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OBJECTIVES: Most Americans have insurance that uses managed care arrangements. Regulators have long sought to ensure access to care through network adequacy regulations. However, consumers have largely been excluded from conversations about network adequacy. To our knowledge, our study is the first to assess consumer preferences for various definitions of network adequacy including those aimed at supporting health equity and reducing disparities. STUDY DESIGN: We fielded a large and demographically diverse survey of US adults (N = 4008) from June 30 to July 2, 2023. The survey queried respondents about their perceptions of what adequate provider networks look like in the abstract. METHODS: Analyses were conducted using ordinary least squares regression with survey weights as well as t tests. RESULTS: Consumers were overwhelmingly supportive of standard definitions of adequacy focused on the number of providers and travel distance. Majorities also favored more expansive, health equity-focused definitions such as public transportation access, cultural competency, and lesbian, gay, bisexual, and transgender (LGBT+)-inclusive care. Being a woman; having higher levels of education, worse health, and recent experiences with the medical system; and ease of completing administrative tasks were relatively consistent positive predictors of supporting more expansive definitions. More controversial definitions saw effects of partisanship and LGBT+ identification. Rurality, insurance status, education, and recent experiences with the medical system affected perceptions of reasonable appointment wait times and travel distances. CONCLUSIONS: Our findings indicate that consumers have broad conceptions of network adequacy. Future work should assess consumer trade-offs in resource-constrained settings as well as perceptions of providers and carriers.
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Comportamiento del Consumidor , Accesibilidad a los Servicios de Salud , Programas Controlados de Atención en Salud , Humanos , Femenino , Masculino , Estados Unidos , Adulto , Programas Controlados de Atención en Salud/organización & administración , Programas Controlados de Atención en Salud/normas , Persona de Mediana Edad , Equidad en Salud , Seguro de Salud/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
Numerous states implemented laws to protect emergency patients from surprise out-of-network medical bills. We investigated the effects of the state laws on emergency clinician reimbursements, charges, network participation, and potential surprise billing episodes. We did not find consistent evidence of effects on prices or charges. However, the state laws resulted in increased network participation and a reduction in potential surprise billing episodes. Our results suggest that the federal No Surprises Act, which is similar to many of the state laws, is unlikely to lead to price increases, but may benefit patients through increased provider network participation and alignment.
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BACKGROUND: Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice. OBJECTIVE: Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life. DESIGN: This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020. PARTICIPANTS: A total of 48,466 deceased patients diagnosed with heart failure on Medicare. MAIN MEASURES: Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services. KEY RESULTS: In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter. CONCLUSIONS: Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.
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OBJECTIVES: To evaluate the accuracy of provider directories for mental health providers and network adequacy, defined as timely access to urgent and general care appointments in California. STUDY DESIGN: We assessed provider directory accuracy and timely access using a novel, comprehensive, and representative data set of mental health providers for all plans regulated by the California Department of Managed Health Care with 1,146,954 observations (480,013 for 2018 and 666,941 for 2019). METHODS: We used descriptive statistics to assess provider directory accuracy and network adequacy assessed via access to timely appointments. We used t tests to make comparison across markets. RESULTS: We found that mental health provider directories are highly inaccurate. Commercial plans were consistently more accurate than both Covered California marketplace and Medi-Cal plans. Moreover, plans were highly limited in providing timely access to urgent care and general appointments, although Medi-Cal plans outperformed plans from both other markets when it came to timely access. CONCLUSIONS: These findings are concerning from both the consumer and regulatory perspectives and provide further evidence of the tremendous challenge that consumers face in accessing mental health care. Although California's laws and regulations are some of the strongest in the country, they are still falling short, indicating the need to further expand efforts to protect consumers.
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Accesibilidad a los Servicios de Salud , Salud Mental , Humanos , Estados Unidos , Programas Controlados de Atención en Salud , California , MedicaidRESUMEN
BACKGROUND: Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs. METHODS: Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012-2017. The analytic sample included 2054 CHC-year observations. RESULTS: Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01). CONCLUSIONS: Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.
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Procedimientos Quirúrgicos Orales , Patient Protection and Affordable Care Act , Adulto , Accesibilidad a los Servicios de Salud , Humanos , Cobertura del Seguro , Medicaid , Salud Pública , Estados UnidosRESUMEN
OBJECTIVES: Providers who do not contract with insurance plans are considered out-of-network (OON) providers. There were 2 objectives in this study: (1) to examine the variations of OON cost sharing, both at the state level and by care settings, and (2) to investigate the pattern of OON care use and cost sharing associated with OON care over time. STUDY DESIGN: Secondary data analysis using claims data of employer-sponsored insurance enrollees. METHODS: The study sample included adults aged 18 to 64 years who were continuously enrolled for at least a full calendar year with medical and prescription drug coverage and for whom OON care payment data were available. We examined levels and distributions of cost sharing for OON care from 2012 to 2017, in both emergency department (ED) and non-ED care settings. Outcome measures included annual use of health plan-covered OON care and total out-of-pocket (OOP) cost sharing for OON care. We also measured the use of and cost-sharing spending for OON care based on urgency and site of service. Logistic regression models were constructed to estimate the probability of OON care. Among those with each type of OON care, a generalized linear regression model was used to estimate the OOP spending on OON care. RESULTS: Slowly decreasing rates of OON care over time occurred in different care settings and at different urgency levels. The cost-sharing amounts for OON care rose rapidly from 2012 through 2016, before slowing slightly in 2017. The growth of cost sharing for OON care during nonemergent hospitalizations especially increased from $671 to $1286 during the study period. The amount enrollees spent on OON care grew in most states, but there were substantial variations. CONCLUSIONS: Cost-sharing payments for OON care represent a growing financial burden for some enrollees. Consumers should be held harmless from higher cost sharing for OON care when it occurs without their knowledge or consent. Further, health plan network adequacy may also merit closer scrutiny. Leveraging provider participation in narrow networks must be balanced with broader consumer protections.
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Seguro de Costos Compartidos/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Adolescente , Adulto , Seguro de Costos Compartidos/economía , Femenino , Gastos en Salud/estadística & datos numéricos , Humanos , Revisión de Utilización de Seguros , Seguro de Salud/economía , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
Importance: Individuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans. Objective: To evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes. Design, Setting, and Participants: This cross-sectional study used data from a large commercial claims database from 2012 to 2017. The study included adults with mental health conditions, with alcohol use disorders, with drug use disorders, with CHF, and with diabetes who were aged 18 to 64 years and enrolled in employer-sponsored insurance plans. Main Outcomes and Measures: Main outcomes included OON care during hospitalization, OON care during outpatient care, cost-sharing payments with OON care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing. Results: The study sample included 3â¯209â¯929 enrollees with mental health conditions (mean [SD] age, 45.9 [12.6] years; 64.8% women), 294â¯550 with alcohol use disorders (mean [SD] age, 42.8 [13.4] years; 60.9% men), 321â¯535 with drug use disorders (mean [SD] age, 41.1 [13.9] years; 59.1% men), 178â¯701 with CHF (mean [SD] age, 53.8 [8.9] years; 62.6% men), and 1â¯383â¯398 with diabetes (mean [SD] age, 52.5 [9.0] years; 58.9% men). Enrollees with behavioral conditions were more likely to encounter OON clinicians in inpatient and outpatient settings. For instance, those with drug use disorders were 12.9 percentage points (95% CI, 12.5-13.2 percentage points; P < .001) more likely to have inpatient OON care than those with CHF and 15.3 percentage points (95% CI, 15.1-15.6 percentage points; P < .001) more likely to receive outpatient OON care. Behavioral conditions also had higher cost sharing for OON care. For example, individuals with mental health conditions had cost-sharing payments for OON care $341 (95% CI, $331-$351) higher than those with diabetes (P < .001), individuals with drug use disorders had cost-sharing payments for OON care $1242 (95% CI, $1209-$1276) higher than those with diabetes (P < .001), and individuals with alcohol use disorders had cost-sharing payments for OON care $1138 (95% CI, $1101-$1174) higher than those with diabetes (P < .001). The OON care rates and cost-sharing payments were much higher when enrollees sought care from behavioral clinicians and facilities. Conclusions and Relevance: In this cross-sectional study of enrollees in commercial insurance plans, cost sharing for OON care among those with behavioral health conditions was significantly higher than those with chronic physical conditions. These disparities may be indicative of limited in-network availability for behavioral health care.
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Seguro de Costos Compartidos , Deducibles y Coseguros , Seguro de Salud/economía , Trastornos Mentales/economía , Servicios de Salud Mental/economía , Adulto , Atención Ambulatoria/economía , Estudios Transversales , Bases de Datos Factuales , Diabetes Mellitus/economía , Diabetes Mellitus/epidemiología , Femenino , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/epidemiología , Hospitalización/economía , Humanos , Masculino , Trastornos Mentales/epidemiología , Persona de Mediana Edad , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To examine the impact of a Medicaid-serving pediatric accountable care organization (ACO) on health service use by children who qualify for Medicaid by virtue of a disability under the "aged, blind, and disabled" (ABD) eligibility criteria. DATA SOURCES/STUDY SETTING: We evaluated a 2013 Ohio policy change that effectively moved ABD Medicaid children into an ACO model of care using Ohio Medicaid administrative claims data for years 2011-2016. STUDY DESIGN: We used a difference-in-difference design to examine changes in patterns of health care service use by ABD-enrolled children before and after enrolling in an ACO compared with ABD-enrolled children enrolled in non-ACO managed care plans. DATA COLLECTION/EXTRACTION METHODS: We identified 17 356 children who resided in 34 of 88 counties as the ACO "intervention" group and 47 026 ABD-enrolled children who resided outside of the ACO region as non-ACO controls. PRINCIPAL FINDINGS: Being part of the ACO increased adolescent preventative service and decreased use of ADHD medications as compared to similar children in non-ACO capitated managed care plans. Relative home health service use decreased for children in the ACO. CONCLUSIONS: Our overall results indicate that being part of an ACO may improve quality in certain areas, such as adolescent well-child visits, though there may be room for improvement in other areas considered important by patients and their families such as home health service.
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Organizaciones Responsables por la Atención/normas , Niños con Discapacidad/rehabilitación , Hospitales Pediátricos/estadística & datos numéricos , Hospitales Pediátricos/normas , Programas Controlados de Atención en Salud/normas , Medicaid/normas , Aceptación de la Atención de Salud/estadística & datos numéricos , Organizaciones Responsables por la Atención/estadística & datos numéricos , Adolescente , Niño , Preescolar , Niños con Discapacidad/estadística & datos numéricos , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Programas Controlados de Atención en Salud/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Ohio , Estados UnidosRESUMEN
This study examined income-based disparities in financial burdens from out-of-pocket (OOP) medical spending among individuals with multiple chronic physical and behavioral conditions, before and after the Affordable Care Act's (ACA) implementation in 2014. Using the 2012-2015 Medical Expenditure Panel Survey data, we studied changes in financial burdens experienced by nonelderly U.S. populations. Financial burdens were measured by (1) high financial burden, defined as total OOP medical spending exceeding 10% of annual household income; (2) health care cost-sharing ratio, defined as self-paid payments as a percent of total health care payments, excluding individual contributions to premiums; and (3) the total OOP costs spent on health care utilization. The findings indicated reductions in the proportion of those who experienced a high financial burden, as well as reductions in the OOP costs for some individuals. However, individuals with incomes below 138% federal poverty level (FPL) and those with incomes between 251% and 400% FPL who had multiple physical and/or behavioral chronic conditions experienced large increases in high financial burden after the ACA, relative to those with incomes greater than 400% FPL. While the ACA was associated with relieved medical financial burdens for some individuals, the worsening high financial burden for moderate-income individuals with chronic physical and behavioral conditions is a concern. Policymakers should revisit the cost subsidies for these individuals, with a particular focus on those with chronic conditions.
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Enfermedad Crónica/economía , Familia , Gastos en Salud/estadística & datos numéricos , Cobertura del Seguro/economía , Seguro de Salud/economía , Pobreza/estadística & datos numéricos , Factores Socioeconómicos , Adulto , Seguro de Costos Compartidos , Femenino , Humanos , Masculino , Trastornos Mentales/economía , Persona de Mediana Edad , Patient Protection and Affordable Care Act/economía , Encuestas y Cuestionarios , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA. METHODS: The primary data were the 2007-2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups. The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded. The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data. RESULTS: After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary's probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90-1.29; post-policy period: OR = 1.08, 95% CI = 0.83-1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91-1.17; post-policy period: OR = 1.07, 95% CI = 0.88-1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69-1.09; post-policy period: OR = 0.72, 95% CI = 0.51-1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50-75 years old, biennial mammograms by women 50-74, and triennial Pap smear tests among women 21-65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time. CONCLUSIONS: Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.
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Detección Precoz del Cáncer/economía , Detección Precoz del Cáncer/estadística & datos numéricos , Medicare/economía , Neoplasias/diagnóstico , Aceptación de la Atención de Salud/estadística & datos numéricos , Servicios Preventivos de Salud , Anciano , Seguro de Costos Compartidos , Análisis Costo-Beneficio , Femenino , Investigación sobre Servicios de Salud , Humanos , Cobertura del Seguro , Masculino , Persona de Mediana Edad , Neoplasias/economía , Servicios Preventivos de Salud/economía , Servicios Preventivos de Salud/estadística & datos numéricos , Estados UnidosRESUMEN
OBJECTIVES: To describe the extent and implications of "churn" between different Medicaid eligibility classifications in a pediatric population: (1) aged, blind, and disabled (ABD) Medicaid eligibility, determined by disability status and family income; and (2) Healthy Start Medicaid eligibility, determined by family income alone. STUDY DESIGN: As a result of a 2013 policy change, children with ABD eligibility transitioned from fee-for-service to capitated care. We used Ohio Medicaid claims data from July 2013 through June 2015 to explore the relationships among instability in eligibility category, demographics, and utilization. METHODS: To examine the potential financial effect of categorical churn, an effective capitation rate was created to capture the proportion of the maximum potential capitation rate that was realized. RESULTS: More than 20% of children exited ABD-based eligibility at least once. Switching was associated with younger age and rural residence and was not associated with healthcare use. CONCLUSIONS: Switching between eligibility categories is common and affects average capitation but not health service use.
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Determinación de la Elegibilidad/organización & administración , Determinación de la Elegibilidad/estadística & datos numéricos , Servicios de Salud/estadística & datos numéricos , Medicaid/organización & administración , Medicaid/estadística & datos numéricos , Factores de Edad , Niño , Preescolar , Niños con Discapacidad/estadística & datos numéricos , Determinación de la Elegibilidad/economía , Femenino , Humanos , Renta , Masculino , Medicaid/economía , Ohio , Población Rural , Estados Unidos , Personas con Daño Visual/estadística & datos numéricosRESUMEN
Although they represent less than 8% of all U.S. hospitals, academic health centers (AHCs) deliver almost 40% of the inpatient care for Medicaid beneficiaries. However, because of low Medicaid reimbursement rates, AHCs have had to rely on supplemental funding sources, such as disproportionate share hospital (DSH) payments and upper payment limit (UPL) payments. Recent legislative efforts and changes to payment structures have made these sources vulnerable to severe reductions. For instance, DSH payments are scheduled to be cut by $8 billion by 2021, and UPL payments are a diminishing resource for many states because the program is based on a fee-for-service model and most states are moving to managed care.In this Invited Commentary, the authors argue that cuts to supplemental funding sources would harm AHCs. They advocate instead for restructuring traditional supplemental payments to accommodate novel reimbursement models. They cite Medicaid's Delivery System Reform Incentive Payment program as an example of work to leverage supplemental payments to transform the delivery of care for Medicaid beneficiaries. AHCs should be at the epicenter of such innovations in population health for Medicaid beneficiaries. To that end, the authors encourage AHCs to build new partnerships with community-based primary care physicians and community health centers to balance the specialty composition of their faculty providers to assume the risk for Medicaid beneficiaries and other vulnerable populations.
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Planes de Aranceles por Servicios , Medicaid , Programas Controlados de Atención en Salud , Estados UnidosRESUMEN
OBJECTIVES: Specialty drugs can bring significant benefits to patients, but they can be expensive. Medicare Part D plans charge relatively high cost-sharing costs for specialty drugs. A provision in the Affordable Care Act reduced cost sharing in the Part D coverage gap phase in an attempt to mitigate the financial burden of beneficiaries with high drug spending. We examined the early impact of the Part D in-gap discount on specialty cancer drug use and patients' out-of-pocket (OOP) spending. STUDY DESIGN: Natural experimental design. METHODS: We compared changes in outcomes before and after the in-gap discount among beneficiaries with and without low-income subsidies (LIS). Beneficiaries with LIS, who were not affected by the in-gap discount, made up the control group. We studied a random sample of elderly standalone prescription drug plan enrollees with relatively uncommon cancers (eg, leukemia, skin, pancreas, kidney, sarcomas, and non-Hodgkin lymphoma) between 2009 and 2013. We constructed 4 outcome variables annually: 1) use of any specialty cancer drug, 2) the number of specialty cancer drug fills, 3) total specialty drug spending, and 4) OOP spending for specialty cancer drugs. RESULTS: The in-gap discount did not influence specialty cancer drug use, but reduced annual OOP spending for specialty cancer drugs among users without LIS by $1108. CONCLUSIONS: In-gap discounts in Part D decreased patients' financial burden to some extent, but resulted in no change in specialty drug use. As demand for specialty drugs increases, it will be important to ensure patients' access to needed drugs, while simultaneously reducing their financial burden.
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Costos de los Medicamentos/estadística & datos numéricos , Medicare Part D , Anciano , Antineoplásicos/economía , Antineoplásicos/uso terapéutico , Femenino , Financiación Gubernamental/economía , Financiación Gubernamental/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Humanos , Seguro Adicional/estadística & datos numéricos , Masculino , Medicare Part D/economía , Medicare Part D/organización & administración , Patient Protection and Affordable Care Act , Estados UnidosRESUMEN
OBJECTIVES: To evaluate the association between patient satisfaction and cost, outcomes, and clinical performance of stroke care. STUDY DESIGN: An ecological study was conducted on all participating hospitals of the Hospital Consumer Assessment of Healthcare Providers and Systems patient survey that reported stroke outcomes. METHODS: Patient satisfaction measures were grouped into global, environmental, communication, pain control, staff responsiveness, care transition, and discharge information categories. Linear regression models compared risk-adjusted 30-day mortality, 30-day readmission, inpatient costs, and clinical performances by patient satisfaction. RESULTS: Global patient satisfaction was negatively associated with risk-adjusted 30-day mortality (beta coefficient [ß] = -0.39; standard error [SE], 0.16; P = .02) and readmission rates (ß = -0.30; SE, 0.11; P = .006). Satisfaction with discharge information was positively associated with risk-adjusted 30-day mortality rate (ß = 0.70; SE, 0.14; P <.001) and negatively associated with readmission rate (ß = -0.37; SE, 0.09; P <.001). Satisfaction with discharge information were positively associated with inpatient management (ß = 1.67; SE, 0.43; P <.001) and secondary care performance (ß = 1.82; SE, 0.47; P <.001). The average cost among most satisfied hospitals was $6785, 7.3% higher than that among least satisfied hospitals ($6324). Hospitals with the highest environment satisfaction rating had 7% higher costs compared with the least satisfied hospitals. CONCLUSIONS: Global patient satisfaction was positively associated with the quality of stroke care; however, improvements in patient satisfaction were linked to higher stroke care costs. In addition, patient satisfaction with discharge information was linked to worse outcomes. As a result, patient satisfaction should be used with caution as a quality indicator for stroke care.
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Satisfacción del Paciente/estadística & datos numéricos , Calidad de la Atención de Salud/organización & administración , Accidente Cerebrovascular/terapia , Comunicación , Ambiente , Gastos en Salud/estadística & datos numéricos , Humanos , Manejo del Dolor/métodos , Alta del Paciente , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Satisfacción del Paciente/economía , Calidad de la Atención de Salud/economía , Accidente Cerebrovascular/economía , Accidente Cerebrovascular/mortalidad , Resultado del TratamientoRESUMEN
OBJECTIVE: Consuming low-value health care not only highlights inefficient resource use but also brings an important concern regarding the economics of disparities. We identify the relation of socioeconomic characteristics to the use of low-value cancer screenings in Medicare fee-for-service (FFS) settings, and quantify the amount subsidized from nonusers and taxpayers to users of these screenings. DATA SOURCES: 2007-2013 Medicare Current Beneficiary Survey, Medicare FFS claims, and the Area Health Resource Files. STUDY DESIGN: Our sample included enrollees in FFS Part B for the entire calendar year. We excluded beneficiaries with a claims-documented or self-reported history of targeted cancers, or those enrolled in Medicaid or Medicare Advantage plans. We identified use of low-value Pap smears, mammograms, and prostate-specific antigen tests based on established algorithms, and estimated a logistic model with year dummies separately for each test. DATA COLLECTION/EXTRACTION METHODS: Secondary data analyses. PRINCIPAL FINDINGS: We found a statistically significant positive association between privileged socioeconomic characteristics and use of low-value screenings. Having higher income and supplemental private insurance strongly predicted more net subsidies from Medicare. CONCLUSIONS: FFS enrollees who are better off in terms of sociodemographic characteristics receive greater subsidies from taxpayers for using low-value cancer screenings.
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Detección Precoz del Cáncer/estadística & datos numéricos , Planes de Aranceles por Servicios/estadística & datos numéricos , Renta/estadística & datos numéricos , Medicare/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Mamografía/estadística & datos numéricos , Prueba de Papanicolaou/estadística & datos numéricos , Antígeno Prostático Específico/sangre , Factores Socioeconómicos , Estados UnidosRESUMEN
We use the 1997-2008 Medical Expenditure Panel Survey (MEPS) and variation in the timing of state mandates for coverage of colorectal, cervical, and prostate cancer screenings to investigate the behavioral and financial effects of mandates on privately insured adults. We find that state mandates did not result in increased rates of cancer screening. However, coverage of preventive care, whether mandated or not, moves the cost of care from the consumer's out-of-pocket expense to the premium, resulting in a cross-subsidy of users of the service by non-users. While some cross-subsidies are intentional, others may be unintentional. We find that users of cancer screening have higher levels of income and education, while non-users tend to be racial minorities, lack a usual source of care, and live in communities with fewer physicians per capita. These results suggest that coverage of preventive care may transfer resources from more advantaged individuals to less advantaged individuals.
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Detección Precoz del Cáncer/economía , Exámenes Obligatorios/economía , Gobierno Estatal , Adulto , Anciano , Colonoscopía/economía , Colonoscopía/estadística & datos numéricos , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/economía , Detección Precoz del Cáncer/estadística & datos numéricos , Femenino , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Seguro de Salud/economía , Seguro de Salud/legislación & jurisprudencia , Masculino , Exámenes Obligatorios/estadística & datos numéricos , Persona de Mediana Edad , Prueba de Papanicolaou/economía , Prueba de Papanicolaou/estadística & datos numéricos , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/diagnóstico , Neoplasias de la Próstata/economía , Estados Unidos , Neoplasias del Cuello Uterino/diagnóstico , Neoplasias del Cuello Uterino/economíaRESUMEN
This study examines the relationship between Healthcare Effectiveness Data and Information Set-based diabetes quality measures and resource use for evaluation and management (E&M), inpatient facility, and surgical procedure services for a national sample of Medicare fee-for-service beneficiaries in 1685 Hospital Service Areas. Using multivariate regression analyses, the study findings suggest that higher rates of beneficiaries' receipt of HbA1c, low-density lipoprotein cholesterol, and retinal eye exam tests ("composite quality") during the year is inversely related to average inpatient resource use. However, no association is found between composite quality and E&M services, suggesting that quality improvement with respect to increased rates of testing could be achieved without significant increases in resource use.
Asunto(s)
Diabetes Mellitus/terapia , Planes de Aranceles por Servicios , Recursos en Salud/estadística & datos numéricos , Medicare , Calidad de la Atención de Salud , Anciano , Bases de Datos Factuales , Femenino , Humanos , Masculino , Análisis de Regresión , Estados UnidosRESUMEN
Under the 1997 Balanced Budget Act, Medicare expanded coverage of colonoscopy and prostate-specific antigen tests from diagnostic and surveillance tests to preventive screenings. The preventive tests now are covered with no deductibles or copayments. Reducing out-of-pocket costs increases premiums, resulting in a subsidy to beneficiaries who use the service by nonusers, and by taxpayers who shoulder the bulk of Medicare's costs. Using Medicare fee-for-service claims and the Medicare Current Beneficiary Survey, we estimate the behavioral and financial consequences of these Balanced Budget Act coverage expansions. We find that fee-for-service Medicare-covered colonoscopies increased by 3.5 percentage points after the coverage expansion, and prostate-specific antigen tests increased by 6.8 percentage points. Beneficiaries with lower incomes, less education, and those lacking a usual source of care or supplemental insurance were less likely to use these tests. Therefore, they generally received much smaller net benefits from the coverage of colonoscopies than more advantaged beneficiaries.