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OBJECTIVE:To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix. DATA SOURCES:Medicare provider and claims data, 2012 and 2013. STUDY DESIGN:We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks. DATA EXTRACTION METHODS:We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay. PRINCIPAL FINDINGS:Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs. CONCLUSIONS:Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health.

Objective: To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes., Data Sources: Medicare provider, beneficiary, and claims data from 2012 to 2014., Study Design: We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias., Data Extraction Methods: We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data., Principal Findings: Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P < .001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2 days, P = .001) and shorter initial SNF stays (adjusted difference: -2.7 days, P = .049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias., Conclusions: Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration., (© 2021 Health Research and Educational Trust.)

Objective: To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence., Data Sources: We analyzed 2007-2015 claims data from OptumLabs ® Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data., Study Design: We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty., Data Extraction: We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs., Principal Findings: Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo R 2  = 0.000)., Conclusion: On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings., (© 2021 Health Research and Educational Trust.)

Objective: To examine state and community factors that contributed to geographic variation in qualified health plan selection during the first open enrollment period., Data Sources/study Setting: Administrative data on qualified health plan selections at the ZIP code area merged with survey estimates from the American Community Survey., Study Design: Descriptive and regression analyses., Data Collection/extraction Methods: Data were generated by healthcare.gov and from a household survey., Principal Findings: Thirty-one percent of the variation in qualified health plan selection ratios resulted from between-state differences, and the rest was driven by local area differences. Education, language, age, gender, and the ethnic composition of communities contributed to disparate levels of plan selection. Medicaid expansion states had a qualified health plan selection ratio that was 4.4 points lower than non-Medicaid expansion states, controlling for covariates., Conclusions: Our results suggest community-level differences in the intensity or receptiveness to outreach and enrollment activities during the first open enrollment period., (© Health Research and Educational Trust.)

Objective: To examine the influence of physician and hospital market structures on medical technology diffusion, studying the diffusion of drug-eluting stents (DESs), which became available in April 2003., Data Sources/study Setting: Medicare claims linked to physician demographic data from the American Medical Association and to hospital characteristics from the American Hospital Association Survey., Study Design: Retrospective claims data analyses., Data Collection/extraction Methods: All fee-for-service Medicare beneficiaries who received a percutaneous coronary intervention (PCI) with a cardiac stent in 2003 or 2004. Each PCI record was joined to characteristics on the patient, the procedure, the cardiologist, and the hospital where the PCI was delivered. We accounted for the endogeneity of physician and hospital market structure using exogenous variation in the distances between patient, physician, and hospital locations. We estimated multivariate linear probability models that related the use of a DES in the PCI on market structure while controlling for patient, physician, and hospital characteristics., Principal Findings: DESs diffused faster in markets where cardiology practices faced more competition. Conversely, we found no evidence that the structure of the hospital market mattered., Conclusions: Competitive pressure to maintain or expand PCI volume shares compelled cardiologists to adopt DESs more quickly., (© Health Research and Educational Trust.)

Objectives: To examine the association between statin out-of-pocket (OOP) costs and utilization among the Medicare Part D population., Data Sources/study Setting: 2006-2008 administrative claims and enrollment data for the 5 percent Medicare sample., Study Design: Sample included 346,583 beneficiary-year observations of statin users enrolled in stand-alone prescription drug plans, excluding low-income subsidy recipients. We estimated the association between a plan's OOP statin costs and statin utilization using an instrumental variable approach to account for potential bias due to plan selection. Adherence was defined as percentage of days covered (PDC) of at least 80 percent. Plan OOP costs were constructed for a representative market basket of statin medications. Analyses controlled for demographic characteristics, cardiovascular disease risk, co-morbidity presence, and regional characteristics., Principal Findings: About 67 percent of the sample had a PDC of at least 80 percent. An increase in annual statin OOP from $200 (50th percentile) to $240 (75th percentile) was associated with a reduction in the rate of adherent beneficiaries from 67 percent to 56 percent (p < .001)., Conclusions: Greater OOP costs for statins are associated with reductions in statin utilization., (© Health Research and Educational Trust.)

Objectives: To explain the use of interaction terms in nonlinear models., Study Design: We discuss the motivation for including interaction terms in multivariate analyses. We then explain how the straightforward interpretation of interaction terms in linear models changes in nonlinear models, using graphs and equations. We extend the basic results from logit and probit to difference-in-differences models, models with higher powers of explanatory variables, other nonlinear models (including log transformation and ordered models), and panel data models. EMPIRICAL APPLICATION: We show how to calculate and interpret interaction effects using a publicly available Stata data set with a binary outcome. Stata 11 has added several features which make those calculations easier. LIMDEP code also is provided., Conclusions: It is important to understand why interaction terms are included in nonlinear models in order to be clear about their substantive interpretation., (© Health Research and Educational Trust.)

Objectives: The aim of this study was to investigate factors associated with utilization of health plan Internet-based decision tools., Data Sources and Study Setting: Enrollment, claims, plan design, and web transaction data during 2008 provided by a national health insurer for 253,398 subscribers from 919 employers., Study Design: Multivariate models of the effects of demographic, health, employer, and plan benefit design characteristics on the use of the tool and its individual function categories., Data Extraction Methods: Subscribers, who were either an individual member or a family, were included if at least one family member had 12 months of coverage in 2008. Members older than 65 and those with multiple insurance carriers were excluded., Principal Findings: Higher education, higher income, younger age, female gender, higher co-morbidity risk, prevalence of chronic conditions, Caucasian race, and English as the primary language were positively associated with using the tool. Plan benefit characteristics such as free preventive coverage, higher deductible, moderate coinsurance rate, family coverage, and enrollment in health savings accounts were also associated with higher likelihood of using the tool., Conclusions: Insurers provide consumers information on cost efficiency, quality, and wellness through Internet-based decision tools, but more effort is needed to reach certain demographics., (© Health Research and Educational Trust.)

Objectives: To examine the impact of benefit generosity and household health care financial burden on the demand for specialty drugs in the treatment of rheumatoid arthritis (RA)., Data Sources/study Setting: Enrollment, claims, and benefit design information for 35 large private employers during 2000-2005., Study Design: We estimated multivariate models of the effects of benefit generosity and household financial burden on initiation and continuation of biologic therapies., Data Extraction Methods: We defined initiation of biologic therapy as first-time use of etanercept, adalimumab, or infliximab, and we constructed an index of plan generosity based on coverage of biologic therapies in each plan. We estimated the household's burden by summing up the annual out-of-pocket (OOP) expenses of other family members., Principal Findings: Benefit generosity affected both the likelihood of initiating a biologic and continuing drug therapy, although the effects were stronger for initiation. Initiation of a biologic was lower in households where other family members incurred high OOP expenses., Conclusions: The use of biologic therapy for RA is sensitive to benefit generosity and household financial burden. The increasing use of coinsurance rates for specialty drugs (as under Medicare Part D) raises concern about adverse health consequences., (Copyright © Health Research and Educational Trust.)