Does universal insurance influence disparities in high-quality hospital use for inpatient pediatric congenital heart defect care within the first year of diagnosis?

BACKGROUND: Healthcare disparities are an issue in the management of Congenital Heart Defects (CHD) in children. Although universal insurance may mitigate racial or socioeconomic status (SES) disparities in CHD care, prior studies have not examined these effects in the use of High-Quality Hospitals (HQH) for inpatient pediatric CHD care in the Military Healthcare System (MHS). To assess for racial and SES disparities in inpatient pediatric CHD care that may persist despite universal insurance coverage, we performed a cross-sectional study of the HQH use for children treated for CHD in the TRICARE system, a universal healthcare system for the U.S. Department of Defense. In the present work we evaluated for the presence of disparities, like those seen in the civilian U.S. healthcare system, among military ranks (SES surrogate) and races and ethnicities in HQH use for pediatric inpatient admissions for CHD care within a universal healthcare system (MHS). METHODS: We conducted a cross-sectional study using claims data from the U.S. MHS Data Repository from 2016 to 2020. We identified 11,748 beneficiaries aged 0 to 17 years who had an inpatient admission for CHD care from 2016 to 2020. The outcome variable was a dichotomous indicator for HQH utilization. In the sample, 42 hospitals were designated as HQH. Of the population, 82.9% did not use an HQH at any point for CHD care and 17.1% used an HQH at some point for CHD care. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of SES status. Patient demographic information at the time of index admission post initial CHD diagnosis (age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, and provider region) and clinical information (complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity) were used as covariates in multivariable logistic regression analysis. RESULTS: After controlling for demographic and clinical factors including age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, provider region, complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity, we did not find disparities in HQH use for inpatient pediatric CHD care based upon military rank. After controlling for demographic and clinical factors, lower SES (Other rank) was less likely to use an HQH for inpatient pediatric CHD care; OR of 0.47 (95% CI of 0.31 to 0.73). CONCLUSIONS: We found that for inpatient pediatric CHD care in the universally insured TRICARE system, historically reported racial disparities in care were mitigated, suggesting that this population benefitted from expanded access to care. Despite universal coverage, SES disparities persisted in the civilian care setting, suggesting that universal insurance alone cannot sufficiently address differences in SES disparities in CHD care. Future studies are needed to address the pervasiveness of SES disparities and potential interventions to mitigate these disparities such as a more comprehensive patient travel program.

Geographic Variations and the Associated Factors in Adherence to and Persistence with Adjuvant Hormonal Therapy for the Privately Insured women Aged 18-64 with Breast Cancer in Texas.

The purpose of this study is to examine the geographical patterns of adjuvant hormonal therapy adherence and persistence and the associated factors in insured Texan women aged 18-64 with early breast cancer. A retrospective cohort study was conducted using 5-year claims data for the population insured by the Blue Cross Blue Shield of Texas (BCBSTX). Women diagnosed with early breast cancer who were taking tamoxifen or aromatase inhibitors (AIs) for adjuvant hormonal therapy with at least one prescription claim were identified. Adherence to adjuvant hormonal therapy and persistence with adjuvant hormonal therapy were calculated as outcome measures. Women without a gap between two consecutively dispensed prescriptions of at least 90 days were considered to be persistently taking the medications. Patient-level multivariate logistic regression models with repeated regional-level adjustments and a Cox proportional hazards model with mixed effects were used to determine the geographical variations and patient-, provider-, and area-level factors that were associated with adjuvant hormonal therapy adherence and persistence. Of the 938 women in the cohort, 627 (66.8%) initiated adjuvant hormonal therapy. Most of the smaller HRRs have significantly higher or lower rates of treatment adherence and persistence rates relative to the median regions. The use of AHT varies substantially from one geographical area to another, especially for adherence, with an approximately two-fold difference between the lowest and highest areas, and area-level factors were found to be significantly associated with the compliance of AHT. There are geographical variations in AHT adherence and persistence in Texas. Patient-level and area-level factors have significant associations explaining these patterns.

Disparities in Audio-only Telemedicine Use Among Medicare Beneficiaries During the Coronavirus Disease 2019 Pandemic.

BACKGROUND: Under emergency coronavirus disease 2019 pandemic regulations, Medicare granted temporary payment parity with in-person visits for audio-only (telephone) telemedicine visits. This policy was designed to expand telemedicine to patients without camera-equipped devices and broadband internet. However, audio-only telemedicine use has been substantial. OBJECTIVE: The aim of this study was to explore whether the rate of audio-only telemedicine during the pandemic is related to patient access to technology or provider behavior. DESIGN: Cross-sectional analysis of the Summer and Fall 2020 Medicare Current Beneficiary Survey coronavirus disease 2019 supplements, using multivariable logistic models and accounting for complex survey design. SUBJECTS: A total of 3375 participants in the summer survey and 2633 participants in the fall 2020 were offered a telemedicine visit to replace a scheduled in-person visit by their usual care provider. MEASURES: We compared beneficiaries who were exclusively offered audio-only telemedicine to beneficiaries who were offered video telemedicine or both audio and video. RESULTS: We found that among Medicare beneficiaries who were offered telemedicine to replace a scheduled in-person appointment, ~35% were exclusively offered audio-only. 65.8% of beneficiaries exclusively offered audio-only reported having a smartphone/tablet and home internet. After controlling for personal access to technology, Hispanic [adjusted odds ratio (AOR)=2.09, P<0.001], dually eligible (AOR=1.63, P=0.002), nonprimary English speaking (AOR=1.64, P<0.001), and nonmetro beneficiaries (AOR=1.71, P=0.003) were more likely to be offered audio-only during July-November 2020. CONCLUSIONS: These findings suggest audio-only telemedicine use during the pandemic is only partially related to patient access to technology. Policymakers must work to both expand programs that provide smartphones and broadband internet to disparity communities and telemedicine infrastructure to providers.

Maryland's Global Budget Revenue Program: Impact on Neonatal Intensive Care Unit Admissions and Infant Mortality.

BACKGROUND: In 2014, Maryland implemented the Global Budget Revenue (GBR) program to reduce unnecessary hospital utilization and contain spending. Little is known about its impact on pediatric health outcomes and high-cost services that are primarily financed by payers other than Medicare. OBJECTIVE: The aim was to examine the impact of the GBR program on neonatal intensive care unit (NICU) admission and infant mortality. RESEARCH DESIGN: We conducted a difference-in-differences analysis comparing changes of NICU admissions and infant mortality in Maryland with changes in 20 comparison states (including DC), before and after implementation of the GBR program. Effects were estimated for all infants and for risk groups defined by birthweight and gestation. SUBJECTS: A total of 11,965,997 newborns in Maryland and the comparison states was identified using US birth certificate data from 2011 to 2017. MEASURES: NICU admissions, the infant mortality rate, and the neonatal mortality rate. RESULTS: The GBR program was associated with a 1.26 percentage points (-16.8%, P=0.03) decline in NICU admissions over three full years of implementation. Reductions were driven by fewer admissions among moderately low to normal birthweight (1500-3999 g) and moderately preterm to term (32-41 wk) infants. The effects for very-low birthweight and very preterm infants were small and not statistically precise. There was no significant change in infant or neonatal mortality rates. CONCLUSIONS: Maryland's hospitals reacted to the GBR program by reducing NICU services for infants that did not have clear observed clinical need. Our results suggest that GBR constrained high-cost services, without adversely affecting infant mortality.

Disparities in Health Care Access and Utilization at the Intersections of Urbanicity and Sexual Identity in California.

Purpose: The aim was to examine differences in health care access at the intersections of urbanicity and sexual identity in California. Methods: We used the 2014-2017 Adult California Health Interview Survey paired with the sexual orientation special use research file to create dummy groups representing each dimension of urbanicity and sexual identity to compare access to health care outcomes. We calculated unadjusted proportions and estimated adjusted odds ratios of each dimension relative to urban heterosexual people using logistic regressions. Results: Relative to urban heterosexual people, urban gay/lesbian people had 1.651 odds of using the emergency room (ER). Urban bisexual people had 1.429 odds of being uninsured, 1.575 odds of delaying prescriptions, and 1.907 odds of using the ER. Rural bisexual people experienced similar access barriers having 1.904 odds of uninsurance and 2.571 odds of using the ER. Conclusions: Our study findings demonstrated disparate access to health care across sexual orientation and rurality. The findings are consistent with literature that suggests urban and rural sexual minority people experience health care differently and demonstrate that bisexual people experience health care differently than gay/lesbian people. These findings warrant further study to examine how social identities, such as race/ethnicity, interact with sexual orientation to determine health care access. Furthermore, these findings demonstrate the need to emphasize the health care access needs of sexual minority people in both rural and urban areas to eliminate health care access disparities.

Evidence of the Linkage Between Hospital-based Care Coordination Strategies and Hospital Overall (Star) Ratings.

BACKGROUND: In the new era of value-based payment models and pay for performance, hospitals are in search of the silver bullet strategy or bundle of strategies capable of improving their performance on quality measures. OBJECTIVES: To determine whether there is an association between adoption of hospital-based care coordination strategies and Centers for Medicare and Medicaid Services overall hospital quality (star) ratings and readmission rates. RESEARCH DESIGN: We used survey data from the American Hospital Association (AHA) and categorized respondents by the number of care coordination strategies that they reported having widely implemented. We used multiple logistic regression models to examine the association between the number of strategies and hospital overall rating performance and disease-specific 30-day excess readmission ratios, while controlling for hospital and county characteristics and state-fixed effects. SUBJECTS: A total of 710 general acute care noncritical access hospitals that received star ratings and responded to the 2015 AHA Care Systems and Payment Survey. MEASURES: Centers for Medicare and Medicaid Services overall hospital ratings, 30-day excess readmission ratios. RESULTS: As compared with hospitals with 0-2 strategies, hospitals with 3 to 4 strategies (P=0.007), 5-7 strategies (P=0.002), or 8-12 strategies (P=0.002) had approximately 2.5× the odds of receiving a top rating (4 or 5 stars). Care coordination strategies were positively associated with lower 30-day readmission ratios for patients with chronic medical conditions, but not for surgical patients. Medication reconciliation, visit summaries, outreach after discharge, discharge care plans, and disease management programs were each individually associated with top ratings. CONCLUSIONS: Care coordination strategies are associated with high overall hospital ratings.

Neonatal Intensive Care Variation in Medicaid-Insured Newborns: A Population-Based Study.

OBJECTIVE: To assess the contribution of maternal and newborn characteristics to variation in neonatal intensive care use across regions and hospitals. STUDY DESIGN: This was a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 2 subcohorts: very low birth weight (VLBW) singletons and late preterm singletons. Crude and risk-adjusted neonatal intensive care unit (NICU) admission rates, intensive and intermediate special care days, and imaging procedures were calculated across Neonatal Intensive Care Regions (n = 21) and hospitals (n = 100). Total Medicaid payments were calculated. RESULTS: Overall, 11.5% of live born, 91.7% of VLBW, and 37.6% of infants born late preterm were admitted to a NICU, receiving an average of 2 days, 58 days, and 5 days of special care with payments per newborn inpatient episode of $5231, $128 075, and $10 837, respectively. There was little variation across regions and hospitals in VLBW NICU admissions but marked variation for NICU admissions in late preterm newborn infants and for special care days and imaging rates in all cohorts. The variation decreased slightly after health risk adjustment. There was moderate substitution of intermediate for intensive care days across hospitals (Pearson r VLBW -0.63 P < .001; late preterm newborn -0.53 P < .001). CONCLUSIONS: Across all risk groups, the variation in NICU use was poorly explained by differences in newborn illness levels and is likely to indicate varying practice styles. Although the "right" rates are uncertain, it is unlikely that all of these use patterns represent effective and efficient care.

Role of Prices, Utilization, and Health in Explaining Texas Medicaid Newborn Care Spending Variation.

BACKGROUND: Newborn care is one of the most frequent types of hospitalization and Medicaid covers over 50% of all births nationwide. However, little is known about regional variation in Medicaid newborn care spending and its drivers. OBJECTIVES: To measure the contribution of market-level prices, utilization, and health risk on regional variation in spending among newborn Medicaid population in Texas. RESEARCH DESIGN AND METHODS: The study used 2014 Texas Medicaid newborn claims and encounters linked to birth and death certificate data. Newborn care spending was defined as Medicaid payments per newborn hospital stay, including hospital transfers, from birth through discharge home or death. Spending was further categorized into inpatient facility and related professional spending. Variation in spending across neonatal intensive care regions was decomposed into price and utilization, accounting for input price and health risk differences. RESULTS: Newborn care spending across Texas regions varied significantly (coefficient of variation, 0.31), with most of the variation attributed to spending on inpatient facility services (91%). Both price (41%) and utilization (27%) played a role in explaining this variation, after adjusting for health status (29%) and input price (4%). Though most regions with the highest spending indexes had high price and utilization indexes, some had high spending driven mostly by high prices and others by high utilization. CONCLUSIONS: Significant regional variations in price, utilization, and health status exist in Medicaid newborn care across Texas in 2014. Disentangling the effect of each driver is important to address spending variation and improve efficiency in newborn care.

Association between financial burden and adjuvant hormonal therapy adherence and persistent use for privately insured women aged 18-64 years in BCBS of Texas.

PURPOSE: The objective of this study is to understand an impact of financial burden on the adjuvant hormonal therapy (AHT) adherence and persistence for insured women aged 18-64 with early breast cancer in Texas. METHODS: We conducted a retrospective cohort study using claims data for population insured by Blue Cross Blue Shield of Texas from the year 2008 to 2013. Outcomes include adherence to adjuvant hormonal therapy, which was measured by medication possession ratio and persistence on AHT, which is the duration of time from initiation to discontinuation of therapy. Multivariate logistic regression models with repeated regional-level adjustments were used to explore the odds of AHT adherence. Cox proportional hazards model was conducted to assess time to the first 90+-day gap for persistence and a Kaplan-Meier curve were used to estimate probabilities to calculate the percentages of women who experienced 90+-day gaps in AHT. RESULTS: Of the 938 women in the cohort, 627 (66.8%) initiated the treatment. By year 1, 66.9% of women were adherent to the therapy, and by year 5, only 29% of those were adherent. The percentage of women with no gap in therapy greater than 90 days was 80.8%. Both higher out-of-pocket costs spent on all prescription drugs except AHT and AHT-specific out-of-pocket costs were negatively associated with adherence to AHT as well as continuing AHT as recommended. CONCLUSIONS: Financial burdens including both non-AHT medication and AHT-specific out-of-pocket costs were significantly associated with adherence and persistence to the therapy.

Clinical and Economic Evaluation of Treatment Strategies for T1N0 Anal Canal Cancer.

OBJECTIVE: A comparative assessment of treatment alternatives for T1N0 anal canal cancer has never been conducted. We compared the outcomes associated with the treatment alternatives-chemoradiotherapy (CRT), radiotherapy (RT), and surgery or ablation techniques (surgery/ablation)-for T1N0 anal canal cancer. MATERIALS AND METHODS: This retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results (SEER) registries linked with Medicare longitudinal data (SEER-Medicare database). Analysis included 190 patients who were treated for T1N0 anal canal cancer using surgery/ablation (n=44), RT (n=50), or CRT (n=96). The outcomes were reported in terms of survival and hazards ratios using Kaplan-Meier and Cox proportional hazards modeling, respectively; lifetime costs; and cost-effectiveness measured in terms of incremental cost-effectiveness ratio, that is, the ratio of the difference in costs between the 2 alternatives to the difference in effectiveness between the same 2 alternatives. RESULTS: There was no significant difference in the survival duration between the treatment groups as predicted by the Kaplan-Meier curves. After adjusting for patient characteristics and propensity score, the hazard ratio of death for the patients who received CRT compared with surgery/ablation was 1.742 (95% confidence interval, 0.793-3.829) and RT was 2.170 (95% confidence interval, 0.923-5.101); however, the relationship did not reach statistical significance. Surgery/ablation resulted in lower lifetime cost than RT or CRT. The incremental cost-effectiveness ratio associated with CRT compared with surgery/ablation was $142,883 per life year gained. CONCLUSIONS: There was no statistically significant difference in survival among the treatment alternatives for T1N0 anal canal cancer. Given that surgery/ablation costs less than RT or CRT and might be cost-effective compared with RT and CRT, it is crucial to explore this finding further in this era of limited health care resources.

Total Lifetime and Cancer-related Costs for Elderly Patients Diagnosed With Anal Cancer in the United States.

OBJECTIVE: To determine the lifetime and phase-specific cost of anal cancer management and the economic burden of anal cancer care in elderly (66 y and older) patients in the United States. PATIENTS AND METHODS: For this study, we used Surveillance Epidemiology and End Results-Medicare linked database (1992 to 2009). We matched newly diagnosed anal cancer patients (by age and sex) to noncancer controls. We estimated survival time from the date of diagnosis until death. Lifetime and average annual cost by stage and age at diagnosis were estimated by combining survival data with Medicare claims. The average lifetime cost, proportion of patients who were elderly, and the number of incident cases were used to estimate the economic burden. RESULTS: The average lifetime cost for patients with anal cancer was US$50,150 (N=2227) (2014 US dollars). The average annual cost in men and women was US$8025 and US$5124, respectively. The overall survival after the diagnosis of cancer was 8.42 years. As the age and stage at diagnosis increased, so did the cost of cancer-related care. The anal cancer-related lifetime economic burden in Medicare patients in the United States was US$112 million. CONCLUSIONS: Although the prevalence of anal cancer among the elderly in the United States is small, its economic burden is considerable.

Examining Drivers of Health Care Spending: Evidence on Self-referral Among a Privately Insured Population.

BACKGROUND: Despite the enactment of laws to restrict the practice of self-referral, exceptions in these prohibitions have enabled these arrangements to persist and proliferate. Most research documenting the effects of self-referral arrangements analyzed claims records from Medicare beneficiaries. Empirical evidence documenting the effects of self-referral on use of services and spending incurred by persons with private insurance is sparse. OBJECTIVES: We analyzed health insurance claims records from a large private insurer in Texas to evaluate the effects of physician self-referral arrangements involving physical therapy on the treatment of patients with frozen shoulder syndrome, elbow tendinopathy or tendinitis, and patellofemoral pain syndrome. STUDY DESIGN: We used regression analysis to evaluate the effects of episode self-referral status on: (1) initiation of physical therapy; (2) physical therapy visits and services for those who had at least 1 visit; and (3) total condition-related insurer allowed amounts per episode. RESULTS: For all 3 conditions, we found that patients treated by physician owners were much more likely to be referred for a course of physical therapy when compared with patients seen by physician nonowners. A consistent pattern emerged among patients who had at least 1 physical therapy visit; non-self-referred episodes included more physical therapy visits, and more physical therapy services per episode in comparison with episodes classified as self-referral. Most self-referred episodes were short and the initial visit did not include an evaluation. CONCLUSION: Physician owners of physical therapy services refer significantly higher percentages of patients to physical therapy and many are equivocal cases.

Future expenditure risk of silent members: a statistical analysis.

BACKGROUND: Silent-members are members of a medical health plan who submit no claims for healthcare services in a benefit year despite 12 months of continuous-enrollment. This study was conducted to evaluate the future expenditure risk of commercial-insured members who avoid all medical care despite coverage. In order to determine if the silent-members were at greater risk, we compared them to members who received care in the anchor year (2009) but had low-expenditures. The low-expenditure members were assumed to represent persons without significant medical conditions and without care-avoidance behaviors. We examined the claims experience of a cohort of silent members in the 2 years after the silent year (2009) and compared it with the corresponding claims experience for a cohort of low-expenditure members from the same anchor year (2009). METHODS: Members of commercial health plans (BCBS of Texas) were selected based on continuous-enrollment in 2009. Two sub-groups were identified based on annual claims expenditure: Care avoiders were members with 12 months continuous-enrollment and no medical claims, and are thus referred to as "silent members" in the insurance industry. Low-Expenditure members were those with 12 months continuous-enrollment and total PMPY (per member per year) annual medical claims expenditure in the lowest 10th percentile of members with claims experience. "Low-expenditure" members served as a comparison group to the "silent members", under the assumption that such claimants were using benefits for minor healthcare issues as needed. Key variables were enrollment and expenditures. Enrollment data identified demographics and continuous-enrollment. Medical claims data were used to calculate utilization and expenditures. All claims data were de-identified and no consent was required, as approved by the Institutional Review Board. No research involved human subjects. Multivariate logistic regression models were applied. RESULTS: Silent members who seek care in subsequent years have a greater probability of becoming high-expenditure claimants than those with low-expenditure experience. CONCLUSIONS: For silent members who subsequently seek treatment, the probability of becoming high-expenditure is significantly greater than low-expenditure members from the anchor year. The implications of future high costs for silent members who become claimants may support the need for additional research to address the risks of care avoidance behaviors.

Migrant integration policies and health inequalities in Europe.

BACKGROUND: Research on socio-economic determinants of migrant health inequalities has produced a large body of evidence. There is lack of evidence on the influence of structural factors on lives of fragile groups, frequently exposed to health inequalities. The role of poor socio-economic status and country level structural factors, such as migrant integration policies, in explaining migrant health inequalities is unclear. The objective of this paper is to examine the role of migrant socio-economic status and the impact of migrant integration policies on health inequalities during the recent economic crisis in Europe. METHODS: Using the 2012 wave of Eurostat EU-SILC data for a set of 23 European countries, we estimate multilevel mixed-effects ordered logit models for self-assessed poor health (SAH) and self-reported limiting long-standing illnesses (LLS), and multilevel mixed-effects logit models for self-reported chronic illness (SC). We estimate two-level models with individuals nested within countries, allowing for both individual socio-economic determinants of health and country-level characteristics (healthy life years expectancy, proportion of health care expenditure over the GDP, and problems in migrant integration policies, derived from the Migrant Integration Policy Index (MIPEX). RESULTS: Being a non-European citizen or born outside Europe does not increase the odds of reporting poor health conditions, in accordance with the "healthy migrant effect". However, the country context in terms of problems in migrant integration policies influences negatively all of the three measures of health (self-reported health status, limiting long-standing illnesses, and self-reported chronic illness) in foreign people living in European countries, and partially offsets the "healthy migrant effect". CONCLUSIONS: Policies for migrant integration can reduce migrant health disparities.

Primary Care Availability, Safety Net Clinics, and Health Insurance Coverage: The Association of These Access Factors With Preventable Hospitalizations.

The objective of the study was to examine the relationship between physician/safety net availability and health insurance coverage and preventable hospitalizations (PHs) in nonelderly adults in an urban area. Preventable conditions (PHs) were identified for nonelderly adults in Harris County using the Texas Health Care Information Collection hospital database. Multivariable logistic regression models examined the association of health insurance and patient proximity to physicians and safety net clinics with the risk of a PH. Safety net availability reduced PH risk by 23% (P < .05) but only among the uninsured. Lack of health insurance increased PH risk by 30% (P < .05).

Novel Measure of Opioid Dose and Costs of Care for Diabetes Mellitus: Opioid Dose and Health Care Costs.

UNLABELLED: Diabetes mellitus (DM) has well known costly complications but we hypothesized that costs of care for chronic pain treated with opioid analgesic (OA) medications would also be substantial. In a statewide, privately insured cohort of 29,033 adults aged 18 to 64 years with DM and noncancer pain who filled OA prescription(s) from 2008 to 2012, our outcomes were costs for specific health care services and total costs per 6-month intervals after the first filled OA prescription. Average daily OA dose (4 categories) and total dose (quartiles) in morphine-equivalent milligrams were calculated per 6-month interval after the first OA prescription and combined into a novel OA dose measure. Associations of OA measures with costs of care (n = 126,854 6-month intervals) were examined using generalized estimating equations adjusted for clinical conditions, psychotherapeutic drugs, and DM treatment. Incremental costs for each type of health care service and total cost of care increased progressively with average daily and total OA dose versus no OAs. The combined OA measure identified the highest incremental total costs per 6-month interval that were increased by $8,389 for 50- to 99-mg average daily dose plus >900 mg total dose and, by $9,181 and $9,958 respectively, for ≥100 mg average daily dose plus 301- to 900-mg or >900 mg total dose. In this statewide DM cohort, total health care costs per 6-month interval increased progressively with higher average daily OA dose and with total OA dose but the greatest increases of >$8,000 were distinguished by combinations of higher average daily and total OA doses. PERSPECTIVE: The higher costs of care for opioid-treated patients appeared for all types of services and likely reflects multiple factors including morbidity from the underlying cause of pain, care and complications related to opioid use, and poorer control of diabetes as found in other studies.

Physician Self-Referral of Physical Therapy Services for Patients with Low Back Pain: Implications for Use, Types of Treatments Received and Expenditures.

Prior research on treatment of low back pain has documented large increases in use of spinal surgery, MRIs and lumbosacral injections linked to physician self-referral arrangements. No recent research has examined whether physician ownership of physical therapy services results in greater use of physical therapy to treat low back pain. The objective of this study is to investigate whether physician ownership of physical therapy services affects frequency of use, visits and types of physical therapy services received by patients with low back pain. Using claims records from insured patients covered by Blue Cross Blue Shield of Texas (2008-2011) we compared several metrics of use of physical therapy services for low back pain episodes controlling for self-referral status. We identified 158,151 low back pain episodes, 27% met the criteria to be classified as "self-referral." Only 10% of "non-self-referral" episodes received physical therapy compared to 26% of self-referral episodes (p<0.001). The unadjusted and regression adjusted self-referral effect was identical - about 16 percentage point difference (p<0.001). Among patients who received some physical therapy, self-referral episodes were comprised of 2.26 fewer visits and 11 fewer physical therapy service units (p<0.001). Non-self-referring episodes included a significantly higher proportion of "active" (hands on or patient engaged) as opposed to "passive" treatments (p<0.001). The regression-adjusted difference was 30 percentage points when measured as actual counts and 29 percentage points when measured in RVUs (p<0.001). Total spending on back-related care was 35% higher for self-referred episodes compared to their non-self-referred counterparts (p<0.001). Ownership of physical therapy services influence physicians' referral to initiate a course of physical therapy to treat low back pain, but also affect the types of physical therapy services a patient receives.

Effects of Health Insurance on Tumor Stage, Treatment, and Survival in Large Cohorts of Patients with Breast and Colorectal Cancer.

To examine the impact of health insurance status on tumor stage at diagnosis, treatment rendered, and overall survival, we identified 52,566 breast cancer patients and 34,316 colorectal cancer patients aged 20 or older in 2007-2010 from Texas Cancer Registry. Those aged younger than 65 years without health insurance coverage had significantly higher risks of mortality than those with private health insurance regardless of tumor stage, chemotherapy, or surgery for colorectal cancer. However, in patients younger than 65 years with breast cancer, the risk of mortality was not significantly higher for those who received chemotherapy or cancer-directed surgery in patients without insurance coverage compared with those with private health insurance. In Medicare beneficiaries aged 65 years or older, risk of mortality was not significantly different between those with Medicare only and those with additional private health insurance, except an increased mortality in patients without chemotherapy for breast and colorectal cancer and in those without receiving surgery for colorectal cancer.

Cardiorespiratory Fitness in Middle Age and Health Care Costs in Later Life.

BACKGROUND: Low cardiovascular risk factor burdens in middle age are associated with lower health care costs in later life. However, there are few data regarding the effect of cardiorespiratory fitness on health care costs independent of these risk factors. OBJECTIVES: This study sought to evaluate the association of health care costs in later life with cardiorespiratory fitness in midlife after adjustment for cardiovascular risk factors. METHODS: We studied 19,571 healthy individuals in the Cooper Center Longitudinal Study who underwent cardiorespiratory fitness assessment at a mean age of 49 years and received Medicare coverage from 1999 to 2009 at an average age of 71 years. Cardiorespiratory fitness was estimated by maximal metabolic equivalents (METs) calculated from treadmill time. The primary outcome was average annual health care costs obtained from Medicare standard analytical files. RESULTS: Over 126,388 person-years of follow-up, average annual health care costs were significantly lower forparticipants aged 65 years or older with high midlife fitness than with low midlife fitness in both men($7,569 vs. $12,811; p < 0.001) and women ($6,065 vs. $10,029; p < 0.001). [corrected].In a generalized linear model adjusted for cardiovascular risk factors, average annual health care costs in later life were incrementally lower per MET achieved in midlife in men (6.8% decrease in costs per MET achieved; 95% confidence interval: 5.7% to 7.8%; p < 0.001) and women (6.7% decrease in costs per MET achieved; 95% confidence interval: 4.1% to 9.3%; p < 0.001). These associations persisted when participants were separated into those who died during Medicare follow-up and those who survived. CONCLUSIONS: Higher cardiorespiratory fitness in middle age is strongly associated with lower health care costs at an average of 22 years later in life, independent of cardiovascular risk factors. These findings may have important implications for health policies directed at improving physical fitness.

Roles of prices, poverty, and health in Medicare and private spending in Texas.

OBJECTIVES: To investigate the roles of prices, poverty, and health in divergences between Medicare and private spending in Texas. STUDY DESIGN: Retrospective observational design using 2011 Blue Cross Blue Shield of Texas claims data and publicly available Medicare data. METHODS: We measured market-level spending per enrollee among the privately insured. Variation in Medicare and private spending per person are decomposed into prices and quantities, and their associations with poverty are measured. Markets are divided into 4 groups and are compared based on the ratio of Medicare to private spending: "high-private," "proportional," "high-Medicare," and "extremely high-Medicare." RESULTS: Among the privately insured, poverty appears to have large spillover effects; it is strongly associated with lower prices, quantities, and spending. Among Medicare beneficiaries, health status is a key driver of spending variation. The 2 markets with extremely high Medicare-to-private spending ratios (Harlingen and McAllen) are predominantly Hispanic communities with markedly higher rates of poverty and lack of insurance and also extremely low physician supply. The markets with relatively high private spending stand out for having good health-system performance and health outcomes, and higher than average hospital prices. CONCLUSIONS: Variation in private spending appears to reflect the ability of the local population to pay for healthcare, whereas variation in Medicare is more heavily driven by health status, and presumably, by clinical need. These findings highlight the inadvisability of using Medicare spending as a proxy for systemwide spending, and the need for comprehensive market-level spending data that allow comparisons among populations with different sources of insurance coverage.