Early Impact of the Affordable Care Act Coverage Expansion on Safety-Net Hospital Inpatient Payer Mix and Market Shares.

OBJECTIVE: To examine the impact of the Affordable Care Act's coverage expansion on safety-net hospitals (SNHs). STUDY SETTING: Nine Medicaid expansion states. STUDY DESIGN: Differences-in-differences (DID) models compare payer-specific pre-post changes in inpatient stays of adults aged 19-64 years at SNHs and non-SNHs. DATA COLLECTION METHODS: 2013-2014 Healthcare Cost and Utilization Project State Inpatient Databases. PRINCIPAL FINDINGS: On average per quarter postexpansion, SNHs and non-SNHs experienced similar relative decreases in uninsured stays (DID = -2.2 percent, p = .916). Non-SNHs experienced a greater percentage increase in Medicaid stays than did SNHs (DID = 13.8 percent, p = .041). For SNHs, the average decrease in uninsured stays (-146) was similar to the increase in Medicaid stays (153); privately insured stays were stable. For non-SNHs, the decrease in uninsured (-63) plus privately insured (-33) stays was similar to the increase in Medicaid stays (105). SNHs and non-SNHs experienced a similar absolute increase in Medicaid, uninsured, and privately insured stays combined (DID = -16, p = .162). CONCLUSIONS: Postexpansion, non-SNHs experienced a greater percentage increase in Medicaid stays than did SNHs, which may reflect patients choosing non-SNHs over SNHs or a crowd-out of private insurance. More research is needed to understand these trends.

Comparison of Long-run Trends in 30-day Readmission by Degrees of Medicare Payment Cuts.

BACKGROUND AND OBJECTIVE: The Affordable Care Act enacted significant Medicare payment reductions to providers, yet long-term effects of such major reductions on patient outcomes remain uncertain. Using the 1997 Balanced Budget Act (BBA) as an experiment, we compare long-run trends in 30-day readmission across hospitals with different amount of payment cuts. RESEARCH DESIGN, SUBJECTS, AND MEASURES: Using 100% Medicare claims between 1995 and 2011 and instrumental variable hospital fixed-effects regression models, we compared changes in 30-day readmission trends for 5 leading Medicare conditions between urban hospitals facing small, moderate, and large BBA payment reductions across 4 periods [1995-1997 (pre-BBA period), 1998-2000, 2001-2005, 2006-2001]. Patient sample includes Medicare patients who were admitted to general, acute, urban, short-stay hospitals in the United States 1995-2011. Sample size ranges from 1.4 million patients for acute myocardial infarction to 3 million for pneumonia. RESULTS: We found that 30-day readmission trends diverged post-BBA (2001-2005) between hospitals facing small and large payment cuts, where large-cut hospitals experience slower improvement in readmission rates relative to small-cut hospitals. The gap between small-cut and large-cut hospitals readmission trend was 6% for acute myocardial infarction, 4% for congestive heart failure and pneumonia (all P<0.01) in the 2001-2005 period. The gaps between hospitals were eliminated by the 2006-2011 period as the effect of BBA naturally dissipated over time. CONCLUSIONS: Although payment-cut differences are associated with widening gaps in readmission rates across hospitals, the negative association appears to dissipate in the long run.

Effectiveness of aripiprazole, olanzapine, quetiapine, and risperidone augmentation treatment for major depressive disorder: a nationwide population-based study.

OBJECTIVE: Previous studies suggested that antidepressants augmented with second-generation antipsychotics (SGAs), including aripiprazole, olanzapine, quetiapine, and risperidone, resulted in better treatment response or higher rates of remission in patients with major depressive disorder (MDD). However, population-based study on SGA augmentation for patients with MDD remains limited. The purpose of this study was to investigate the effectiveness of SGA augmentation for treatment of MDD using the National Health Insurance Research Database in Taiwan. METHOD: The subjects were patients with MDD (ICD-9-CM code: 296.2 and 296.3) who were initially admitted to psychiatric inpatient settings for the first time between January 1, 1996, and December 31, 2007, and could be tracked until December 31, 2011. To assess the treatment effect of SGA augmentation, 993 MDD patients who received aripiprazole, olanzapine, quetiapine, or risperidone augmentation treatment for 8 weeks or more were included in this 1-year mirror-image study. Outcome measures included length of psychiatric hospitalization and number of psychiatric admissions and emergency room (ER) visits. RESULTS: After patients received SGA augmentation treatment, key psychiatric service use (including length of psychiatric hospitalization [P < .0001], number of psychiatric admissions [P < .0001], and ER visits [P = .0006]) due to MDD diagnosis was significantly reduced. Subgrouping analysis for each SGA drug also showed significant reduction in number of psychiatric admissions for MDD patients who received aripiprazole (P < .0001), olanzapine (P = .003), quetiapine (P < .0001), and risperidone (P < .0001). CONCLUSIONS: The study provides support that aripiprazole, olanzapine, quetiapine, and risperidone augmentation therapy could be effective in reducing psychiatric service utilization among MDD patients.

Decomposition of the drivers of the U.S. hospital spending growth, 2001-2009.

BACKGROUND: United States health care spending rose rapidly in the 2000s, after a period of temporary slowdown in the 1990s. However, the description of the overall trend and the understanding of the underlying drivers of this trend are very limited. This study investigates how well historical hospital cost/revenue drivers explain the recent hospital spending trend in the 2000s, and how important each of these drivers is. METHODS: We used aggregated time series data to describe the trend in total hospital spending, price, and quantity between 2001 and 2009. We used the Oaxaca-Blinder method to investigate the relative importance of major hospital cost/spending drivers (derived from the literature) in explaining the change in hospital spending patterns between 2001 and 2007. We assembled data from Medicare Cost Reports, American Hospital Association annual surveys, Prospective Payment System (PPS) Impact Files, Medicare Provider Analysis and Review (MedPAR) Medicare claims data, InterStudy reports, National Health Expenditure data, and Area Resource Files. RESULTS: Aggregated time series trends show that high hospital spending between 2001 and 2009 appears to be driven by higher payment per unit of hospital output, not by increased utilization. Results using the Oaxaca-Blinder regression decomposition method indicate that changes in historically important spending drivers explain a limited 30% of unit-payment growth, but a higher 60% of utilization growth. Hospital staffing and labor-related costs, casemix, and demographics are the most important drivers of higher hospital revenue, utilization, and unit-payment. Technology is associated with lower utilization, higher unit payment, and limited increases in total revenue. Market competition, primarily because of increased managed care concentration, moderates total revenue growth by driving lower unit payment. CONCLUSIONS: Much of the rapidly rising hospital spending growth in the 2000s in the United States is driven by factors not commonly known or well measured. Future studies need to explore new factors and dynamics that drive longer-term hospital spending growth in recent years, particularly through the channel of higher prices.

Long-term impact of medicare payment reductions on patient outcomes.

OBJECTIVE: To examine the long-term impact of Medicare payment reductions on patient outcomes for Medicare acute myocardial infarction (AMI) patients. DATA SOURCES: Analysis of secondary data compiled from 100 percent Medicare Provider Analysis and Review between 1995 and 2005, Medicare hospital cost reports, Inpatient Prospective Payment System Payment Impact Files, American Hospital Association annual surveys, InterStudy, Area Resource Files, and County Business Patterns. STUDY DESIGN: We used a natural experiment-the Balanced Budget Act (BBA) of 1997-as an instrument to predict cumulative Medicare revenue loss due solely to the BBA, and basing on the predicted loss categorized hospitals into small, moderate, or large payment-cut groups and followed Medicare AMI patient outcomes in these hospitals over an 11-year panel between 1995 and 2005. PRINCIPAL FINDINGS: We found that while Medicare AMI mortality trends remained similar across hospitals between pre-BBA and initial-BBA periods, hospitals facing large payment cuts saw smaller improvement in mortality rates relative to that of hospitals facing small cuts in the post-BBA period. Part of the relatively higher AMI mortalities among large-cut hospitals might be related to reductions in staffing levels and operating costs, and a small part might be due to patient selection. CONCLUSIONS: We found evidence that hospitals facing large Medicare payment cuts as a result of BBA of 1997 were associated with deteriorating patient outcomes in the long run. Medicare payment reductions may have an unintended consequence of widening the gap in quality across hospitals.

Reductions in Medicare payments and patient outcomes: an analysis of 5 leading Medicare conditions.

BACKGROUND: The Affordable Care Act enacted significant Medicare payment reductions to providers, yet the effects of such major reductions on patients remain unclear. We used the Balanced Budget Act (BBA) of 1997 as a natural experiment to study the long-term consequence of major payment reductions on patient outcomes. OBJECTIVES: To analyze whether mortality trends diverge over the years between hospitals facing different levels of payment cuts because of the BBA for 5 leading conditions: acute myocardial infarction, congestive heart failure, stroke, pneumonia, and hip fracture. RESEARCH DESIGN: Using 100% Medicare claims between 1995 and 2005, hospital database, and published reports on BBA policy components, we compared changes in outcomes between hospitals facing small and large BBA payment reductions across 3 periods (pre-BBA, initial-BBA, and post-BBA) using instrumental variable hospital fixed-effects regression models. SETTING: All general, acute, nonrural, short-stay hospitals in the United States 1995-2005. MAIN OUTCOME MEASURES: Hospital risk-adjusted mortality rates (7, 30, 90 d, and 1 y). RESULTS: Mortality trends between hospitals in small and large payment-cut categories were similar between pre-BBA and initial-BBA periods, but diverged in the post-BBA period. Relative to the small-cut hospitals, hospitals in the large-cut category experienced smaller decline in 1-year mortality rates in the post-BBA period compared with their pre-BBA trends by 0.8-1.4 percentage points, depending on the condition (P<0.05 for all conditions, except for hip fracture). CONCLUSION: We found consistent evidence across multiple conditions that reductions in Medicare payments are associated with slower improvement in mortality outcomes.

Inverse association between cancer risks and age in schizophrenic patients: a 12-year nationwide cohort study.

The association between schizophrenia and cancer risk is contentious in the clinical and epidemiological literature. Studies from different populations, tumor sites, or health care systems have provided inconsistent findings. In the present study, we examined a less well-investigated hypothesis that age plays a crucial role in cancer risk in schizophrenia. We conducted a nationwide cohort study using Taiwan's National Health Insurance Research Database (NHIRD) between 1995 and 2007. Overall, gender-, and age-stratified standardized incidence ratios (SIR) were used to investigate the pattern of cancer risk by age. Of the 102 202 schizophrenic patients, 1738 developed cancer after a diagnosis of schizophrenia (SIR = 0.92; 95% confidence interval [CI] 0.90-0.96). However, the age-stratified SIR declined with age (e.g. SIR [95% CI] = 1.97 [1.85-2.33], 0.68 [0.65-0.78], and 0.36 [0.34-0.45] for those aged 20-29, 60-69, and ≥70 years, respectively) in both genders and for major cancers. Cancer risks in schizophrenic patients were lower for cancers that are more likely to develop at an older age in the general population (e.g. stomach cancer [SIR = 0.62; 95% CI 0.57-0.80], pancreatic cancer [SIR = 0.49; 95% CI 0.39-0.84], and prostate cancer [SIR = 0.35; 95% CI 0.29-0.58]). In contrast, cancer risks were higher for cancers that have a younger age of onset, such as cancers of the nasopharynx (SIR = 1.18; 95% CI 1.08-1.49), breast (SIR = 1.50; 95% CI 1.44-1.66) and uterine corpus (SIR = 2.15; 95% CI 1.98-2.74). The unique age structures and early aging potential of schizophrenia populations may contribute to the observed inverse relationship between age and cancer risk. Higher cancer comorbidity in young schizophrenic patients deserves more attention.

Hospital cost shifting revisited: new evidence from the balanced budget act of 1997.

This paper analyzes hospital cost shifting using a natural experiment generated by the Balanced Budget Act (BBA) of 1997. I find evidence that urban hospitals were able to shift part of the burden of Medicare payment reduction onto private payers. However, the overall estimated degree of cost shifting is small and varies according to a hospital's share of private patients. At hospitals where Medicare is a small payer relative to private insurers, up to 37% of BBA cuts was transferred to private payers through higher payments. In contrast, hospitals with greater reliance on Medicare were more financially distressed, as these hospitals saw large BBA cuts but were limited in their abilities to cost shift.

Trends in hospital cost and revenue, 1994-2005: how are they related to HMO penetration, concentration, and for-profit ownership?

OBJECTIVE: Analyze trends in hospital cost and revenue, as well as price and quantity (1994-2005) as a function of health maintenance organization (HMO) penetration, HMO concentration, and for-profit (FP) HMO market share. DATA: Medicare hospital cost reports, AHA Annual Surveys, HMO data from Interstudy, and other supplemental data. STUDY DESIGN: A retrospective study of all short-term, general, nonfederal hospitals in metropolitan statistical areas (MSAs) in the United States from 1994 to 2005, using hospital/MSA fixed-effects translog regression models. PRINCIPAL FINDINGS: A 10 percentage point increase in HMO enrollment is associated with 4.1-4.2 percent reduction in costs and revenues in the pre-2000 period but only a 2.1-2.5 percent reduction in the post-2000 period. Hospital revenue in HMO-dominant markets (highly concentrated HMO market and competitive hospital market) is 19-27 percent lower than other types of markets, and the difference is most likely due mainly to lower prices and to a lesser extent lower utilization. CONCLUSIONS: The historical difference of lower spending in high HMO penetration markets compared with low HMO markets narrowed after 2000 and the relative concentration between HMO and hospital markets can substantially influence hospital spending. Additional research is needed to understand how different aspects of these two markets have changed and interacted and how they are causally linked to spending trends.

Managed care's price bargaining with hospitals.

Research has shown that managed care (MC) slowed the rate of growth in health care spending in the 1990s, primarily via lower unit prices paid. However, the mechanism of MC's price bargaining has not been well studied. This article uses a unique panel dataset with actual hospital prices in Massachusetts between 1994 and 2000 to examine the sources of MC's bargaining power. I find two significant determinants of price discounts. First, plans with large memberships are able to extract volume discounts across hospitals. Second, health plans that are more successful at channeling patients can extract greater discounts. Patient channeling can add to the volume discount that plans negotiate.

The price effect of hospital closures.

This paper analyzes the anti-competitive effect of hospital closures between 1993 and 1998. Using a modified rival analysis with difference-in-differences (DD) and difference-in-difference-in-differences (DDD) identification strategies, this study finds that competitors located nearest to closed hospitals were best able to improve their bargaining position. Moreover, rivals that experienced multiple neighborhood closures, that faced large closures relative to their own sizes, and that were located in more concentrated markets were all able to raise prices even more. The overall estimate suggests a 4%, one-time, permanent price increase due to closure, a strong price effect that has been overlooked in the literature.

How are patients' specific ambulatory care experiences related to trust, satisfaction, and considering changing physicians?

CONTEXT: Few data are available regarding the consequences of patients' problems with interpersonal aspects of medical care. OBJECTIVE: To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want. DESIGN: Telephone survey during 1997. PARTICIPANTS: Patients (N=2,052; 58% response) insured by a large national health insurer. MEASUREMENTS: Patient trust, overall ratings of physicians, and having considered changing physicians. RESULTS: Most patients (78%) reported at least 1 problem experience. In multivariable analyses, each problem experience was independently associated with lower trust (all P <.001) and 5 of 6 with lower overall ratings (P <.001). Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3 to 3.0), not always taking enough time to answer questions (OR, 3.3; 95% CI, 2.2 to 5.2), and not always giving enough medical information (OR, 4.0; 95% CI, 2.4 to 6.6). CONCLUSIONS: Problem experiences in the ambulatory setting are strongly related to lower trust. Several are also associated with lower overall ratings and with considering changing physicians, particularly problems related to communication of health information. Efforts to improve patients' experiences may promote more trusting relationships and greater continuity and therefore should be a priority for physicians, educators, and health care organizations.