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Objective: In light of Department of Justice investigations of for-profit chains for over-admitting patients, we sought to evaluate whether for-profit hospitals are more likely to admit patients from the emergency department. Data Sources: We used statewide visit-level inpatient and emergency department records from Florida's Agency for Healthcare Administration for 2007-2019. Study Design: We calculated differences in admission rates between for-profit and other hospitals, adjusting for patient and hospital characteristics. We also estimated instrumental variables models using differential distance to a for-profit hospital as an instrument. Data Collection/Extraction Methods: Our main analysis focuses on patients ages 65 and older treated in hospitals that primarily serve adults. Principal Findings: Adjusted admission rates among patients ages 65 and older were 7.1 percentage points (95% CI: 5.1-9.1) higher at for-profit hospitals in 2019 (or 18.8% of the sample mean of 37.8%). Differences in admission rates have remained constant since 2009. Conclusion: Our results are consistent with allegations that for-profit hospitals maintain lower admission thresholds to increase occupancy levels. KEYWORDS fraud, hospital economics, hospital emergency service, medical overuse, ownership, patient admission, 1 | INTRODUCTION Patients make almost 150 million visits to the emergency room annually (AHRQ 2021). At each visit, physicians must decide whether to admit the patient to the hospital [...]

Objective: To estimate the impact of a large Medicare fee reduction for intensity-modulated radiation therapy (IMRT) on its use in prostate and breast cancer patients. Data Sources/Study Setting: SEER-Medicare. Study Design: We compared trends in the use of IMRT between patients treated in practices directly affected by fee reductions (for prostate cancer, men treated in urology practices that own IMRT equipment; for breast cancer, women treated in freestanding radiotherapy clinics) and patients treated in other types of practices. Data Collection/Extraction Methods: We identified breast and prostate cancer patients receiving IMRT using outpatient and physician office claims. We classified urology practices based on whether they billed for IMRT and radiotherapy clinics based on whether they were reimbursed under the Physician Fee Schedule. Principal Findings: Between 2006 and 2015 the payment for IMRT delivered in freestanding clinics and physician offices declined by $367 (-54.7%). However, the use of IMRT increased in physician practices subject to payment cuts, both in absolute terms and relative to use in practices unaffected by the payment cut. Use of IMRT in prostate cancer patients treated at urology practices that own IMRT equipment increased by 9.1 (95% CI: 2.0-16.2) percentage points between 2005 and 2016 relative to use in patients treated at other urology practices. Use of IMRT in breast cancer patients treated at freestanding radiotherapy centers increased by 7.5 (95% CI: -5.1 to 20.1) percentage points relative to use in patients treated at hospital-based centers. Conclusions: A steep decline in IMRT fees did not decrease IMRT use over the period from 2006 to 2015, though use has declined since 2010. KEYWORDS Medicare, Medicare care supply, physician decision making, physicians' practice patterns, reimbursement, 1 | INTRODUCTION The Affordable Care Act and the Protecting Access to Medicare Act of 2014 require CMS to identify 'misvalued services' and set a target for reducing payments for [...]

Objective: To determine whether women treated by older physicians are more likely to undergo episiotomy. Data Sources/Study Setting: Hospital discharge data from Pennsylvania for the period 1994 to 2010. Study Design: We examined the impact of the year in which physicians started delivering babies (a proxy for age) in Pennsylvania on episiotomy rates using a linear probability model with hospital fixed effects. Data Collection/Extraction Methods: Using diagnosis and procedure codes, we identified women delivering vaginally (N = 1 658 327) and determined the proportion who had an episiotomy. Principal Findings: The average physician-level episiotomy rate declined from 54 percent in 1994 to 13 percent in 2010. Rates declined among older and younger physicians, but, at any point in time, women treated by older physicians were more likely to have an episiotomy. A 10-year difference in physician age is associated with a 6 percentage point increase in episiotomy rates. Conclusions: Results indicate that older physicians, who entered practice when episiotomy was common, were slow to adjust their practices in response to evidence showing that routine episiotomy is unnecessary. KEYWORDS abandonment, childbirth, de-adoption, obstetric delivery, physicians' practice patterns, 1 | INTRODUCTION Episiotomy is a surgical procedure to enlarge the vaginal opening during childbirth. Seven randomized trials published between 1984 and 2004 have found that routine use of episiotomy [...]

Objectives. To quantify end-of-life (EOL) medical costs for adult Medicaid beneficiaries diagnosed with cancer. Data Sources. We linked Medicaid administrative data with 2000-2003 cancer registry data to identify 3,512 adult Medicaid beneficiaries who died after a cancer diagnosis and matched them to a cohort of beneficiaries without cancer who died during the same period. Study Design. We used multivariable regression analysis to estimate incremental per-person EOL cost after controlling for beneficiaries' age, race/ethnicity, sex, cancer site, and state of residence. Principal Findings. End-of-life costs during the final 4 months of life were about $ 10,000 higher for Medicaid cancer patients than for those without cancer. Medicaid cancer patients are more intensive users of inpatient and ambulatory services than are Medicaid patients without cancer. Medicaid cancer patients who die soon after diagnosis have higher costs of care and use inpatient services more intensely than do Medicaid patients without cancer. Conclusions. Medicaid cancer patients incur substantially higher EOL costs than noncancer patients. This increased cost may reflect the cost of palliative care. Future studies should assess the types and timing of services provided to Medicaid cancer patients at the EOL. Key Words. Econometrics, health care costs, Medicaid, chronic disease, cancer, end-of-life cost, BACKGROUND Cancer has been the leading cause of death among men and women younger than 85 years of age in the United States since 2005 (Jemal et al. 2010). Medicaid [...]

Objective. To describe trends in the use of percutaneous coronary intervention (PCI) following the COURAGE trial, which found that medical therapy is as effective as PCI for patients with stable angina. Data Sources. We used the National Hospital Discharge Survey; inpatient and outpatient discharge data from Florida, Maryland, and New Jersey; and the English Hospital Episode Statistics database. Study Design. We report trends in PCI volume by diagnosis (stable angina vs. unstable angina or AMI) before and after publication of the COURAGE trial. Principal Findings. The number of PCIs in patients without a diagnosis of AMI or unstable angina in Florida, Maryland, and New Jersey declined from 48,000 in 2006 to 40,000 in 2008 (-17 percent). There was no change in the number of PCIs in patients with a diagnosis of AMI. We observed similar patterns in U.S. community hospitals. PCI volume did not decline in England. Conclusions. PCI volume declined after publication of the COURAGE trial. The experience of the COURAGE trial suggests that comparative effectiveness research can lead to cost-saving changes in medical practice patterns. However, there are many patients with stable coronary disease who continue to receive PCI post-COURAGE. Key Words. Medical decision making, access, demand, utilization of services, technology adoption, diffusion, use, When a major study finds that a widely used medical treatment is no better than a less expensive alternative, do physicians stop using it? The premise behind comparative effectiveness research [...]