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Objective. To examine the relationship of physician versus hospital ownership of small- and medium-sized practices with spending and utilization of care. Data Source/Study Setting/Data Collection. Survey data for 1,045 primary care-based practices of 1-19 physicians linked to Medicare claims data for 2008 for 282, 372 beneficiaries attributed to the 3,010 physicians in these practices. Study Design. We used generalized linear models to estimate the associations between practice characteristics and outcomes (emergency department visits, index admissions, readmissions, and spending). Principal Findings. Beneficiaries linked to hospital-owned practices had 7.3 percent more emergency department visits and 6.4 percent higher total spending compared to beneficiaries linked to physician-owned practices. Conclusions. Physician practices are increasingly being purchased by hospitals. This may result in higher total spending on care. Key Words. Ambulatory/outpatient care, health care organizations and systems, ownership/governance, Health care reform appears to be accelerating two decades-old trends: physician practices are increasingly owned by hospitals, and physicians in small practices are moving into medium-sized and large practices (Burns, [...]

Objective. To examine differences in access to health care and receipt of clinical preventive services by type of disability among working-age adults with disabilities. Data Source. Secondary analysis of Medical Expenditure Panel Survey (MEPS) data from 2002 to 2008. Study Design. We conducted cross-sectional logistic regression analyses comparing people with different types of disabilities on health insurance status and type; presence of a usual source of health care; delayed or forgone care; and receipt of dental checkups and cancer screening. Data Collection. We pooled annualized MEPS data files across years. Our analytic sample consisted of adults (18-64 years) with physical, sensory, or cognitive disabilities and nonmissing data for all variables of interest. Principal Findings. Individuals with hearing impairment had better health care access and receipt than people with other disability types. People with multiple types of limitations were especially likely to have health care access problems and unmet health care needs. Conclusions. There are differences in health care access and receipt of preventive care depending on what type of disability people have. More in-depth research is needed to identify specific causes of these disparities and assess interventions to address health care barriers for particular disability groups. Key Words. People with disabilities, health care disparities, insurance coverage, adult, population surveillance, Timely receipt of appropriate health care plays a key role in facilitating wellness, preventing injury and illness, promoting optimal recovery when injuries and illness do occur, and managing chronic health [...]

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. Key Words. Medicare, mortality, payment reduction, BBA, hospital, Health policy researchers and decision makers have long been concerned about the relationship between provider payment generosity and quality of care for many reasons. One view about Medicare spending suggests [...]

Objective. The Medicare and Premier Inc. Hospital Quality Incentive Demonstration (HQID), a hospital-based pay-for-performance program, changed its incentive design from one rewarding only high performance (Phase 1) to another rewarding high performance, moderate performance, and improvement (Phase 2). We tested whether this design change reduced the gap in incentive payments among hospitals treating patients across the gradient of socioeconomic disadvantage. Data. To estimate incentive payments in both phases, we used data from the Premier Inc. website and from Medicare Provider Analysis and Review files. We used data from the American Hospital Association Annual Survey and Centers for Medicare and Medicaid Services Impact File to identify hospital characteristics. Study Design. Hospitals were divided into quartiles based on their Disproportionate Share Index (DSH), from lowest disadvantage (Quartile 1) to highest disadvantage (Quartile 4). In both phases of the HQID, we tested for differences across the DSH quartiles for three outcomes: (1) receipt of any incentive payments; (2) total incentive payments; and (3) incentive payments per discharge. For each of the study outcomes, we performed a hospital-level difference-in-differences analysis to test whether the gap between Quartile 1 and the other quartiles decreased from Phase 1 to Phase 2. Principal Findings. In Phase 1, there were significant gaps across the DSH quartiles for the receipt of any payment and for payment per discharge. In Phase 2, the gap was not significant for the receipt of any payment, but it remained significant for payment per discharge. For the receipt of any incentive payment, difference-in-difference estimates showed significant reductions in the gap between Quartile 1 and the other quartiles (Quartile 2, 17.5 percentage points [p < .0,5]; Quartile 3, 18.1 percentage points [p < .01]; Quartile 4, 28.3 percentage points [p < .01]). For payments per discharge, the gap was also significantly reduced between Quartile 1 and the other quartiles (Quartile 2, $14.92 per discharge [p < .10]; Quartile 3, $17.34 per discharge [p < .05]; Quartile 4, $21.31 per discharge [p < .01]). There were no significant reductions in the gap for total payments. Conclusions. The design change in the HQID reduced the disparity in the receipt of any incentive payment and for incentive payments per discharge between hospitals caring for the most and least socioeconomically disadvantaged patient populations. Key Words. Health economics, hospitals, incentives in health care, Medicare, INTRODUCTION Hospital pay-for-performance (P4P) is scheduled for nationwide implementation in the United States as part of Medicare's Value-Based Purchasing Program in 2013 (United States Congress 2010). Despite the growing interest [...]

Objective. To examine whether high performance or improvement on quality measures leads to economic rewards for nursing homes in the presence of public reporting. Data Sources. Data from 6,286 freestanding Medicare-certified nursing homes between 1999 and 2005 were identified in Medicare Cost Reports, Minimum Data Set, and Online Survey and Certification Reporting System. Study Design. Using a facility-level fixed-effects model, the effect of public reporting on financial performance was measured by comparing each of four financial outcomes (revenues, expenses, operating, and total profit margins) before (1999-2002) to after (2003-2005) public reporting was initiated. The effects were estimated separately by level of performance and improvement over time. Principal Findings. Facilities that improved on publicly reported performance had increased revenues and higher profit margins after public reporting, mainly through increased Medicare admissions. High-scoring facilities showed similar patterns, though differences were not statistically significant. Conclusions. Providers that improve their performance under public reporting may receive a return on their investment in quality improvement. This supports the business case for public reporting. Key Words. Public reporting, quality of care, nursing homes, financial performance, Improving quality of care in nursing homes is a national priority as evidenced by the recent widespread adoption of market-based quality improvement initiatives, such as public reporting and pay-for-performance. In [...]

Objectives. To examine the extent of variation in public health agency spending levels across communities and over time, and to identify institutional and community correlates of this variation. Data Sources and Setting. Three cross-sectional surveys of the nation&apos;s 2,900 local public health agencies conducted by the National Association of County and City Health Officials in 1993, 1997, and 2005, linked with contemporaneous information on population demographics, socioeconomic characteristics, and health resources. Study Design. A longitudinal cohort design was used to analyze community-level variation and change in per-capita public health agency spending between 1993 and 2005. Multivariate regression models for panel data were used to estimate associations between spending, institutional characteristics, health resources, and population characteristics. Principal Findings. The top 20 percent of communities had public health agency spending levels > 13 times higher than communities in the lowest quintile, and most of this variation persisted after adjusting for differences in demographics and service mix. Local boards of health and decentralized state-local administrative structures were associated with higher spending levels and lower risks of spending reductions. Local public health agency spending was inversely associated with local-area medical spending. Conclusions. The mechanisms that determine funding flows to local agencies may place some communities at a disadvantage in securing resources for public health activities. Key Words. Public health spending, population health, practice variation, Geographic variation in health care spending within the United States has long been a source of policy concern because it implies large inefficiencies and inequities in resource use (Wennberg and [...]

Background. The Medical Expenditure Panel Survey (MEPS) is a widely used nationally representative survey of health care use and expenditures. Numerous studies raise concerns that use is underreported in household surveys. Objective. To assess the quality of household reports in the MEPS and the impact of misreporting on descriptive and behavioral analyses. Research Design. Participants in MEPS with Medicare coverage during 2001-2003 were matched to their Medicare enrollment and claims data (4,045 person-year observations). Household reports of Medicare-covered services for the matched sample were validated against Medicare claims. Standard models of the determinants of health care utilization were estimated with both MEPS and claims-based utilization measures. Measures. In-person interviews with household informants obtained data on hospital inpatient, emergency department (ED), and office-based visits. Comparable measures were created from the claims. Results. In the validation sample, households accurately reported inpatient stays (agreement rate = 0.96, K = 0.89) and number of nights (Lin&apos;s concordance statistic = 0.88). Households underreported ED visits by one-third (Lin&apos;s concordance statistic = 0.51) and office visits by 19 percent (Lin&apos;s concordance statistic = 0.67). Conclusions. Household respondents in the validation sample accurately report inpatient hospitalizations but underreport ED and office visits. Behavioral analyses are largely unaffected because underreporting cuts across all sociodemographic groups. Key Words. Self-reported utilization, concordance, validity, The Medical Expenditure Panel Survey (MEPS) is a widely used nationally representative survey of the levels and determinants of health care use and spending by U.S. households. Before its inception [...]