Regional Economic Conditions and Preventable Hospitalization Among Older Patients With Diabetes.

OBJECTIVE: The aim was to explore the relationship between changes in regional economic conditions and quality of care-preventable hospitalization or death among older patients with diabetes at Veterans Health Administration (VHA), safety-net system for veterans. SUBJECTS: VHA patients aged 65 years and older with a diabetes diagnosis between July 2012 and June 2014, who had at least 1 primary care visit in the past year. MEASURES: County-level and state-level public data were used to characterize regional health insurance coverage and affluence surrounding the VHA facilities. Each patient was associated with a VHA facility and its corresponding regional market variables, and followed up to 48 months or until they experienced diabetes-related Prevention Quality Indicators or death. RESULTS: Discrete-time Cox proportional hazards models estimated that changes in regional market variables characterizing regional health insurance coverage and affluence were significant factors associated with preventable hospitalization or death. All regional market variables were combined into a demand index, where 1 SD decrease in the demand index was associated with a 2.0-point increase in predicted survival for an average patient at an average VHA facility. For comparison, a 1 SD increase in primary care capacity was associated with 4.7-point increase. CONCLUSIONS: Downturns in regional economic conditions could increase demand for VHA care and raise the risk of diabetes-related preventable hospitalization or death among older VHA patients diagnosed with diabetes. Safety-net hospitals may be unfairly penalized for lower quality of care when experiencing higher demand for care because of an economic downturn.

Regional market factors and patient experience in primary care.

OBJECTIVES: To evaluate the association between regional market factors and experience with patient-provider communication in primary care services of safety net hospitals. STUDY DESIGN: A retrospective cohort study with 933,407 patient experience survey respondents from 128 Veterans Health Administration (VHA) hospitals between fiscal years 2013 and 2016. METHODS: Patient responses on 5 patient-provider communication questions were used to evaluate quality of care. Six regional market factors were used to characterize veterans' health care insurance coverage and affluence. A logistic regression was used to examine changes in individual-level patient-provider communication experience when regional market factors increase or decrease the demand for VHA primary care services. RESULTS: Our findings supported our hypothesis that changes in regional market factors shift patient demand for VHA care and affect patient-provider communication measured by patient experience surveys. The adjusted odds ratio (AOR) of positive patient-provider communication was associated with a regional increase (first to third quartile) of employer-sponsored insurance (AOR, 1.028; 95% CI, 1.001-1.055) and a decrease (third to first quartile) in the veterans' unemployment rate (AOR, 0.966; 95% CI, 0.944-0.990). Higher primary care capacity (first to third quartile) was also associated with positive patient-provider communication (AOR, 1.050; 95% CI, 1.018-1.082). CONCLUSIONS: Findings from this study raise concerns that safety net hospitals could be unfairly penalized by value-based payment programs and Medicare Hospital Compare. Such policies and programs could improve resource allocation by accounting for regional market factors before acting on quality of care measures.

State-Level Community Benefit Regulation and Nonprofit Hospitals' Provision of Community Benefits.

Do nonprofit hospitals provide enough community benefits to justify their tax exemptions? States have sought to enhance nonprofit hospitals' accountability and oversight through regulation, including requirements to report community benefits, conduct community health needs assessments, provide minimum levels of community benefits, and adhere to minimum income eligibility standards for charity care. However, little research has assessed these regulations' impact on community benefits. Using 2009-11 Internal Revenue Service data on community benefit spending for more than eighteen hundred hospitals and the Hilltop Institute's data on community benefit regulation, we investigated the relationship between these four types of regulation and the level and types of hospital-provided community benefits. Our multivariate regression analyses showed that only community health needs assessments were consistently associated with greater community benefit spending. The results for reporting and minimum spending requirements were mixed, while minimum income eligibility standards for charity care were unrelated to community benefit spending. State adoption of multiple types of regulation was consistently associated with higher levels of hospital-provided community benefits, possibly because regulatory intensity conveys a strong signal to the hospital community that more spending is expected. This study can inform efforts to design regulations that will encourage hospitals to provide community benefits consistent with policy makers' goals.

The Risks Of Using Workplace Wellness Programs To Foster A Culture Of Health.

In many respects, employers are well positioned to take a leading role in helping create a culture of health. Employers have access to many programs that could be beneficial to their employees' health. The potential for financial gains related to health improvement may motivate employers to offer these programs, and if the gains are realized, they may help finance the programs. At the same time, employers' involvement in such programs may create substantial risks. Enthusiasm about the financial and health gains that wellness programs might yield coexists with concerns about health costs shouldered by employees, the possibility of employment discrimination, and the potential for employers' invasion of employees' privacy. A fragmented regulatory regime, including a recently issued final rule under the Americans with Disabilities Act, has been created to address these concerns. Whether the regime strikes the right balance between wellness program benefits and risks remains to be determined.

Using reporting requirements to improve employer wellness incentives and their regulation.

Employer interest in offering financial incentives for healthy behaviors has been increasing. Some employers have begun to tie health plan-based rewards or penalties to standards involving tobacco use or biometric measures such as body mass index. The Patient Protection and Affordable Care Act attempts to strike a balance between the potential benefits and risks of wellness incentive programs by permitting these incentives but simultaneously limiting their use. Evidence about the implications of the newest generation of incentive programs for health, health costs, and burdens on individual employees will be critical for informing both private and public decision makers. After describing the many pieces of information that would be valuable for assessing these programs, this article proposes more narrowly targeted reporting requirements that could facilitate incentive program development, evaluation, and oversight.

The law, policy, and ethics of employers' use of financial incentives to improve health.

The Patient Protection and Affordable Care Act (ACA) turns to a nontraditional mechanism to improve public health: employer-provided financial incentives for healthy behaviors. Critics raise questions about incentive programs' effectiveness, employer involvement, and potential discrimination. We support incentive program development despite these concerns. The ACA sets the stage for a broad-based research and implementation agenda through which we can learn to structure incentive programs to not only promote public health but also address prevalent concerns.

Written informed-consent statutes and HIV testing.

BACKGROUND: Almost 1 million Americans are infected with HIV, yet it is estimated that as many as 250,000 of them do not know their serostatus. This study examined whether people residing in states with statutes requiring written informed consent prior to HIV testing were less likely to report a recent HIV test. METHODS: The study is based on survey data from the 2004 Behavioral Risk Factor Surveillance System. Logistic regression was used to assess the association between residence in a state with a pre-test written informed-consent requirement and individual self-report of recent HIV testing. The regression analyses controlled for potential state- and individual-level confounders. RESULTS: Almost 17% of respondents reported that they had been tested for HIV in the prior 12 months. Ten states had statutes requiring written informed consent prior to routine HIV testing; nine of those were analyzed in this study. After adjusting for other state- and individual-level factors, people who resided in these nine states were less likely to report a recent history of HIV testing (OR=0.85; 95% CI=0.80, 0.90). The average marginal effect was -0.02 (p<0.001, 95% CI=-0.03, -0.01); thus, written informed-consent statutes are associated with a 12% reduction in HIV testing from the baseline testing level of 17%. The association between a consent requirement and lack of testing was greatest among respondents who denied HIV risk factors, were non-Hispanic whites, or who had higher levels of education. CONCLUSIONS: This study's findings suggest that the removal of written informed-consent requirements might promote the non-risk-based routine-testing approach that the Centers for Disease Control and Prevention (CDC) advocates in its new testing guidelines.

Multihospital system membership and patient treatments, expenditures, and outcomes.

OBJECTIVE: To determine the relationship between hospital membership in systems and the treatments, expenditures, and outcomes of patients. DATA SOURCES: The Medicare Provider Analysis and Review dataset, for data on Medicare patients admitted to general medical-surgical hospitals between 1985 and 1998 with a diagnosis of acute myocardial infarction (AMI); the American Hospital Association Annual Survey, for data on hospitals. STUDY DESIGN: A multivariate regression analysis. An observation is a fee-for-service Medicare AMI patient admitted to a study hospital. Dependent variables include patient transfers, catheterizations, angioplasties or bypass surgeries, 90-day mortality, and Medicare expenditures. Independent variables include system participation, other admission hospital and patient traits, and hospital and year fixed effects. The five-part system definition incorporates the size and location of the index admission hospital and the size and distance of its partners. PRINCIPAL FINDINGS: While the effects of multihospital system membership on patients are in general limited, patients initially admitted to small rural system hospitals that have big partners within 100 miles experience lower mortality rates than patients initially admitted to independent hospitals. Regression results show that to the extent system hospital patients experience differences in treatments and outcomes relative to patients of independent hospitals, these differences remain even after controlling for the admission hospital's capacity to provide cardiac services. CONCLUSIONS: Multihospital system participation may affect AMI patient treatment and outcomes through factors other than cardiac service offerings. Additional investigation into the nature of these factors is warranted.

Hospital-physician affiliations and patient treatments, expenditures, and outcomes.

OBJECTIVE: To determine the relationship between hospital-physician affiliations and the treatments, expenditures, and outcomes of patients. DATA SOURCES: Sources include the Medicare Provider Analysis and Review dataset, the American Hospital Association (AHA) Annual Survey, and the Area Resource File (ARF). STUDY DESIGN: A multivariate regression analysis of the relationship between hospital-physician affiliations (such as physician-hospital organizations [PHOs] or salaried employment) and the treatment of Medicare patients with a diagnosis of acute myocardial infarction admitted to general medical-surgical hospitals between 1994 and 1998. Dependent variables include whether the patient received a catheterization or angioplasty or bypass surgery; whether a patient was readmitted, or died within 90 days of initial admission; and expenditures. Independent variables include patient, admission hospital, and market characteristics, as well as hospital and year fixed effects. PRINCIPAL FINDINGS: The integrated salary model form of hospital-physician affiliation is associated with slightly higher procedure rates, and higher patient expenditures. At the same time, there is little evidence that hospital-physician affiliations in the aggregate have had any measurable impact on patient treatment or outcomes. CONCLUSIONS: The limited effect of hospital-physician affiliations on patient outcomes is consistent with previous research showing that affiliations have not much changed the nature of health care delivery. However, the finding that the integrated salary model is associated with higher treatment intensity suggests that affiliations may have had some impact on patients, and could have more in the future.