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Objective: Scientific and clinical interest in attention-deficit hyperactivity disorder (ADHD) is increasing worldwide. This article presents data from a cross-national workshop and survey related to questions of variability in diagnostic and, particularly, treatment procedures.Methods: Representatives of nine nations (Australia, Brazil, Canada, China, Germany, Israel, the Netherlands, Norway, and the United Kingdom), plus the United States, who attended a 2010 workshop on ADHD, responded to a survey that addressed diagnostic procedures for ADHD; treated prevalence of medication approaches, as well as psychosocial interventions; types of medications and psychosocial treatments in use; payment systems; beliefs and values of the education system; trends related to adult ADHD; and cultural and historical attitudes and influences related to treatment.Results: Use of both medication and psychosocial treatment for ADHD varies widely within and across nations. More expensive long-acting formulations of medications are becoming more widespread. Nations with socialized medical care provide a wide array of evidence-based interventions. Economic, historical, and political forces and cultural values are related to predominant attitudes and practices. Strong antipsychiatry and antimedication voices remain influential in many nations.Conclusions: There is considerable variation in implementation of care for ADHD. Recognition of the social context of ADHD is an important step in ensuring access to evidence-based interventions for this prevalent, chronic, and impairing condition. [ABSTRACT FROM AUTHOR]

Objectives: Attention-deficit hyperactivity disorder (ADHD) diagnostic prevalence and medication use vary across U.S. census regions, but little is known about state-level variation. The purpose of this study was to estimate this variation across states and examine whether a state's health care provider characteristics and education policies are associated with this variation.Methods: Logistic regression models were estimated with 69,505 children aged four to 17 from the state-stratified and nationally representative 2003 National Survey of Children's Health, conducted by the Centers for Disease Control and Prevention.Results: Diagnostic prevalence was higher in the South (odds ratio [OR]=1.42, p<.001) than in the West; among children with ADHD diagnoses, medication use was higher in the South (OR=1.60, p<.01) and the Midwest (OR=1.53, p<.01) versus the West. On these measures, several states differed from the U.S. averages, including some states that, on the basis of the regional patterns found above, would not be expected to differ: Michigan had a high diagnostic prevalence; Vermont, South Dakota, and Nebraska had low diagnostic prevalences; and Connecticut, New Jersey, and Kentucky had low medication rates. Both diagnosis and medication status were associated with the number, age, and type of physicians within a state, particularly pediatricians. However, state education policies were not significantly associated with either diagnostic prevalence or medication rates.Conclusions: To better understand the association between a state's health care provider characteristics and both diagnostic prevalence and medication use, it may be fruitful to examine the content of provider continuing education programs, including the recommendations of major health professional organization guidelines to treat ADHD. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Approximately 4.4 million (7.8%) children in the United States have been diagnosed with attention-deficit/hyperactivity disorder, and 56% of affected children take prescription medications to treat the disorder. Attention-deficit/hyperactivity disorder is strongly linked with low academic achievement, but the association between medication use and academic achievement in school settings is largely unknown. Our objective was to determine if reported medication use for attention-deficit/hyperactivity disorder is positively associated with academic achievement during elementary school. METHOD: To estimate the association between reported medication use and standardized mathematics and reading achievement scores for a US sample of 594 children with attention-deficit/hyperactivity disorder, we used 5 survey waves between kindergarten and fifth grade from the nationally representative Early Childhood Longitudinal Study--Kindergarten Class of 1998-1999 to estimate a first-differenced regression model, which controlled for time-invariant confounding variables. RESULTS: Medicated children had a mean mathematics score that was 2.9 points higher than the mean score of unmedicated peers with attention-deficit/hyperactivity disorder. Children who were medicated for a longer duration (at >2 waves) had a mean reading score that was 5.4 points higher than the mean score of unmedicated peers with attention-deficit/hyperactivity disorder. The medication-reading association was lower for children who had an individualized education program than for those without such educational accommodation. CONCLUSIONS: The finding of a positive association between medication use and standardized mathematics and reading test scores is important, given the high prevalence of attention-deficit/hyperactivity disorder and its association with low academic achievement. The 2.9-point mathematics and 5.4-point reading score differences are comparable with score gains of 0.19 and 0.29 school years, respectively, but these gains are insufficient to eliminate the test-score gap between children with attention-deficit/hyperactivity disorder and those without the disorder. Long-term trials are needed to better understand the relationship between medication use and academic achievement. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Global achievements in health may be limited by critical shortages of health-care workers. To help guide workforce policy, we estimate the future demand for, need for and supply of physicians, by WHO region, to determine where likely shortages will occur by 2015, the target date of the Millennium Development Goals. METHODS: Using World Bank and WHO data on physicians per capita from 1980 to 2001 for 158 countries, we employ two modelling approaches for estimating the future global requirement for physicians. A needs-based model determines the number of physicians per capita required to achieve 80% coverage of live births by a skilled health-care attendant. In contrast, our economic model identifies the number of physicians per capita that are likely to be demanded, given each country's economic growth. These estimates are compared to the future supply of physicians projected by extrapolating the historical rate of increase in physicians per capita for each country. FINDINGS: By 2015, the global supply of physicians appears to be in balance with projected economic demand. Because our measure of need reflects the minimum level of workforce density required to provide a basic health service that is met in all but the least developed countries, the needs-based estimates predict a global surplus of physicians. However, on a regional basis, both models predict shortages for many countries in the WHO African Region in 2015, with some countries experiencing a needs-based shortage, a demand-based shortage, or both. CONCLUSION: The type of policy intervention needed to alleviate projected shortages, such as increasing health-care training or adopting measures to discourage migration, depends on the type of shortage projected. [ABSTRACT FROM AUTHOR]

Social capital has been shown to be associated with reduced mortality due to cardiovascular disease. Our aim was to determine the association of time-varying community-level social capital (CSC) with recurrence of acute coronary syndrome using a retrospective cohort study design. A total of 34,752 men and women were identified, aged 30-85 years, who were hospitalized for acute coronary syndrome between January 1, 1998 and December 31, 2002 in Kaiser Permanente Northern California, USA, an integrated health care delivery system. The primary outcome was recurrent non-fatal or fatal acute coronary syndrome; median follow-up was 19 months. We estimated random-effects, three-level Cox proportional hazard models adjusting for sex, age, race/ethnicity, comorbidities, medication use, and revascularization procedures at level 1, median household income for the census block-group at level 2, and income inequality, racial/ethnic concentration, penetration of health maintenance organizations, and CSC at level 3. Our measure of CSC was the previously validated Petris Social Capital Index (PSCI). We found that a one-standard deviation increase in the PSCI, after adjusting for the above covariates, was significantly associated with decreased recurrence of acute coronary syndrome only for those living in areas where block-group level median household income was below the grand median compared to those living in areas where block-group level median household income was at the grand median or above. These results suggest that community-level social capital may be negatively associated with recurrence of acute coronary syndrome among lower-income individuals. [ABSTRACT FROM AUTHOR]

Objective: To determine if the market-determined earnings per hour of physicians is sensitive to the degree of area-level racial/ethnic concordance (ALREC) in the local physician labor market.Data Sources: 1998-1999 and 2000-2001 Community Tracking Study Physician Surveys and Household Surveys, 2000 U.S. Census, and the Area Resource File.Study Design: Population-averaged regression models with area-level fixed effects were used to estimate the determinants of log earnings per hour for physicians in a two-period panel (N=12,886). ALREC for a given racial/ethnic group is measured as the percentage of physicians who are of a given race/ethnicity less the percentage of the population who are of the corresponding race/ethnicity. Relevant control variables were included.Principal Findings: Average earnings per hour for Hispanic and Asian physicians varies with the degree of ALREC that corresponds to a physician's race/ethnicity. Both Hispanic and Asian physicians earn more per hour in areas where corresponding ALREC is negative, other things equal. ALREC varies from negative to positive for all groups. ALREC for Hispanics is negative, on average, due to the small percentage of the physician workforce that is Hispanic. This results in an average 5.6 percent earnings-per-hour premium for Hispanic physicians. However, ALREC for Asians is positive, on average, due to the large percentage of the physician workforce that is Asian. This results in an average 4.0 percent earnings-per-hour discount for Asian physicians. No similar statistically significant results were found for black physicians.Conclusions: The market-determined earnings per hour of Hispanic and Asian physicians are sensitive to the degree of ALREC in the local labor market. Larger sample sizes may be needed to find statistically significant results for black physicians. [ABSTRACT FROM AUTHOR]

A joint Wharton School--World Bank conference called attention to the high proportions of medical care spending paid out of pocket in most developing countries. One of the reasons for this, attendees said, is the problem in such economies of generating high tax revenues in a nondistortive way. Since people are paying out of pocket, they should be able to afford some private insurance that can spread the risk of above-average out-of-pocket payments. The potential efficiency gains from greater use of voluntary private insurance seem large, but there are a number of possible impediments to the emergence of such insurance. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of "cross-market" hospital mergers on prices and quality and the extent to which serial acquisitions contribute to any measured effects., Data Sources: 2009-2017 commercial claims from the Health Care Cost Institute (HCCI) and quality measures from Hospital Compare., Study Design: Event study models in which the treated group consisted of hospitals that acquired hospitals further than 50 miles, and the control group was hospitals that were not part of any merger activity (as a target or acquirer) during the study period., Data Extraction Methods: We extracted data for 214 treated hospitals and 955 control hospitals., Principal Findings: Six years after acquisition, cross-market hospital mergers had increased acquirer prices by 12.9% (CI: 0.6%-26.6%) relative to control hospitals, but had no discernible impact on mortality and readmission rates for heart failure, heart attacks and pneumonia. For serial acquirers, the price effect increased to 16.3% (CI: 4.8%-29.1%). For all acquisitions, the price effect was 21.8% (CI: 4.6%-41.7%) when the target's market share was greater than the acquirer's market share versus 9.7% (CI: -0.5% to 20.9%) when the opposite was true. The magnitude of the price effect was similar for out-of-state and in-state cross-market mergers., Conclusions: Additional evidence on the price and quality effects of cross-market mergers is needed at a time when over half of recent hospital mergers have been cross-market. To date, no hospital mergers have been challenged by the Federal Trade Commission on cross-market grounds. Our study is the third to find a positive price effect associated with cross-market mergers and the first to show no quality effect and how serial acquisitions contribute to the price effect. More research is needed to identify the mechanism behind the price effects we observe and analyze price effect heterogeneity., (© 2024 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Private equity (PE) firms have been acquiring physician practices at an increasing rate, raising concerns about such firms' penetration at the physician level into local markets and the impact on health care quality and prices. However, limited knowledge exists about the extent of PE firms' control in local markets. By linking data on PE acquisitions to physician data and using full-time-equivalent physicians as the base of assessment, we estimated the local market share of each PE firm within ten physician specialties at the Metropolitan Statistical Area (MSA) level. PE-acquired physician practice sites increased from 816 across 119 MSAs in 2012 to 5,779 across 307 MSAs in 2021. Single PE firms had significant market share, exceeding 30 percent in 108 MSA specialty markets and exceeding 50 percent in 50 of those markets. The findings raise concerns about competition and call for closer scrutiny by the Federal Trade Commission, state regulators, and policy makers.

The United States falls far short of its potential for delivering care that is effective, efficient, safe, timely, patient-centered, and equitable. We put forward the Better Care Plan, an overarching blueprint to address the flaws in our current system. The plan calls for continuously improving care, moving all payers to risk-adjusted prospective payment, and creating national entities for collecting, analyzing, and reporting patient safety and quality-of-care outcomes data. A number of recommendations are made to achieve these goals., Competing Interests: Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2023. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

Importance: Empirical evidence is needed on how a capitated, risk-based county plan performs as a viable public option in the Affordable Care Act (ACA) Marketplace in California., Objective: To estimate whether LA Care-a capitated, county-based public option and California's largest public insurer-was associated with health insurance premium growth in the Los Angeles (LA) regions of Covered California (CC), the ACA exchange in California., Design, Setting, and Participants: This economic evaluation used ACA silver plan premium data within the 19 CC regions. Difference-in-differences and event study models used data on plan-level premiums from Health Insurance Exchange Compare for years 2014 to 2022 to estimate the association between LA Care and ACA premium growth in LA., Exposures: The intervention was LA Care becoming the lowest-cost health plan on the ACA exchange in 2018. The treatment group included the East and West LA regions, and the control group included the remaining 17 CC regions., Main Outcomes and Measures: The main outcome variable was annual premium growth of plans on CC from 2014 to 2022., Results: Using 504 plan-level observations for 2014 to 2022, ACA premium growth in LA declined by 4.8% after LA Care became the lowest-cost health plan on the exchange in 2018 (coefficient estimate, -0.048; SE, 0.022; 95% CI, -0.093 to -0.002). Savings due to lower premium growth from 2019 to 2022 were calculated to be $345 million, with approximately 70% of the savings ($242 million) going to the federal government., Conclusions and Relevance: In this economic evaluation, LA Care was associated with lower premium growth of other health insurance plans in the LA regions of CC, with the majority of savings going to the federal government. California could have captured these savings if it had applied for and received a State Innovation Waiver under section 1332 of the ACA. LA Care may be a viable public option with the potential to be expanded across California through the state's 16 other county-based health plans.

Although hospital consolidation within markets has been well documented, consolidation across markets has not, even though economic theory predicts-and evidence is emerging-that cross-market hospital systems raise prices by exerting market power across markets when negotiating with common customers (primarily insurers). This study analyzes hospital systems using the American Hospital Association Annual Survey Database and defines hospital geographic markets as commuting zones that link workers to places of employment. The share of community hospitals in the US that were part of hospital systems increased from 10 percent in 1970 to 67 percent in 2019, resulting in 3,436 hospitals within 368 systems in 2019. Of these systems, 216 (59 percent) owned hospitals in multiple commuting zones, in part because 55 percent of the 1,500 hospitals targeted for a merger or acquisition between 2010 and 2019 were located in a different commuting zone than the acquirer. Based on market-power differences among hospitals in systems, the number of systems in urban commuting zones that could potentially exert enhanced cross-market power increased from thirty-seven systems in 2009 to fifty-seven systems in 2019, an increase of 54 percent. The increase in cross-market hospital systems warrants concern and scrutiny because of the potential anticompetitive impact of hospital systems exerting market power across markets in negotiations with common customers.

Context: Dramatic increases in pharmaceutical merger and acquisition (M&A) activity since 2010 suggest we are in the midst of a third wave of industry consolidation., Methods: The authors reviewed 168 economic, legal, medical, industry, and government sources to examine the effects of consolidation on competition and innovation and to explore how industry attributes complicate M&A regulation in a pharmaceutical context., Findings: The authors find that, in spite of certain metrics that might argue otherwise, consolidation consistently reduces innovation and harms the public good. They also find that several factors within the pharmaceutical industry impede proper evaluation of proposed mergers. Because consumer choice across substitutes is limited, pharmaceutical markets frustrate conventional methods of defining markets. Volume bargaining in the pharmaceutical supply chain and asset managers' common ownership of pharmaceutical firms further complicate the definitional process. Hence, the Herfindahl-Hirschman Index (HHI), one measure used by the Federal Trade Commission and the Department of Justice to screen for concerning M&A activity, sometimes depends on faulty market definitions and fails to capture the implications of consolidation for future market share., Conclusions: The authors describe ways to improve how pharmaceutical markets are defined, highlight quantitative alterations to HHI to account for common ownership, and propose areas requiring further research., (Copyright © 2022 by Duke University Press.)

Policy Points Looking for a way to curtail market power abuses in health care and rein in prices, 20 states have restricted most-favored-nation (MFN) clauses in some health care contracts. Little is known as to whether restrictions on MFN clauses slow health care price growth. Banning MFN clauses between insurers and hospitals in highly concentrated insurer markets seems to improve competition and lead to lower hospital prices., Context: Most-favored-nation (MFN) contract clauses have recently garnered attention from both Congress and state legislatures looking for ways to curtail market power abuses in health care and rein in prices. In health care, a typical MFN contract clause is stipulated by the insurer and requires a health care provider to grant the insurer the lowest (i.e., the most-favored) price among the insurers it contracts with. As of August 2020, 20 states restrict the use of MFN clauses in health care contracts (19 states ban their use in at least some health care contracts), with 8 states prohibiting their use between 2010 and 2016., Methods: Using event study and difference-in-differences research designs, we compared prices for a standardized hospital admission in states that banned MFN clauses between 2010 and 2016 with standardized hospital admission prices in states without MFN bans., Findings: Our results show that bans on MFN clauses reduced hospital price growth in metropolitan statistical areas (MSAs) with highly concentrated insurer markets. Specifically, we found that mean hospital prices in MSAs with highly concentrated insurer markets would have been $472 (2.8%) lower in 2016 had the MSAs been in states that banned MFN clauses in 2010. In 2016, the population in our sample that resided in MSAs with highly concentrated insurer markets was just under 75 million (23% of the US population). Hence, banning MFN clauses in all MSAs in our sample with highly concentrated insurer markets in 2010 would have generated savings on hospital expenditures in the range of $2.4 billion per year., Conclusions: Our empirical findings suggest banning MFN clauses between insurers and providers in highly concentrated insurer markets would improve competition and lead to lower prices and expenditures., (© 2022 Milbank Memorial Fund.)

States can challenge proposed hospital mergers by using antitrust laws to prevent anticompetitive harms. This observational study examined additional state laws-principally charitable trust, nonprofit corporation, health and safety, and certificate-of-need laws-that can serve as complements and substitutes for antitrust laws by empowering states to be notified of, review, and challenge proposed hospital mergers through administrative processes. During the period 2010-19, 862 hospital mergers were proposed, but only forty-two (4.9 percent) were challenged by states, including thirty-five by states without federal involvement, of which twenty-five (71.4 percent) originated in the eight states with the most robust merger review authority. The twenty-five challenges resulted in two mergers being blocked; three being abandoned; and twenty being approved with conditions, including seven with competitive-impact conditions. Hospital market concentration and prices increased at similar rates in these eight states versus other states, potentially because most challenges allowed mergers to proceed with conditions that did not adequately address competitive concerns. Although these findings do not reveal an optimal state framework, elements of advanced state merger review authority may have the potential to improve poorly functioning hospital markets.

This study assessed the relationship between hospital ownership of physician organizations (known as hospital-physician vertical integration) and facility fees billed to commercial insurers and physician service prices. Healthcare claims came from the IBM® MarketScan® Commercial Database (2012-2016, N = 30,716,800 office visit claims [CPT codes 99211-99215]), and hospital-physician vertical integration measures were from SK&A Office Based Physicians Database provided by IQVIA. Multi-variate, fixed-effect models were used to regress prices on market-level hospital-physician vertical integration; models included geographic market and year fixed effects, claim-level variables, and time-varying market-level variables. Analyses did not find that market-level hospital-physician vertical integration was associated with the billing of facility fees for office visits. However, vertical integration was associated with office visit physician prices for some specialties. A 10-percentage-point increase in vertical integration was associated with a 1.0% price increase for primary care, a 0.6% increase for orthopedics, and a 0.5% increase for cardiology; no such association was found for obstetrics/gynecology or oncology. When comparing metropolitan statistical areas (MSAs) in the bottom quartile of changes in vertical integration from 2012 to 2016 to MSAs in the top quartile, we found the following relative price increases based on predicted values for claims in the top quartile: $1.64 (1.9% of mean 2012 predicted price) for primary care to $2.30 (3.1%) for orthopedics to $3.13 (3.4%) for cardiology. Differences in predicted price accounted for an estimated $45.8 million in additional expenditure on primary care office visits in the top quartile of MSAs in 2016. In summary, market-level hospital-physician vertical integration was positively associated with physician prices for select specialties, but was not associated with changes in the use of facility-fee billing. More evidence on the quality effects of hospital-physician vertical integration is needed, as price increases that are not accompanied by measurable quality improvements should be part of any regulatory review.

There is little debate that the health workforce is a key component of the health care system. Since the training of doctors and nurses takes several years, and the building of new schools even longer, projections are needed to allow for the development of health workforce policies. Our work develops a projection model for the demand of doctors and nurses by Organisation for Economic Co-operation and Development (OECD) countries in the year 2030. The model is based on a country's demand for health services, which includes the following factors: per capita income, out-of-pocket health expenditures and the ageing of its population. The supply of doctors and nurses is projected using country-specific autoregressive integrated moving average models. Our work shows how dramatic imbalances in the number of doctors and nurses will be in OECD countries should current trends continue. For each country in the OECD with sufficient data, we report its demand, supply and shortage or surplus of doctors and nurses for 2030. We project a shortage of nearly 400,000 doctors across 32 OECD countries and shortage of nearly 2.5 million nurses across 23 OECD countries in 2030. We discuss the results and suggest policies that address the shortages.

California has heavily concentrated hospital, physician, and health insurance markets, but their current structure and functioning is not well understood. We assessed consolidation trends and performed an analysis of "hot spots"-markets that potentially warrant concern and scrutiny by regulators in terms of both horizontal concentration (such as hospital-hospital mergers) and vertical integration (hospitals' acquisition of physician practices). In 2016, seven counties were high on all six measures used in our hot-spot analysis (four horizontal concentration and two vertical integration measures), and five counties were high on five. The percentage of physicians in practices owned by a hospital increased from about 25 percent in 2010 to more than 40 percent in 2016. The estimated impact of the increase in vertical integration from 2013 to 2016 in highly concentrated hospital markets was found to be associated with a 12 percent increase in Marketplace premiums. For physician outpatient services, the increase in vertical integration was also associated with a 9 percent increase in specialist prices and a 5 percent increase in primary care prices. Legislative proposals, actions by the state's attorney general, and other regulatory changes are suggested.

Background: The High-Level Commission on Health Employment and Economic Growth released its report to the United Nations Secretary-General in September 2016. It makes important recommendations that are based on estimates of over 40 million new health sector jobs by 2030 in mostly high- and middle-income countries and a needs-based shortage of 18 million, mostly in low- and middle-income countries. This paper shows how these key findings were developed, the global policy dilemmas they raise, and relevant policy solutions., Methods: Regression analysis is used to produce estimates of health worker need, demand, and supply. Projections of health worker need, demand, and supply in 2030 are made under the assumption that historical trends continue into the future., Results: To deliver essential health services required for the universal health coverage target of the Sustainable Development Goal 3, there will be a need for almost 45 million health workers in 2013 which is projected to reach almost 53 million in 2030 (across 165 countries). This results in a needs-based shortage of almost 17 million in 2013. The demand-based results suggest a projected demand of 80 million health workers by 2030., Conclusions: Demand-based analysis shows that high- and middle-income countries will have the economic capacity to employ tens of millions additional health workers, but they could face shortages due to supply not keeping up with demand. By contrast, low-income countries will face both low demand for and supply of health workers. This means that even if countries are able to produce additional workers to meet the need threshold, they may not be able to employ and retain these workers without considerably higher economic growth, especially in the health sector.

Using prices of hospital admissions and visits to five types of physicians, we analyzed how provider and insurer market concentration-as measured by the Herfindahl-Hirschman Index (HHI)-interact and are correlated with prices. We found evidence that in the range of the Department of Justice's and Federal Trade Commission's definition of a moderately concentrated market (HHI of 1,500-2,500), insurers have the bargaining power to reduce provider prices in highly concentrated provider markets. In particular, hospital admission prices were 5 percent lower and cardiologist, radiologist, and hematologist/oncologist visit prices were 4 percent, 7 percent, and 19 percent lower, respectively, in markets with high provider concentration and insurer HHI above 2,000, compared to such markets with insurer HHI below 2,000. We did not find evidence that high insurer concentration reduced visit prices for primary care physicians or orthopedists, however. The policy dilemma that arises from our findings is that there are no insurer market mechanisms that will pass a portion of these price reductions on to consumers in the form of lower premiums. Large purchasers of health insurance such as state and federal governments, as well as the use of regulatory approaches, could provide a solution., (Project HOPE—The People-to-People Health Foundation, Inc.)

With the notable exception of California, states have not made enrollment data for their Affordable Care Act (ACA) Marketplace plans publicly available. Researchers thus have tracked premium trends by calculating changes in the average price for plans offered (a straight average across plans) rather than for plans purchased (a weighted average). Using publicly available enrollment data for Covered California, we found that the average purchased price for all plans was 11.6 percent less than the average offered price in 2014, 13.2 percent less in 2015, and 15.2 percent less in 2016. Premium growth measured by plans purchased was roughly 2 percentage points less than when measured by plans offered in 2014-15 and 2015-16. We observed shifts in consumer choices toward less costly plans, both between and within tiers, and we estimate that a $100 increase in a plan's net annual premium reduces its probability of selection. These findings suggest that the Marketplaces are helping consumers moderate premium cost growth., (Project HOPE—The People-to-People Health Foundation, Inc.)

Recent increases in market concentration among health plans, hospitals, and medical groups raise questions about what impact such mergers are having on costs to consumers. We examined the impact of market concentration on the growth of health insurance premiums between 2014 and 2015 in two Affordable Care Act state-based Marketplaces: Covered California and NY State of Health. We measured health plan, hospital, and medical group market concentration using the well-known Herfindahl-Hirschman Index (HHI) and used a multivariate regression model to relate these measures to premium growth. Both states exhibited a positive association between hospital concentration and premium growth and a positive (but not statistically significant) association between medical group concentration and premium growth. Our results for health plan concentration differed between the two states: It was positively associated with premium growth in New York but negatively associated with premium growth in California. The health plan concentration finding in Covered California may be the result of its selectively contracting with health plans., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Community-based palliative care can improve outcomes and avoid unnecessary spending, but the effects of its widespread adoption on health care spending in California is unknown., Objective: To estimate the spending avoided if, by 2022, more than 100,000 Californians received community-based palliative care (CBPC) per year., Design: We estimated the 6-month per-patient spending avoided through three mature CBPC programs in California and extrapolated data to predict the total avoided spending statewide over 8 years if enrollment in the three programs proceeded according to our model., Results: If Californians participated in CBPC in the numbers envisioned, in 2014 there would have been a $72 million reduction in intensive hospital based care, while still respecting patients' wishes, and nearly $1.1 billion in spending could be avoided in 2022. Overall hospital spending would be reduced by more than $5.5 billion through 2022., Conclusions: Existing CBPC programs have the potential to provide care that is both in alignment with patients' wishes and avoids substantial amounts of unnecessary hospital-based spending.

We explain the establishment of Covered California, California's health insurance marketplace. The marketplace uses an active purchaser model, which means that Covered California can selectively contract with some health plans and exclude others. During the 2014 open-enrollment period, it enrolled 1.3 million people, who are covered by eleven health plans. We describe the market shares of health plans in California and in each of the nineteen rating regions. We examine the empirical relationship between measures of provider market concentration--spanning health plans, hospitals, and medical groups--and rating region premiums. To do this, we analyze premiums for silver and bronze plans for specific age groups. We find both medical group concentration and hospital concentration to be positively associated with premiums, while health plan concentration is not statistically significant. We simulate the impact of reducing hospital concentration to levels that would exist in moderately competitive markets. This produces a predicted overall premium reduction of more than 2 percent. However, in three of the nineteen rating regions, the predicted premium reduction was more than 10 percent. These results suggest the importance of provider market concentration on premiums., (Copyright © 2016 by Duke University Press.)

Objective: The study's objective was to investigate whether attention-deficit hyperactivity disorder (ADHD) diagnoses from 2003 to 2011 were associated with either public school consequential accountability reforms initiated by the No Child Left Behind (NCLB) Act, particularly for low-income children, or with state psychotropic medication laws that prohibit public schools from recommending or requiring medication use., Methods: Logistic regression difference-in-differences models were estimated with repeated U.S. and state-representative cross-sections of responses to the 2003, 2007, and 2011 National Survey of Children's Health. Each wave included approximately 35,000 public school children between ages six and 13., Results: From 2003 to 2007, the change in adjusted diagnostic prevalence was 2.8 percentage points higher for children ages six to 13 in households with incomes ≤185% of the federal poverty level residing in states first exposed to consequential accountability through NCLB (from 8.5% to 13.2%), compared with demographically similar children residing in other states (from 10.2% to 12.1%). From 2003 to 2011, the change in adjusted diagnostic prevalence was 2.2 percentage points lower for children ages six to 13 residing in states with a psychotropic medication law (from 8.1% to 7.8%), compared with children residing in other states (from 8.1% to 10.1%)., Conclusions: NCLB-initiated consequential accountability reforms were associated with more ADHD diagnoses among low-income children, consistent with increased academic pressures from NCLB for this subgroup. In contrast, psychotropic medication laws were associated with fewer ADHD diagnoses, because they may indirectly reduce diagnoses via restrictions on recommending or requiring medication use. Future research should investigate whether children most affected by these policies are receiving appropriate diagnoses.

The Affordable Care Act (ACA) included financial and regulatory incentives and goals for states to bolster their health insurance rate review programs, increase their anticipated loss ratio requirements, expand Medicaid, and establish state-based exchanges. We grouped states by political party control and compared their reactions across these policy goals. To identify changes in states' rate review programs and anticipated loss ratio requirements in the individual and small group markets since the ACA's enactment, we conducted legal research and contacted each state's insurance regulator. We linked rate review program changes to the Centers for Medicare and Medicaid Services' (CMS) criteria for an effective rate review program. We found, of states that did not meet CMS's criteria when the ACA was enacted, most made changes to meet those criteria, including Republican-controlled states, which generally oppose the ACA. This finding is likely the result of the relatively low administrative burden associated with reviewing health insurance rates and the fact that doing so prevents federal intervention in rate review. However, Republican-controlled states were less likely than non-Republican-controlled states to increase their anticipated loss ratio requirements to align with the federal retrospective medical loss ratio requirement, expand Medicaid, and establish state-based exchanges, because of their general opposition to the ACA. We conclude that federal incentives for states to strengthen their health insurance rate review programs were more effective than the incentives for states to adopt other insurance-related policy goals of the ACA., (© The Author(s) 2015.)

States have varying degrees of review authority over health insurance carriers' rates, including prior approval authority over proposed rates and requirements for loss ratios, the proportion of premium revenues spent on medical claims. The Affordable Care Act (ACA) requires carriers in certain categories of health insurance to provide public justification for rate increases of 10 percent or more. We collected data on how states changed their rate review authority and requirements during 2010-13, the years immediately after enactment of the ACA, and we combined these data with carrier filings. We found that adjusted premiums in the individual market in states that had prior-approval authority combined with loss ratio requirements were lower in 2010-13 ($3,489) than premiums in states with no rate review authority or that had only file-and-use regulations, which gave the states no authority to block rate increases ($3,617). Adjusted premiums declined modestly in prior-approval states with loss ratio requirements, from $3,526 in 2010 to $3,452 in 2013, while premiums increased from $3,422 to $3,683 in states with no rate review authority or file-and-use regulations only. Our findings suggest that states with prior approval authority and loss ratio requirements constrained health insurance premium increases., (Project HOPE—The People-to-People Health Foundation, Inc.)

Will accountable care organizations (ACOs) deliver high-quality care at lower costs? Or will their potential market power lead to higher prices and lower quality? ACOs appear in various forms and structures with financial and clinical integration at their core; however, the tools to assess their quality and the incentive structures that will determine their success are still evolving. Both market forces and regulatory structures will determine how these outcomes emerge. This introduction reviews the evidence presented in this special issue to tackle this thorny trade-off. In general the evidence is promising, but the full potential of ACOs to improve the health care delivery system is still uncertain. This introductory review concludes that the current consensus is to let ACOs grow, anticipating that they will make a contribution to improve our poor-quality and high-cost delivery system., (Copyright © 2015 by Duke University Press.)

Accountable care organizations (ACOs) result in physician organizations' and hospitals' receiving risk-based payments tied to costs, health care quality, and patient outcomes. This article (1) describes California ACOs within Medicare, the commercial market, and Medi-Cal and the safety net; (2) discusses how ACOs are regulated by the California Department of Managed Health Care and the California Department of Insurance; and (3) analyzes the increase of ACOs in California using data from Cattaneo and Stroud. While ACOs in California are well established within Medicare and the commercial market, they are still emerging within Medi-Cal and the safety net. Notwithstanding, the state has not enacted a law or issued a regulation specific to ACOs; they are regulated under existing statutes and regulations. From August 2012 to February 2014, the number of lives covered by ACOs increased from 514,100 to 915,285, representing 2.4 percent of California's population, including 10.6 percent of California's Medicare fee-for-service beneficiaries and 2.3 percent of California's commercially insured lives. By emphasizing health care quality and patient outcomes, ACOs have the potential to build and improve on California's delegated model. If recent trends continue, ACOs will have a greater influence on health care delivery and financial risk sharing in California., (Copyright © 2015 by Duke University Press.)

Accountable care organizations (ACOs) have proliferated under the Affordable Care Act (ACA). If ACOs are to improve health care quality and lower costs, quality measures will be increasingly important in determining if provider consolidations associated with the development of ACOs are achieving their intended purpose. This article assesses quality measurement across public and private sectors. We reviewed available quality measures for a subset of programs in six organizations and assessed the number and domain of measures (structure, process, outcomes, and patient experience). Two-thirds of all quality measures were categorized as process measures. Outcome measures made up nearly 20 percent of measures. Patient experience and structure measures made up approximately 8 percent and 7 percent, respectively. We propose further improvements to quality measurement initiatives. For example, programs that reward providers should consider reward size and distribution within the organization. Quality improvement initiatives should consider what encourages provider buy-in and participation and the effects on populations with disproportionate health care needs. As the focus of quality initiatives may change from year to year, measures should be periodically revisited to ensure continued improvement and sustainability. Finally, we suggest quality measures that regulators could use prior to ACO formation or in the year or two following formation., (Copyright © 2015 by Duke University Press.)

Accountable care organizations (ACOs), one of the most recent and promising health care delivery innovations, encourage care coordination among providers. While ACOs hold promise for decreasing costs by reducing unnecessary procedures, improving resource use as a result of economies of scale and scope, ACOs also raise concerns about provider market power. This study examines the market-level competition factors that are associated with ACO participation and the number of ACOs. Using data from California, we find that higher levels of preexisting managed care leads to higher ACO entry and enrollment growth, while hospital concentration leads to fewer ACOs and lower enrollment. We find interesting results for physician market power - markets with concentrated physician markets have a smaller share of individuals in commercial ACOs but a larger number of commercial ACO organizations. This finding implies smaller ACOs in these markets., (Copyright © 2015 by Duke University Press.)

Background: Progress toward universal health coverage in many low- and middle-income countries is hindered by the lack of an adequate health workforce that can deliver quality services accessible to the entire population., Methods: We used a health labour market framework to investigate the key indicators of the dynamics of the health labour market in Cameroon, Kenya, Sudan, and Zambia, and identified the main policies implemented in these countries in the past ten years to address shortages and maldistribution of health workers., Results: Despite increased availability of health workers in the four countries, major shortages and maldistribution persist. Several factors aggravate these problems, including migration, an aging workforce, and imbalances in skill mix composition., Conclusions: In this paper, we provide new evidence to inform decision-making for health workforce planning and analysis in low- and middle-income countries. Partial health workforce policies are not sufficient to address these issues. It is crucial to perform a comprehensive analysis in order to understand the dynamics of the health labour market and develop effective polices to address health workforce shortages and maldistribution as part of efforts to attain universal health coverage.

This study evaluates the impact of California's full-service partnership (FSP) program using a multidimensional measure of outcomes. The FSP program is a key part of California's 2005 Mental Health Services Act. Secondary data were collected from the Consumer Perception Survey, the Client and Service Information System, and the Data Collection and Reporting System, all data systems which are maintained by the California Department of Mental Health. The analytic sample contained 39,681 observations of which 588 were FSP participants (seven repeated cross-sections from May 2005 to May 2008). We performed instrumental variables (IV) limited information maximum likelihood and IV Tobit analyses. The marginal monthly improvement in outcomes of services for FSP participants was approximately 3.5 % higher than those receiving usual care with the outcomes of the average individual in the program improving by 33.4 %. This shows that the FSP program is causally effective in improving outcomes among the seriously mentally ill.

Purpose: Although much literature reports small-area variation in medication prescriptions used to treat attention-deficit hyperactivity disorder (ADHD), scant research has examined factors that may drive this variation. We examine, across counties in the USA, whether the use of prescription medications to treat ADHD varies positively with supply-side healthcare characteristics., Methods: We retrieved annual prescription data for ADHD medications in 2734 US counties from a nationally representative sample of 35 000 pharmacies in 2001-2003. We used a county-level, multivariable fixed effects analysis to estimate the relation between annual changes in healthcare supply and ADHD medication prescriptions. Methods controlled for time-invariant factors unique to each county as well as ADHD prevalence., Results: From 2001 to 2003, retail prescription purchases for ADHD medications increased 33.2%. In the multivariable analysis, ADHD medication prescriptions move positively with an increase in the concentration of total physicians. In addition, ADHD medication prescriptions move inversely with changes in the percentage of non-Hispanic Black population., Conclusions: Supply-side healthcare factors may contribute to the rise from 2001 to 2003 in ADHD medication prescriptions. This finding warrants attention because it implies that the relative capacity of the healthcare system may influence population prescription rates. We encourage further exploration of the contribution of the supply-side of the healthcare market to secular changes in ADHD medication prescriptions., (Copyright © 2011 John Wiley & Sons, Ltd.)

The potential link between social capital and health suggests important pathways by which health may be improved. We examine this relationship using a unique data set from Argentina. This national survey allows us to determine whether the relationships between social capital and health that have been found in the US and Europe also apply to countries in South America (Argentina is the second-largest country in South America with a population of approximately 40 million). We estimate a causal effect of individual-level social capital on health using a measure of informal social interactions as our measure of social capital. Using information about access to public transportation as instrumental variables, we find that both men and women with higher levels of social capital report better health., (Copyright © 2010 John Wiley & Sons, Ltd.)

Objective: To estimate the shortage of mental health professionals in low- and middle-income countries (LMICs)., Methods: We used data from the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) from 58 LMICs, country-specific information on the burden of various mental disorders and a hypothetical core service delivery package to estimate how many psychiatrists, nurses and psychosocial care providers would be needed to provide mental health care to the total population of the countries studied. We focused on the following eight problems, to which WHO has attached priority: depression, schizophrenia, psychoses other than schizophrenia, suicide, epilepsy, dementia, disorders related to the use of alcohol and illicit drugs, and paediatric mental disorders., Findings: All low-income countries and 59% of the middle-income countries in our sample were found to have far fewer professionals than they need to deliver a core set of mental health interventions. The 58 LMICs sampled would need to increase their total mental health workforce by 239,000 full-time equivalent professionals to address the current shortage., Conclusion: Country-specific policies are needed to overcome the large shortage of mental health-care staff and services throughout LMICs.

Background: Health workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda., Methods: Studies primarily from low-income countries published between 2006 and September 2010 were found using Google Scholar and PubMed. Keywords included terms such as skill mix, task shifting, assistant medical officer, assistant clinical officer, assistant nurse, assistant pharmacist, and community health worker. Thirty-one studies were selected to analyze, based on the strength of evidence., Results: First, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynaecologists. Second, although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV/AIDS in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadre's results to the results from the care that would have been provided--if any care at all--had task shifting not occurred., Conclusions: Task shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.

Objective: The purpose of this paper was to examine the patterns of spending, price, and the utilization of ADHD medications during the 10-year period, from 1994 to 2003 among 4 different per capita GDP group countries., Methods: This study used the IMS Health database and included both branded and generic ADHD medications. We examined the changes in quantity and price as well as the mixed effects of these changes in the U.S.A. and 3 other groups of countries classified according to their level of per capita GDP., Results: During this study (1994-2003), the U.S. expenditures for ADHD medications increased 594%; sales volume rose by 80%; and price increased by 285%. In other high GDP countries, expenditures increased 493%, sales volume 328%, and price increased by 39%. In the middle GDP countries, expenditures increased 164%, sales volume 141%, and price increased by 9%. In the countries with a lower per capita GDP, expenditures increased 149%, sales volume 464%, however price decreased by 37%., Conclusions: The launch of long-acting ADHD medications has dramatically increased the total medication expenditure in the U.S. as well as in other high GDP markets. In the other countries quantity was the most important growth factor.

We performed a pilot study examining the patterns of recovery from severe mental illness in a model integrated service delivery system using measures from the Milestones of Recovery Scale (MORS), a valid and reliable measure of recovery outcomes which ranges from 1 to 8 (8 levels). For purposes of presentation, we constructed an aggregate MORS (6 levels) where the levels are described as follows: (1) extreme risk; (2) unengaged, poorly self-coordinating; (3) engaged, poorly self-coordinating; (4) coping and rehabilitating; (5) early recovery, and (6) self reliant. We analyzed MORS data on individuals followed over time from The Village in Long Beach, California (658 observations). Using Markov Chains, we estimated origin-destination transition probabilities, simulating recovery outcomes for 100 months. Our models suggest that after 12 months only 8% of "extreme risk" clients remain such. Over 40% have moved to "engaged, poorly self-coordinating." After 2 years, almost half of the initial "extreme Risk" clients are "coping/rehabilitating", "early recovery" or "Self reliant." Most gains occur within 2 years.

This paper uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals. We forecast that thirty-one countries will experience needs-based shortages of doctors, nurses, and midwives, totaling approximately 800,000 health professionals. We estimate the additional annual wage bill required to eliminate the shortage at about $2.6 billion (2007 $US)-more than 2.5 times current wage-bill projections for 2015. We illustrate how changes in workforce mix can reduce this cost, and we discuss policy implications of our results.

Objective: To determine whether variation in the representation of minority physicians across geographical areas in California affects the location decisions of minority physicians., Data Sources: We analyzed data on 9,806 residents and 53,606 patient-care physicians from the 1997-2003 American Medical Association Masterfiles for California along with data from the California Department of Finance, RAND, and other sources., Study Design: We estimated departure models using linear probability models and destination models using conditional logit. Each model controlled for physician and county characteristics. Parameters of interest include the interactions of physician race/ethnicity with area-level minority physician representation for the corresponding race/ethnicity., Principal Findings: Departure models show that black and Hispanic physicians are more likely to remain in an area as the level of representation of physicians from their respective groups worsens. The destination models show that black, Asian, and Hispanic physicians tend to move to areas where the level of representation is similar to that of their previous location., Conclusions: Black and Hispanic physicians are influenced by the level of representation of physicians from their respective groups in their location decisions and tend to locate where needed.

In introducing this Special Issue on Social Capital and Health, this article tracks the popularization of the term and sheds light on the controversy surrounding the term and its definitions. It sets out four mechanisms that link social capital with health: making information available to community members, impacting social norms, enhancing the health care services and their accessibility in a community, and offering psychosocial support networks. Approaches to the measurement of social capital include the Social Capital Community Benchmark Survey (SCCBS) developed by Robert Putnam, and the Petris Social Capital Index (PSCI), which looks at community voluntary organizations using public data available for the entire United States. The article defines community social capital (CSC) as the extent and density of trust, cooperation, and associational links and activity within a given population. Four articles on CSC are introduced in two categories: those that address behaviors -- particularly utilization of health services and use of tobacco, alcohol, and drugs; and those that look at links between social capital and physical or mental health. Policy implications include: funding and/or tax subsidies that would support the creation of social capital; laws and regulations; and generation of enthusiasm among communities and leaders to develop social capital. The next steps in the research programme are to continue testing the mechanisms; to look for natural experiments; and to find better public policies to foster social capital.

The objective of this paper is to describe the market structure of health plans (HPs) and physician organizations (POs) in California, a state with high levels of managed care penetration and selective contracting. First we calculate Herfindahl-Hirschman (HHI) concentration indices for HPs and POs in 42 California counties. We then estimate a multivariable regression model to examine the relationship between concentration measures and the prices paid by HPs to POs. Price data is from Medstat MarketScan databases. The findings show that any California counties exhibit what the Department of Justice would consider high HHI concentration measures, in excess of 1,800. More than three quarters of California counties exhibit HP concentration indices over 1,800, and 83% of counties have PO concentration levels in excess of 1,800. Half of the study counties exhibited PO concentration levels in excess of 3,600, compared to only 24% for plans. Multivariate price models suggest that PO concentration is associated with higher physician prices (p < or = 0.05), whereas HP concentration does not appear to be significantly associated with higher outpatient commercial payer prices.

This paper examines the relationship between area-level social capital and non-specific psychological distress. It demonstrates that not controlling for non-time-varying omitted variables can seriously bias research findings. We use data from three cross-sections of the US National Health Interview Survey (1999, 2000, and 2001): 37,172 observations nested within 58 Metropolitan Statistical Areas. We also add data from the Area Resource File and County Business Patterns. We use a validated measure of social capital, the Petris Social Capital Index (PSCI), which measures structural social capital. We estimate a two-level multilevel linear model with a random intercept. Non-specific psychological distress is measured using a valid and reliable indicator, the K6. Individual-level variables include sex, age, race/ethnicity, marital status, education, family income, smoking status, exercise status, and number of visits to a health professional. Area-level covariates include the PSCI, the unemployment rate, psychiatrists per 1000 population, non-psychiatric physicians per 1000 population, and area-level indicators to account for non-time-varying area-level omitted variable bias. Time dummies are also included. We find that lagged area-level social capital is negatively related to non-specific psychological distress among individuals whose family income is less than the median. These associations are much larger when we control for non-time-varying area-level omitted variables.

Little is known about the global use and cost of medications for attention deficit hyperactivity disorder (ADHD). Global use of ADHD medications rose threefold from 1993 through 2003, whereas global spending (2.4 billion US dollars in 2003) rose ninefold, adjusting for inflation. Per capita gross domestic product (GDP) robustly predicted use across countries, but the United States, Canada, and Australia showed significantly higher-than-predicted use. Use and spending grew in both developed and developing countries, but spending growth was concentrated in developed countries, which adopted more costly, long-acting formulations. Promoting optimal prescription and monitoring should be a priority.