local elections, we identify campaign rallies as one important mechanism for the transmission of disease. Our findings provide additional rationale for policies that limit campaign spending on the grounds that it is socially wasteful.

The role of electronic health record developers in hospital patient sharing.

OBJECTIVE: To determine whether hospital adoption of a new electronic health record (EHR) developer increases patient sharing with hospitals using the same developer. MATERIALS AND METHODS: We extracted data on patients shared with other hospitals for 3076 US nonfederal acute care hospitals from the 2011 to 2016 Centers for Medicare & Medicaid Services Physician Shared Patient Patterns database. We calculated the ratio of patients shared with hospitals outside of the focal hospital's network that use the same EHR developer as the focal hospital, and estimated difference-in-differences models to compare same-developer patient sharing among hospitals that switched to a new developer with those that did not switch developer. RESULTS: Switching to a new EHR developer increased the ratio of patients shared with other hospitals having the same EHR developer by 4.1-19.3%, depending on model specification. The magnitude of this effect varied by EHR developer and was increasing in developer market share. DISCUSSION: Consolidation in the EHR industry has led to higher patient sharing among hospitals with the same EHR developer. Contributing factors could include the growth of developer-based health information exchanges, customizable referral management systems, and provider preferences for easy and reliable data exchange. However, hospital transfers that are significantly influenced by EHR developer could lead to poor patient-provider matches. CONCLUSION: Hospitals' choice of EHR developer impacts the flow of patients across hospitals, which could have both desirable and undesirable effects on patient care. Future research should investigate whether health outcomes decline with greater same-developer patient sharing.

COVID-19 prevention, air pollution and transportation patterns in the absence of a lockdown.

Recent studies demonstrate that air quality improved during the coronavirus pandemic due to the imposition of social lockdowns. We investigate the impact of COVID-19 on air pollution in the two largest cities in Taiwan, which were not subject to economic or mobility restrictions. Using a difference-in-differences approach and real-time data on air quality and transportation, we estimate that anthropogenic air pollution from local sources increased during working days and decreased during non-working days during the COVID-19 pandemic. This led to a 3-7 percent increase in CO, O3, SO2, PM10 and PM2.5. We demonstrate that the increase in air pollution resulted from a shift in preferred mode of travel away from public transportation and towards personal motor vehicles during working days. In particular, metro and shared bicycle usage decreased between 8 and 18 percent, on average, while automobile and scooter use increased between 11 and 21 percent during working days. Similar COVID-19 prevention behaviors in regions or countries emerging from lockdowns could likewise result in an increase in air pollution. Taking action to reduce the transmissibility of COVID-19 on metro cars, trains and buses could help policymakers limit the substitution of personal motor vehicles for public transit, and mitigate increases in air pollution when lifting mobility restrictions.

The effects of paid sick leave on worker absenteeism and health care utilization.

We estimate the short-term effects of paid sick leave on worker absenteeism and health care utilization in the United States using data from the 2000-2013 Medical Expenditure Panel Survey. We use both parametric and matching-based difference-in-differences methods to account for nonrandom selection into jobs that offer paid sick leave and estimate the treatment effect separately for workers who gained and lost sick leave benefits. We find consistent evidence of increased absenteeism among female workers who gained paid sick leave but not for other groups. Estimates for office-based visits are mostly statistically insignificant and may not have a causal interpretation due to preexisting trends.

Does covering routine dental care for the Medicare population produce cost savings in Medicare? A preliminary 2-year analysis.

OBJECTIVES: We estimated the association between the use of preventive dental care and medical use and expense for older persons over a 2-year period to determine if a Medicare dental benefit for routine care could result in potential cost savings in Medicare. METHODS: We relied on 2008-2014 Medical Expenditure Panel Survey data to estimate separate logistic and lognormal ordinary least squares regressions to analyze the influence of year 1 preventive dental care on either year 1 or year 2 use and expenses for total health care, office-based care, outpatient care, inpatient stays, emergency department visits, and prescription drugs. RESULTS: Our findings provide evidence over a 2-year period that a Medicare dental benefit for routine care could produce an increase in office-based visits and expense. We also found that older persons currently using routine dental care have healthier lifestyles and greater access to care and use of preventive medical care than current nonusers. CONCLUSION: Our results affirm the need for a longer-term study to provide any conclusive evidence as to the ultimate impact of a Medicare dental benefit on other health care use and expenses.

The effects of Medicaid expansion on labor market outcomes: Evidence from border counties.

This paper provides new empirical evidence on the employment and earning effects of the recent Medicaid expansion. Unlike most existing studies that use a conventional state and year fixed effects approach, our main identification strategy is based on the comparison of employment and wages in contiguous county-pairs in neighboring states (i.e., border counties) with different Medicaid expansion status. Using the 2008-2016 Quarterly Census of Employment and Wages, we estimate a set of distributed lag models in order to examine the dynamic effects of Medicaid expansion. Results from our preferred specification suggest a statistically significant decrease in total employment of 1.2% 1 year after the expansion of Medicaid. This translates into a 37% decrease in employment among newly eligible Medicaid enrollees under the strong assumption that Medicaid coverage did not crowd out private insurance coverage. We also find that this disemployment effect is transitory: 2 years after the Medicaid expansion employment returns to preexpansion levels. We do not find any statistically significant effect of the Medicaid expansion on wages at any point.

The demand for preventive and restorative dental services among older adults.

Many older Americans have poor access to dental care, resulting in a high prevalence of oral health problems. Because traditional Medicare does not include dental care benefits, only older Americans who are employed, have post-retirement dental benefits or spousal coverage, or enroll in certain Medicare Advantage plans are able to obtain dental care coverage. We seek to determine the extent to which poor access to dental insurance and high out-of-pocket costs affect dental service use by the elderly. Using the 2007-2015 Medical Expenditure Panel Survey and supplemental data on dental care prices, we estimate a demand system for preventive dental services and basic and major restorative services. Selection into dental and medical insurance is addressed using a correlated random effects panel data specification. Consistent with prior studies of the nonelderly population, dental service use was not sensitive to out-of-pocket prices. However, private dental insurance increased preventive service use by 25%, and dental coverage through Medicaid increased basic and major service use by 23% and 36%, respectively. The use of services was more responsive to dental insurance for women than men. These estimates suggest that a Medicare dental benefit could significantly increase dental service use by older Americans.

Inter-brand competition in the convenience store industry, store density and healthcare utilization.

We investigate the impact of access to convenience stores and competition between convenience store chains on the use of medical care in Taiwan. Using insurance claims from 0.85 million individuals and administrative data on store sales, we find that greater store density and more inter-brand competition reduced expenditures on outpatient medical services and prescription drugs. In support of these findings, we demonstrate that convenience store competition was associated with greater consumption of healthy foods and lower obesity rates. Our estimates suggest that the rise in convenience store competition from 2002 to 2012 reduced outpatient expenditures in Taiwan by 0.44 percent and prescription drug expenditures by 0.85 percent.

Provider and patient satisfaction with the integration of ambulatory and hospital EHR systems.

Objective: The installation of EHR systems can disrupt operations at clinical practice sites, but also lead to improvements in information availability. We examined how the installation of an ambulatory EHR at OB/GYN practices and its subsequent interface with an inpatient perinatal EHR affected providers' satisfaction with the transmission of clinical information and patients' ratings of their care experience. Methods: We collected data on provider satisfaction through 4 survey rounds during the phased implementation of the EHR. Data on patient satisfaction were drawn from Press Ganey surveys issued by the healthcare network through a standard process. Using multivariable models, we determined how provider satisfaction with information transmission and patient satisfaction with their care experience changed as the EHR system allowed greater information flow between OB/GYN practices and the hospital. Results: Outpatient OB/GYN providers became more satisfied with their access to information from the inpatient perinatal triage unit once system capabilities included automatic data flow from triage back to the OB/GYN offices. Yet physicians were generally less satisfied with how the EHR affected their work processes than other clinical and non-clinical staff. Patient satisfaction dropped after initial EHR installation, and we find no evidence of increased satisfaction linked to system integration. Conclusions: Dissatisfaction of providers with an EHR system and difficulties incorporating EHR technology into patient care may negatively impact patient satisfaction. Care must be taken during EHR implementations to maintain good communication with patients while satisfying documentation requirements.

Projecting the Demand for Dental Care in 2040.

The purpose of this study was to provide a forward-thinking assessment of the underlying factors likely to impact trends in dental care demand and the need for dental providers in 2020, 2025, and beyond. Dental workforce trends and their likely impact on the need for dentists are a function of predicted dental care demand, which will in turn be determined by the size and characteristics of our population size, economic outlook, the state of public and private dental care insurance, trends in dental care delivery, professionally determined dental care need, and population health beliefs. Projecting rates of dental care utilization far into the future is difficult because projections must be made using historical data, and established trends may not persist if there is structural change in the future. Nonetheless, when structural change occurs, it does not typically affect all aspects of the economy, so there is value in describing the likely future impact of current trends. This article was written as part of the project "Advancing Dental Education in the 21st Century."

A mixed methods study of clinical information availability in obstetric triage and prenatal offices.

OBJECTIVE: To determine the effect of availability of clinical information from an integrated electronic health record system on pregnancy outcomes at the point of care. MATERIALS AND METHODS: We used provider interviews and surveys to evaluate the availability of pregnancy-related clinical information in ambulatory practices and the hospital, and applied multiple regression to determine whether greater clinical information availability is associated with improvements in pregnancy outcomes and changes in care processes. Our regression models are risk adjusted and include physician fixed effects to control for unobservable characteristics of physicians that are constant across patients and time. RESULTS: Making nonstress test results, blood pressure data, antenatal problem lists, and tubal sterilization requests from office records available to hospital-based providers is significantly associated with reductions in the likelihood of obstetric trauma and other adverse pregnancy outcomes. Better access to prenatal records also increases the probability of labor induction and decreases the probability of Cesarean section (C-section). Availability of lab test results and new diagnoses generated in the hospital at ambulatory offices is associated with fewer preterm births and low-birth-weight babies. DISCUSSION AND CONCLUSIONS: Increased availability of specific clinical information enables providers to deliver better care and improve outcomes, but some types of clinical data are more important than others. More available information does not always result from automated integration of electronic records, but rather from the availability of the source records. Providers depend upon information that they trust to be reliable, complete, consistent, and easily retrievable, even if this requires multiple interfaces.

Projections Of Dental Care Use Through 2026: Preventive Care To Increase While Treatment Will Decline.

This study provides a forward-thinking assessment of the factors likely to affect future trends in dental care in the United States. We developed a forecasting model based on historical data from the Medical Expenditure Panel Survey to determine how demographic trends and recent health care policies will affect dental care use in the future. Our forecasts suggest that the medical and dental insurance reforms instituted under the Affordable Care Act will increase rates of dental care use and the number of dental visits, with utilization rates reaching 47 percent in 2026 and the number of visits reaching 334 million, under optimistic assumptions about take-up of pediatric dental coverage. Our forecasting model also indicates that visits for preventive dental care will increase in the future, while visits for dental treatment will decline. Our forecasts can be used to infer future need for different types of dental care providers and to provide policy makers with the information needed to consider the expansion of mandates for dental benefit coverage to adult populations covered by Medicaid, Medicare, and individual and small-group plans sold on health insurance exchanges.

Integrating commercial ambulatory electronic health records with hospital systems: An evolutionary process.

OBJECTIVE: The increase in electronic health record implementation in all treatment venues has led to greater demands for integration within and across practice settings with different work cultures. We study the evolution of coordination processes when integrating ambulatory-specific electronic health records with hospital systems. MATERIALS AND METHODS: Longitudinal qualitative study using semi-structured interviews and archival documentation throughout a 5-year implementation and integration of obstetrical ambulatory and hospital records with a goal of achieving a perinatal continuum of care. RESULTS: As users implement and integrate electronic health records, there is an evolution in their focus from technology acceptance to structural adaptation to coordination. The users' perspective on standardization evolves from initial concern about the unintended consequences of standardization to recognition of its importance and then finally to more active acceptance. The system itself cannot drive all reengineering; the organization must impose specific work process changes and as the user's perspective evolves, more individually adapted and aligned change will occur. Computer integration alone does not result in coordination; users must value integrated information and incorporate this information within their workflows. DISCUSSION: Users initially view electronic health records as a documentation tool, but over time they come to recognize the benefits of the system for clinical information retrieval, and finally, for care coordination after the integrated information provided through electronic health records becomes more complete, accessible and adapted to meet user needs. As this occurs, coordination mechanisms move beyond pooled standardization through sequential plans coordinated by the organization to reciprocal mutual adjustments for clinical decision making by individuals. Trust in the information source, not software interoperability, is critical for information sharing. CONCLUSIONS: Organizations implementing commercial electronic health records cannot simply assume that reciprocal coordination will immediately occur. It takes time for users to adjust, and enculturate coordination goals, during which time there are adaptive structurations that require organizational response, and changes in mechanisms for achieving coordination.

The demand for preventive and restorative dental services.

Chronic tooth decay is the most common chronic condition in the United States among children ages 5-17 and also affects a large percentage of adults. Oral health conditions are preventable, but less than half of the US population uses dental services annually. We seek to examine the extent to which limited dental coverage and high out-of-pocket costs reduce dental service use by the nonelderly privately insured and uninsured. Using data from the 2001-2006 Medical Expenditure Panel Survey and an American Dental Association survey of dental procedure prices, we jointly estimate the probability of using preventive and both basic and major restorative services through a correlated random effects specification that controls for endogeneity. We found that dental coverage increased the probability of preventive care use by 19% and the use of restorative services 11% to 16%. Both conditional and unconditional on dental coverage, the use of dental services was not sensitive to out-of-pocket costs. We conclude that dental coverage is an important determinant of preventive dental service use, but other nonprice factors related to consumer preferences, especially education, are equal if not stronger determinants.

"Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention".

BACKGROUND: We describe and evaluate the development and use of a Clinical Decision Support (CDS) intervention; an alert, in response to an identified medical error of overuse of a diagnostic laboratory test in a Computerized Physician Order Entry (CPOE) system. CPOE with embedded CDS has been shown to improve quality of care and reduce medical errors. CPOE can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. Observational studies are necessary in order to understand how these technologies can be successfully employed by healthcare providers. METHODS: The error was identified by the Test Utilization Committee (TUC) in September, 2008 when they noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may be clinically misleading. The CDS intervention consists of an expert rule that searches the system for a BNP lab value on the patient. If there is a value and the value is within the current hospital stay, an advisory is displayed to the ordering clinician. In order to isolate the impact of this intervention on unnecessary BNP testing we applied multiple regression analysis to the sample of 41,306 patient admissions with at least one BNP test at LVHN between January, 2008 and September, 2011. RESULTS: Our regression results suggest the CDS intervention reduced BNP orders by 21% relative to the mean. The financial impact of the rule was also significant. Multiplying by the direct supply cost of $28.04 per test, the intervention saved approximately $92,000 per year. CONCLUSIONS: The use of alerts has great positive potential to improve care, but should be used judiciously and in the appropriate environment. While these savings may not be generalizable to other interventions, the experience at LVHN suggests that appropriately designed and carefully implemented CDS interventions can have a substantial impact on the efficiency of care provision.

The impact of health information technology adoption by outpatient facilities on pregnancy outcomes.

OBJECTIVE: Examine whether health information technology (HIT) at nonhospital facilities (NHFs) improves health outcomes and decreases resource use at hospitals within the same heath care network, and whether the impact of HIT varies as providers gain experience using the technologies. DATA SOURCES: Administrative claims data on 491,832 births in Pennsylvania during 1998-2004 from the Pennsylvania Health Care Cost Containment Council and HIT applications data from the Dorenfest Institute. STUDY DESIGN: Fixed-effects regression analysis of the impact of HIT at NHFs on adverse birth outcomes and resource use. PRINCIPAL FINDINGS: Greater use of clinical HIT applications by NHFs is associated with reduced incidence of obstetric trauma and preventable complications, as well as longer lengths of stay. In addition, the beneficial effects of HIT increase the longer that technologies have been in use. However, we find no consistent evidence on whether or how nonclinical HIT in NHFs affects either resource use or health outcomes. CONCLUSIONS: Clinical HIT applications at NHFs may reduce the likelihood of adverse birth outcomes, particularly after physicians and staff gain experience using the technologies.

Patient mix in outpatient surgery settings and implications for Medicare payment policy.

In 2008, Medicare implemented a new payment policy for ambulatory surgical centers (ASCs), which aligns the ASC payment system with that used for hospital outpatient departments and reimburses ASCs approximately 65% of what hospitals receive for the same outpatient surgery. The authors assess patient selection across ASCs and hospital outpatient departments for four common surgeries (colonoscopy, hernia repair, knee arthroscopy, cataract repair), using data on procedures performed in Florida from 2004 to 2008. The authors construct measures of patient illness severity and cost risk and find that ASCs benefit from positive selection. Nonetheless, the degree of selection varies by surgery type and patient population. While similar studies in other states are needed, the findings suggest that modifications to the Medicare outpatient payment system may be appropriate to account for the different populations that each setting attracts.

New estimates of the demand for physical and mental health treatment.

Consumers' price responsiveness is central to US health-care reform proposals, but the best available estimates are now more than 25 years old. We estimate health-care demands by calculating expected end-of-year prices and incorporating them into a zero-inflated ordered probit model applied to several overlapping panels of data from 1996 to 2003. Results from our correlated random effects specification indicate that the price responsiveness of ambulatory mental health treatment has decreased substantially and is now slightly lower than physical health treatment. This suggests that concerns over moral hazard alone do not warrant less generous coverage for mental health. However, prescription drug demand is more price elastic.

State variations in the out-of-pocket spending burden for outpatient mental health treatment.

We examine the potential of mental health/substance abuse (MH/SA) parity laws to reduce the out-of-pocket spending burden for outpatient treatment at the state level by exploring cross-state variations and their causes, as well as the provisions of MH/SA parity laws. We find modest (yet important) variation in out-of-pocket burden across states overall, but-because prescription medications account for two-thirds of out-of-pocket spending and are generally beyond the scope of recently enacted federal parity laws-evidence suggests that those laws will do little to reduce the observed burden or its variation. Other policy measures, designed to expand and improve health insurance coverage or reduce racial/ethnic disparities, could have a more profound impact.