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Objective. To produce cost estimates of proposed health insurance benefit mandates for the California legislature. Data Sources. The 2001 California Health Interview Survey, 2002 Kaiser Family Foundation/Health Research and Education Trust California Employer Health Benefits Survey, Milliman Health Cost Guidelines, and ad hoc surveys of large health plans were used. Study Design. We developed an actuarial model to estimate short-term (1 year) changes in utilization and total health care expenditures, including insurance premiums and out-of-pocket expenditures, if insurance mandates were enacted. This model includes baseline estimates of current coverage and total current expenditures for each proposed mandate. Principal Findings. Analysis of seven legislative proposals indicated 1-year increases in total health care expenditures among the insured population in California ranging from 0.006 to 0.200 percent. Even when proposed mandates were expected to reach a large target group, either utilization or cost was sufficiently low to keep total cost increases minimal. Conclusions. Our ability to develop a California-specific model to estimate the impacts of proposed mandates in a timely fashion provided California legislators during the 2004 legislative session with more-detailed coverage and cost information than is generally available to legislative bodies. Key Words. Insurance mandates, health care expenditures, utilization and cost impacts, evidence-based policy analysis, The California Health Benefits Review Program (CHBRP) is charged by the California legislature with estimating the medical effectiveness, public health, and cost implications of proposed health benefit mandates. Cost implications [...]

Medicare's prospective payment system (PPS) for hospital cases is based on diagnosis-related groups (DRGs). A wide vaRiety of other third-party payers for hospital care have adapted elements of this system for their own use. The extent DRG use varies considerably both by type of payer and by geographical area. Users include: 21 State Medicaid programs, 3 workers' compensation systems, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), more than one-half of the Blue Cross and Blue Shield association (BCBSSA) member plans, several self-insured employees, and a few employer coalitions. We describe how each of these payers use DRGs. No single approach is dominant. Some payers negotiate specific prices for so many combinations of DRG and hospital that the paradigm that payment equals rate times weight does not apply. What has emerged appears to be a very flexible payment system in which the only constant is the use of DRGs as a measure of output., INTRODUCTION A variety of Medicaid programs and other third-party payers use DRGs to pay for hospital care. These payment systems are derived from Medicare's PPS, even though they differ from [...]

Medicare's use of diagnosis-related groups (DRGs) and the resource-based relative value scale (RBRVS) has led to interest in developing a national all-payer system in which insurers use the same payment methods and payment rates. Using data for 81 high-volume DRGs from 457 California hospitals, we conclude that a single set of rates for hospital care would not be appropriate. On average, Medicare patients were 11.7 percent more expensive than commercially insured patients, but less expensive in many DRGs. Further research is needed to determine if Medicare patients require more physician resources compared with non-Medicare patients, particularly for surgical procedures., INTRODUCTION Health care reform has emerged as a serious priority at both the national and State levels. The primary goals of most reform efforts are to improve access to health [...]

Hospital length of stay (LOS) declined steadily during the 1970s, then rapidly during the early years of the Medicare prospective payment system (PPS). In this article, the authors examine trends in hospital LOS for Medicare patients from 1979 through 1987 for all cases combined, for medical and surgical cases separately, and for different geographic regions. The increase in LOS for surgical cases from 1985 through 1987 represented two offsetting trends. Continuing declines in LOS for most procedures were offset by an increased shift toward complex, long LOS procedures., INTRODUCTION During the 1970s, hospital LOS for the Medicare population declined at an average annual rate of 1.9 percent (Prospective Payment Assessment Commission, 1988). LOS began to decrease more rapidly [...]

IMPORTANCE: Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common. OBJECTIVES: To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates. DESIGN, SETTING, AND PARTICIPANTS: From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice. INTERVENTIONS: Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment. MAIN OUTCOMES AND MEASURES: Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline. RESULTS: Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (−2.4%; 95% CI, −3.5% to −1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (−6.8%; 95% CI, −9.7% to −3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices. CONCLUSIONS AND RELEVANCE: This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03599557

Background:Because value-based care is critical to the Affordable Care Act success, we forecasted inpatient costs and the potential impact of podiatric medical care on savings in the diabetic population through improved care quality and decreased resource use during implementation of the health reform initiatives in California.Methods:We forecasted enrollment of diabetic adults into Medicaid and subsidized health benefit exchange programs using the California Simulation of Insurance Markets (CalSIM) base model. Amputations and admissions per 1,000 diabetic patients and inpatient costs were based on the California Office of Statewide Health Planning and Development 2009-2011 inpatient discharge files. We evaluated cost in three categories: uncomplicated admissions, amputations during admissions, and discharges to a skilled nursing facility. Total costs and projected savings were calculated by applying the metrics and cost to the projected enrollment.Results:Diabetic patients accounted for 6.6 of those newly eligible for Medicaid or health benefit exchange subsidies, with a 60.8 take-up rate. We project costs to be $24.2 million in the diabetic take-up population from 2014 to 2019. Inpatient costs were 94.3 higher when amputations occurred during the admission and 46.7 higher when discharged to a skilled nursing facility. Meanwhile, 61.0 of costs were attributed to uncomplicated admissions. Podiatric medical services saved 4.1 with a 10 reduction in admissions and amputations and an additional 1 for every 10 improvement in access to podiatric medical care.Conclusions:When implementing the Affordable Care Act, inclusion of podiatric medical services on multidisciplinary teams and in chronic-care models featuring prevention helps shift care to ambulatory settings to realize the greatest cost savings.

Gov. Arnold Schwarzenegger's proposal to reform California's health insurance system represents a fundamental change in the way we do business in the state, so it is likely to generate considerable [...]

To determine the adjusted effect of hospital level of care and volume on mortality of very low birth weight (VLBW) infants in the state of California, where deregionalization of perinatal care has occurred.

A comprehensive population health-forecasting model has the potential to interject new and valuable information about the future health status of the population based on current conditions, socioeconomic and demographic trends, and potential changes in policies and programs. Our Health Forecasting Model uses a continuous-time microsimulation framework to simulate individuals' lifetime histories by using birth, risk exposures, disease incidence, and death rates to mark changes in the state of the individual. The model generates a reference forecast of future health in California, including details on physical activity, obesity, coronary heart disease, all-cause mortality, and medical expenditures. We use the model to answer specific research questions, inform debate on important policy issues in public health, support community advocacy, and provide analysis on the long-term impact of proposed changes in policies and programs, thus informing stakeholders at all levels and supporting decisions that can improve the health of populations.

Tobacco use, the most preventable cause of death in our society and a growing international epidemic, should be well understood by all students preparing to enter the field of public health. Despite its importance, however, tobacco does not always enjoy the prominence it deserves in public health education. We report here on efforts to expand the focus on tobacco in the University of California Los Angeles School of Public Health through a program supported by the Association of Schools of Public Health/American Legacy Foundation's Scholarship, Training, and Education Program for Tobacco Use Prevention funding mechanism. We describe steps to increase tobacco content in required and elective courses; offer elective courses on tobacco; implement a pre-doctoral scholarship program featuring coursework, fieldwork, and exposure to tobacco issues at national meetings; and establish a tobacco-focused workshop series. We outline program successes, structural barriers to achieving some programmatic goals, and the program's early termination.

We sought to compare total outpatient costs of 4 common treatments for low-back pain (LBP) at 18-months follow-up.

Objective. This study was designed to assess the burden of disease and injury in the Los Angeles County population using Disability-Adjusted Life Years (DALYs), a composite measure of premature mortality and disability that equates to years of healthy life lost.Methods. DALYs, stratified by gender and race/ethnicity, were calculated for 105 health conditions and aggregated groups of conditions for the Los Angeles County population for 1997. Years of Life Lost (YLLs) were calculated using 1997 county mortality statistics and published life tables. Years Lived with Disability (YLDs) were derived from age- and gender-specific disease incidence and disability data from the Global Burden of Disease Study.Results. DALYs produced a substantially different ranking of disease and injury burden than did mortality rates alone. The leading five causes of DALYs for males in the county were ischemic heart disease, violence, alcohol dependence, drug overdose and other intoxications, and depression. For females, the leading five causes were ischemic heart disease, alcohol dependence, diabetes, depression, and osteoarthritis. Differences in the rank order were also observed by race/ethnicity. The age-adjusted rate of DALYs for all health conditions combined was highest in African Americans (190 per 1,000), followed by American Indians (149 per 1,000), whites (113 per 1,000), Latinos (94 per 1,000), and Asians/Pacific Islanders (77 per 1,000).Conclusions. The DALYs measure is a promising new tool to improve the capacity of local health departments and other health agencies to assess population health and establish an evidence base for public health decisions.

The authors were interested in exploring the extent to which differences in the complexity of patients could be determined by modifications in combinations of the ICD-9-CM codes used to define DRGs. The 150 most common medical and surgical DRGs in one teaching hospital were studied. With clinical experts they identified 41 DRGs that were believed to have subgroups reflecting quite different types of patients, one group sicker and costlier than the other. Using a national data set, the authors then showed that 24 of these DRGs showed significant differences in standardized charges. In 11 of these 24 DRGs the higher cost subgroups were seen proportionately more often in major teaching hospitals compared with other types of hospitals. Results suggest that clinical modifications of a few DRGs would lead to clinically more meaningful case-mix groupings. These same results can also serve as the basis for a discussion on the implication of DRG payments for those DRGs with distributional differences among the higher-cost subgroups.

The Resource-Based Relative Value Scale (RBRVS) was developed by surveying panels of physicians from single specialties, then merging the specialtyspecific results into a common work scale. The merging process involved two steps 1) specification of links or equivalent services across specialties and 2) use of links to align work values from each specialty onto a common scale. This study examines the sensitivity of physician relative values of work (RVWs) to changes in both the specification of links and in the method for aligning specialties. Using the same survey data employed in developing the RBRVS, we calculated new RVWs based on an alternative specification of links and an alternative method for aligning specialties. Total RVWs declined by almost 50 for anesthesiology, and increased by more than 20 for allergists, neurologists, and thoracic surgeons. Most of this change was attributable to our specification of links. We conclude that future use of the linkage procedure employed in developing the RBRVS is not warranted without further research. Instead, efforts to update and revise work values could be based on a common scale of work developed by cross-specialty panels, thus eliminating the need for a linkage procedure.

In this study, a set of meetings was conducted to pilot a group-discussion-based method anchored by a reference set of services with agreed-on values for revising the Medicare Resource-Based Relative Value Scale (RBRVS). The authors focused on the method as it evolved over the sequence of meetings, rather than on whether the relative values of work obtained were more or less valid than relative values of work obtained elsewhere. Four pilot panels, composed of 46 physicians from different specialties (including primary care), were conducted to rate total physician work. One panel examined 80 urologic services, another panel examined 80 ophthalmologic services, and the last two panels considered the merit of appeals from five specialty and subspecialty societies to 68 and 48 services, respectively. Rather than using the method of ratio estimation relative to a standard service, panelists were asked to estimate magnitudes relative to an established multispecialty reference set of values. Prominent members of that reference set were graphically displayed to panelists on a “ruler.” Measures included physicians'preliminary and final ratings and detailed notes of the group discussions conducted between the ratings. The authors found that a panel process for refining relative values of work is practical, provided that panelists are provided with a valid reference set for comparison purposes and provided that care is taken that all members feel comfortable engaging in the discussion. In Summer 1992, the Health Care Financing Association conducted a series of multispecialty panels based on the methods presented here to produce the 1993 RBRVS; in addition, the RBRVS Update Committee of the American Medical Association is employing group processes and a reference set in determining the relative work values of new Current Procedural Terminology codes.

The Medicare prospective payment system (PPS) pays hospitals a fixed payment for patients in 474 categories of diagnosis-related groups (DRGs). Since the beginning of PPS, many DRGs have been modified to improve the accuracy of patient classification and the equity of hospital payments. There are continuing problems, however, in classifying surgical patients who have no procedure related to their reason for admission. Until recently, these patients were classified into a single miscellaneous category (DRG 468) and paid the same amount, despite considerable variation in their clinical conditions and resource use. Three options for improving the payment and classification of such cases were examined. Improvements are possible using each of the options examined. The greatest improvement, however, was achieved by reassigning patients to existing surgical DRGs, because patients with the same surgery tend to have similar costs, regardless of their original reason for entering the hospital. This change in assignment methodology would increase payments to teaching hospitals, where the most costly DRG 468 cases are concentrated. It also would remove potential incentives to deny access to or withhold appropriate treatments from patients needing high-cost surgical procedures. It was concluded that this change should be implemented for hospital payment under PPS.

In this study, changes in the number, site, and source of follow-up visits and allowed charges were examined for follow-up visits provided to Medicare surgical patients between 1984 and 1986. Among the 21 surgical procedures studied, follow-up visits decreased by 5.2, after adjusting for case mix. Despite the physician fee freeze during the most of the study period, total allowed charges increased by 8.1, indicating that the average intensity of visits increased by 14.0. Inpatient visits decreased 6.7, while outpatient visits increased 3.9. Thus, while some substitution of outpatient for inpatient visits occurred, prospective payment system-related reductions in inpatient length of stay were associated with reductions in both the total visits and total allowed charges. Holding other factors constant, the 9.5 overall reduction in length of stay produced a 6.4 reduction in total allowed charges. The authors concluded, then, that prospective payment system had a significant effect in reducing the growth of Medicare expenditures for physician visits. The reduction in submitted claims for inpatient follow-up visits and the absence of a strong substitution effect suggest that some inpatient visits may not have been necessary. These results also raise several issues concerning Medicare's global fee for surgical procedures, and provide additional evidence in support of a uniform global fee policy under the new Medicare fee schedule.

ObjectiveTo examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17).DesignQuasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions.SettingUnited States.ParticipantsA nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey.Main outcomes and measuresFour annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons.Results37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change −28.0% (95% confidence interval −38.4% to −15.8%); adjusted absolute change −$122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (−29.0% (−40.5% to −15.3%); −$442; adjusted P<0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change −4.7 (−7.9 to −1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions.ConclusionMedicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act’s implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults.

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