Data Management for Applications of Patient Reported Outcomes.

CONTEXT: Patient reported outcomes (PROs) are one means of systematically gathering meaningful subjective information for patient care, population health, and patient centered outcomes research. However, optimal data management for effective PRO applications is unclear. CASE DESCRIPTION: Delivery systems associated with the Health Care Systems Research Network (HCSRN) have implemented PRO data collection as part of the Medicare annual Health Risk Assessment (HRA). A questionnaire assessed data content, collection, storage, and extractability in HCSRN delivery systems. FINDINGS: Responses were received from 15 (83.3 percent) of 18 sites. The proportion of Medicare beneficiaries completing an HRA ranged from less than 10 to 42 percent. Most sites collected core HRA elements and 10 collected information on additional domains such as social support. Measures for core domains varied across sites. Data were collected at and prior to visits. Modes included paper, clinician entry, patient portals, and interactive voice response. Data were stored in the electronic health record (EHR) in scanned documents, free text, and discrete fields, and in summary databases. MAJOR THEMES: PRO implementation requires effectively collecting, storing, extracting, and applying patient-reported data. Standardizing PRO measures and storing data in extractable formats can facilitate multi-site uses for PRO data, while access to individual PROs in the EHR may be sufficient for use at the point of care. CONCLUSION: Collecting comparable PRO data elements, storing data in extractable fields, and collecting data from a higher proportion of eligible respondents represents an optimal approach to support multi-site applications of PRO information.

Do physicians cost shift?

This study analyzes whether physicians charge their privately insured patients more-a practice known as cost shifting-in response to Medicare payment reductions. As part of congressional legislation in 1989 and 1990, Medicare reduced its payment rates for selected procedures by as much as 30 percent. Here we examine whether reductions in Medicare rates increase how much physicians charge privately insured patients. Our data provide no evidence that physicians respond to Medicare payment reductions by shifting costs to their privately insured patients.

Drive-through delivery: where are the "savings"?

Using a natural experiment, this study estimates the effects of Medicaid managed care on total hospital costs of a birth. The authors study 5,585 vaginal deliveries from 1993 through 1995. Hospital length of stay for maternity care has been reduced by 21 percent after the introduction of managed care. The resultant program saving, however, is $280 in total hospital cost per delivery, 12 percent of the total hospital costs before managed care. Furthermore, when the full costs of an earlier discharge, including costs to patients and their families, are taken into account, the savings associated with a shortened hospital stay may be even smaller.

Determinants of antidepressant treatment compliance: implications for policy.

Depression is among the most prevalent, devastating, and undertreated disorders in our society. Treatment with antidepressant medications is effective in controlling symptoms, but treatment beyond the point of symptom resolution is necessary to restore functional status and prevent recurrent episodes. An important step in improving compliance is to identify the determinants of antidepressant treatment compliance. A broader motivation for our study is to examine compliance by patients with a chronic but treatable disease. With claims data between 1990 and 1993, this study uses logistic regression analysis to examine the determinants of compliance among 2,012 antidepressant recipients. The results show that initiating treatment with a tricyclic antidepressant reduces the probability of antidepressant treatment compliance. Initiating treatment with a selective serotonin reuptake inhibitor and undergoing family, group, or individual psychotherapy treatments increase the probability of compliance. Case management does not meaningfully affect compliance. Implications for policy and clinical practice are discussed.

The long-term effects of Medicaid managed care on obstetrics care in three California counties.

OBJECTIVE: To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California. DATA SOURCES/STUDY SETTING: Longitudinal administrative data on Medi-Cal enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties--two long-standing MMC counties and one traditional fee-for-service Medicaid county--in California between 1987 and 1992. STUDY DESIGN: We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medi-Cal enrollment prior to delivery, data censoring, and individual characteristics such as race and age. PRINCIPAL FINDINGS: Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous. CONCLUSIONS: MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes.

Racial disparities in service use among Medicaid beneficiaries after mandatory enrollment in managed care: a difference-in-differences approach.

Managed care may improve access to health care to previously underserved populations when providers need plan enrollees. However, capitation and utilization management often give providers the incentive to withhold care. Managed care organizations have yet to demonstrate that racial disparities in treatment are not exacerbated. Using Medicaid eligibility, claims, and managed care encounter data, we examine racial disparities in service use among Medicaid beneficiaries after mandatory enrollment in managed care. We use count data models adjusted for nonrandom selection within difference-in-differences econometric approaches. The results show that mandatory enrollment has disproportionately reduced the relative use of physician and inpatient services among African-American beneficiaries.

Volume responses to Medicare payment reductions with multiple payers: a test of the McGuire-Pauly model.

The effects of changing financial incentives on physician's practice behaviour have long been of interest to researchers and policy makers. We test a model of physician volume response within the context of multiple payers developed by Thomas McGuire and Mark Pauly. A panel data set covering discharges from about 200 hospitals in the US over 45 months is used to carry out the empirical investigation. A fixed-effect model with generalized least squares and instrumental variable specifications is used to compute empirical evidence of volume responses from eight specialties experiencing varying degrees of Medicare payment reductions following the implementation of Omnibus Budget Reconciliation Acts of 1989 and 1990. The empirical findings are compared with McGuire and Pauly's simulated predictions. We note that in examining physician responses to Medicare payment reductions in the context of a multi-payer environment, it becomes evident that only fixing one payer's reimbursement policy is at best a partial solution to cost containment. We echo observations made by other analysts that physician responses to payment changes can be quite complex. Physicians do not all respond to payment reduction in the same way.

A tale of two bounties: the impact of competing fees on physician behavior.

This study examines how the volume of privately insured services provided in hospital inpatient and outpatient departments changes in response to reductions in Medicare physician payments. We hypothesize that physicians consider relative payment rates when choosing which patients to treat in their practices. When Medicare reduces its payments for surgical procedures, as it did in the late 1980s, physicians are predicted to treat more privately insured patients because they become more lucrative. We use data from 182 hospitals for seventeen major procedures groups, covering a forty-five-month period between 1988 and 1991 that encom passes a twenty-four-month period before the reduction in Medicare fees and twenty-one months after the reduction. Our findings are consistent with the predictions for a number of procedure groups, but not for all of them. One implication of the findings is that societal savings from Medicare fee reductions are overstated if one does not also consider spillover effects in the private insurance market.