The effect of Medicaid expansion on the take-up of disability benefits by race and ethnicity.

Public disability programs provide financial support to 12 million working-age individuals per year, though not all eligible individuals take up these programs. Mixed evidence exists regarding the impact of Medicaid eligibility expansion on program take-up, and even less is known about the relationship between Medicaid expansion and racial and ethnic disparities in take-up. Using 2009-2020 Current Population Survey data, we compare changes in Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) take-up among respondents with disabilities living in Medicaid expansion states to respondents with disabilities living in non-expansion states, before and after Medicaid expansion. We further explore heterogeneity by race/ethnicity. We find that Medicaid expansion reduced SSI take-up by 10% overall, particularly among White and Hispanic respondents (10% and 21%, respectively). Medicaid expansion increased SSDI take-up by 8% overall, particularly among White and Black respondents (9% and 11%, respectively). Moreover, we find that Medicaid expansion reduced the probability that respondents with disabilities had employer-sponsored health insurance by approximately 8%, suggesting that expansion may have reduced job-lock among the SSDI-eligible, contributing to the observed increase in SSDI take-up.

Access to cardiac PET/CT by sarcoidosis patients and cost-effectiveness analysis of cardiac PET/MR compared to the standard of care.

IMPORTANCE: Cardiac sarcoidosis is associated with a high mortality rate. Given multiple barriers to obtaining cardiac PET imaging, we suspect individuals with access to this imaging modality are not representative of the Sarcoid patient population, which in the United States are predominantly Black females. OBJECTIVE: To evaluate the demographics of patients with cardiac PET access and the cost-effectiveness of cardiac PET/MR imaging relative to standard of care. DESIGN: This is a retrospective, observational study. The demographic information of patients with suspected cardiac sarcoidosis and cardiac PET/CT imaging within a national registry of sarcoidosis were reviewed (n = 4561). An individual-level, continuous, time-state transition model was used for the evaluation of long-term cost-effectiveness for the combined cardiac PET/MR compared to standard of care cardiac MR followed by cardiac PET/CT. RESULTS: Patients who underwent cardiac PET in the national registry had 88.35% higher odds of being male (p < 0.001) and 43.82% higher odds of being White (p = 0.003) than their counterparts who did not have cardiac PET imaging. Combined cardiac PET/MR had overall lower total lifetime costs ($8761 vs $10,777) and overall improved expected quality of life-years compared to the standard of care (0.77 vs 0.69). CONCLUSION AND RELEVANCE: The findings suggest that patients with access to cardiac PET/CT are not representative of the patient population most likely to have cardiac sarcoidosis in this limited study evaluation. Universal insurance coverage should be considered for Cardiac PET imaging as same day cardiac PET and MR imaging has potential long-term cost and quality of life benefit.

Comparing Health Outcomes of Privileged US Citizens With Those of Average Residents of Other Developed Countries.

Importance: The average health outcomes in the US are not as good as the average health outcomes in other developed countries. However, whether high-income US citizens have better health outcomes than average individuals in other developed countries is unknown. Objective: To assess whether the health outcomes of White US citizens living in the 1% and 5% richest counties (hereafter referred to as privileged White US citizens) are better than the health outcomes of average residents in other developed countries. Design, Setting, and Participants: This comparative effectiveness study, conducted from January 1, 2013, to December 31, 2015, identified White US citizens living in the 1% (n = 32) and 5% (n = 157) highest-income counties in the US and measured the following 6 health outcomes associated with health care interventions: infant and maternal mortality, colon and breast cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction. The study used Organisation for Economic Co-operation and Development data, CONCORD-3 cancer data, and Medicare data to compare their outcomes with all residents in 12 other developed countries: Australia, Austria, Canada, Denmark, Finland, France, Germany, Japan, the Netherlands, Norway, Sweden, and Switzerland. Statistical analysis took place from July 25, 2017, to August 29, 2020. Main Outcomes and Measures: Infant mortality; maternal mortality; 5-year survival of patients with colon cancer, breast cancer, or childhood acute lymphocytic leukemia; and 30-day age-standardized case fatality after acute myocardial infarction. Results: The infant mortality rate among White US citizens in the 5% highest-income counties was 4.01 per 1000, and the maternal mortality rate among White US citizens in the 5% highest-income counties was 10.85 per 100 000, both higher than the mean rates for any of the 12 comparison countries. (The infant mortality rate for the top 1% counties was 3.54 per 1000, and the maternal mortality rate was 10.05 per 100 000.) The 5-year survival rate for White US citizens in the 5% highest-income counties was 67.2% (95% CI, 66.7%-67.7%) for colon cancer, higher than that of average US citizens (64.9% [95% CI, 64.7%-65.1%]) and average citizens in 6 countries, comparable with that of average citizens in 4 countries, and lower than that of average citizens for 2 countries. The 5-year survival rate for breast cancer among White US women in the 5% highest-income US counties was 92.0% (95% CI, 91.6%-92.4%), higher than in all 12 comparison countries. The 5-year survival rate for White children with acute lymphocytic leukemia in the 5% highest-income US counties was 92.6% (95% CI, 90.7%-94.2%), exceeding the mean survival rate for only 1 country and comparable with the mean survival rates in 11 countries. The adjusted 30-day acute myocardial infarction case-fatality rate for White US citizens in the 5% highest-income US counties was 8% below the rate for all US citizens and was 5% below the rate for all US citizens in the 1% highest-income US counties; these estimates were similar to the median outcome of other high-income countries. Conclusions and Relevance: This study suggests that privileged White US citizens have better health outcomes than average US citizens for 6 health outcomes but often fare worse than the mean measure of health outcomes of 12 other developed countries. These findings imply that even if all US citizens experienced the same health outcomes enjoyed by privileged White US citizens, US health indicators would still lag behind those in many other countries.

Association of Regional Practice Environment Intensity and the Ability of Internists to Practice High-Value Care After Residency.

Importance: Use of health care services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns-in particular, physicians' ability to provide high-quality, high-value care-develop during training, the association of a physician's regional practice environment with that ability is less well understood. Objective: To examine the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians whose practice environment changed due to relocation after residency. Design, Setting, and Participants: This cohort study included a national sample of 3896 internal medicine physicians who took the 2002 American Board of Internal Medicine initial certification examination followed approximately 1 decade (April 21, 2011, to May 7, 2015) later by the Maintenance of Certification (MOC) examination. At the time of the MOC examination, 2714 of these internists were practicing in a new region. Data were analyzed from March 6, 2016, to May 21, 2018. Exposures: Intensity of care in the Dartmouth Atlas hospital referral region (HRR), measured by per-enrollee end-of-life physician visits (primary) and current practice type (secondary). Main Outcomes and Measures: The outcome, a physician's ability to practice high-value care, was assessed using the Appropriately Conservative Management (ACM) score on the MOC examination, measuring performance across all questions for which the correct answer was the most conservative option. The exposure, regional health care intensity, was measured as per-enrollee end-of-life physician visits in the Dartmouth Atlas HRR of the physician's practice. Results: Among the 3860 participating internists included in the analysis (2030 men [52.6%]; mean [SD] age, 45.6 [4.5] years), those who moved to regions in the quintile of highest health care intensity had an ACM score 0.22 SD lower (95% CI, -0.32 to -0.12) than internists who moved to regions in the quintile of lowest intensity, controlling for postresidency ACM scores. This difference reflected scoring in the 44th compared with the 53rd percentile of all examinees. This association was mildly attenuated (0.18 SD less; 95% CI, -0.28 to -0.09) after adjustment for physician and practice characteristics. Conclusions and Relevance: This study found that practice patterns of internists who relocate after residency training appear to migrate toward norms of the new region. The demands of practicing in high-intensity regions may erode the ability to practice high-value conservative care.

Primary care physician practice styles and patient care: Evidence from physician exits in Medicare.

Primary care physicians (PCPs) provide frontline health care to patients in the U.S.; however, it is unclear how their practice styles affect patient care. In this paper, we estimate the long-lasting effects of PCP practice styles on patient health care utilization by focusing on Medicare patients affected by PCP relocations or retirements, which we refer to as "exits." Observing where patients receive care after these exits, we estimate event studies to compare patients who switch to PCPs with different practice style intensities. We find that PCPs have large effects on a range of aggregate utilization measures, including physician and outpatient spending and the number of diagnosed conditions. Moreover, we find that PCPs have large effects on the quality of care that patients receive, and that all of these effects persist for several years. Our results suggest that switching to higher-quality PCPs could significantly affect patients' longer-run health outcomes.

Association Between Medicare Expenditure Growth and Mortality Rates in Patients With Acute Myocardial Infarction: A Comparison From 1999 Through 2014.

Importance: Many studies have considered the association between Medicare spending and health outcomes at a point in time; few have considered the association between the long-term growth in spending and outcomes. Objective: To assess whether components of growth in Medicare expenditures are associated with mortality rates between January 1, 1999, and June 30, 2014, for beneficiaries hospitalized for acute myocardial infarction. Design, Setting, and Participants: Cross-sectional analysis of a random 20% sample of fee-for-service Medicare beneficiaries from January 1, 1999, through December 31, 2000 (n=72 473) and January 1, 2004, through December 31, 2004 (n=38 248), and 100% sample from January 1, 2008, through December 31, 2008 (n=159 558) and January 1, 2013, through June 30, 2014 (n=209 614) admitted with acute myocardial infarction to 1220 hospitals. Main Outcomes and Measures: Primary exposure measures include the growth of 180-day expenditure components (eg, inpatient, physician, and postacute care) and early percutaneous coronary intervention by hospitals adjusted for price differences and inflation. The primary outcome is the risk-adjusted 180-day case fatality rate. Results: Patients in each of the years 2004, 2008, and 2013-2014 (relative to those in 1999-2000) were qualitatively of equivalent age, less likely to be white or female, and more likely to be diabetic (all P < .001). Adjusted expenditures per patient increased 13.9% from January 1, 1999, through December 31, 2000, and January 1, 2013, through June 30, 2014, but declined 0.5% between 2008 and 2013-2014. Mean (SD) expenditures in the 5.0% of hospitals (n = 61) with the most rapid expenditure growth between 1999-2000 and 2013-2014 increased by 44.1% ($12 828 [$2315]); for the 5.0% of hospitals with the slowest expenditure growth (n = 61), mean expenditures decreased by 18.7% (-$7384 [$4141]; 95% CI, $8177-$6496). The growth in early percutaneous coronary intervention exhibited a negative association with 180-day case fatality. Spending on cardiac procedures was positively associated with 180-day mortality, while postacute care spending exhibited moderate cost-effectiveness ($455 000 per life saved after 180 days; 95% CI, $323 000-$833 000). Beyond spending on noncardiac procedures, growth in other components of spending was not associated with health improvements. Conclusions and Relevance: Health improvements for patients with acute myocardial infarction varied across hospitals and were associated with the diffusion of cost-effective care, such as early percutaneous coronary intervention and, to a lesser extent, postacute care, rather than overall expenditure growth. Interventions designed to promote hospital adoption of cost-effective care could improve patient outcomes and, if accompanied by cuts in cost-ineffective care (inside and outside of the hospital setting), also reduce expenditures.

Variation in Physician Practice Styles within and across Emergency Departments.

Despite the significant responsibility that physicians have in healthcare delivery, we know surprisingly little about why physician practice styles vary within or across institutions. Estimating variation in physician practice styles is complicated by the fact that patients are rarely randomly assigned to physicians. This paper uses the quasi-random assignment of patients to physicians in emergency departments (EDs) to show how physicians vary in their treatment of patients with minor injuries. The results reveal a considerable degree of variation in practice styles within EDs; physicians at the 75th percentile of the spending distribution spend 20% more than physicians at the 25th percentile. Observable physician characteristics do not explain much of the variation across physicians, but there is a significant degree of sorting between physicians and EDs over time, with high-cost physicians sorting into high-cost EDs as they gain experience. The results may shed light on why some EDs remain persistently higher-cost than others.

Provider practice style and patient health outcomes: The case of heart attacks.

When a patient arrives at the Emergency Room with acute myocardial infarction (AMI), the provider on duty must quickly decide how aggressively the patient should be treated. Using Florida data on all such patients from 1992 to 2014, we decompose practice style into two components: The provider's probability of conducting invasive procedures on the average patient (which we characterize as aggressiveness), and the responsiveness of the choice of procedure to the patient's characteristics. We show that within hospitals and years, patients with more aggressive providers have consistently higher costs and better outcomes. Since all patients benefit from higher utilization of invasive procedures, targeting procedure use to the most appropriate patients benefits these patients at the expense of the less appropriate patients. We also find that the most aggressive and responsive physicians are young, male, and trained in top 20 schools.