Changes in regional variation of Medicare home health care utilization and service mix for patients undergoing major orthopedic procedures in response to changes in reimbursement policy

BACKGROUND

Significant variation in regional utilization of home health (HH) services has been documented. Under Medicare's Home Health Interim and Prospective Payment Systems, reimbursement policies designed to curb expenditure growth and reduce regional variation were instituted.

OBJECTIVE

To examine the impact of Medicare reimbursement policy on regional variation in HH care utilization and type of HH services delivered.

RESEARCH DESIGN

We postulated that the reimbursement changes would reduce regional variation in HH services and that HH agencies would respond by reducing less skilled HH aide visits disproportionately compared with physical therapy or nursing visits. An interrupted time-series analysis was conducted to examine regional variation in the month-to-month probability of HH selection, and the number of and type of visits among HH users.

SUBJECTS

A 100 percent sample of all Medicare recipients undergoing either elective joint replacement (1.6 million hospital discharges) or surgical management of hip fracture (1.2 million hospital discharges) between January 1996 and December 2001 was selected.

RESULTS

Before the reimbursement changes, there was great variability in the probability of HH selection and the number of HH visits provided across regions. In response to the reimbursement changes, though there was little change in the variation of probability of HH utilization, there were marked reductions in the number and variation of HH visits, with greatest reductions in regions with highest baseline utilization. HH aide visits were the source of the baseline variation and accounted for the majority of the reductions in utilization after implementation.

CONCLUSIONS

The HH interim and prospective payment policies were effective in reducing regional variation in HH utilization.

Investing time in health: do socioeconomically disadvantaged patients spend more or less extra time on diabetes self-care?

BACKGROUND

Research on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time.

OBJECTIVE

To examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes.

DATA

Eleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001.

METHODS

Bayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics.

RESULTS

Proportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day.

DISCUSSION

Extra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.

A cost analysis of San Diego County's REACH program for homeless persons

OBJECTIVE

This study examined mental health service utilization and costs associated with the California Assembly Bill 2034 housing-first program for homeless persons in San Diego County: Reaching Out and Engaging to Achieve Consumer Health (REACH).

METHODS

Encounter data were used to identify REACH clients and a control group that was matched by propensity score. Mental health services costs for case management, outpatient services, inpatient and emergency services, criminal justice system services, and total services were summarized for two-year periods before and after clients initiated REACH. Incremental costs of the program were calculated as the difference in cost among clients in the REACH group, from pre- to postintervention, less the difference in cost among those in the control group from pre- to postintervention.

RESULTS

A total of 177 REACH clients and 161 clients in a control group matched by propensity score were identified. Among REACH participants, case management costs increased by $6,403 (p<.001) from pre- to postintervention, inpatient plus emergency services costs declined by $6,103 (p=.034), and costs for mental health services provided by the criminal justice system declined by $570 (p=.020) compared with the control group. The standardized difference-in-difference estimate of the total costs between REACH clients and the control group was not significant.

CONCLUSIONS

Participation in REACH was associated with substantial increases in outpatient services as well as cost offsets in inpatient and emergency services and criminal justice system services. The net cost of services, $417 over two years, was substantially lower than the total cost of services ($20,241).

The contribution of cancer incidence, stage at diagnosis and survival to racial differences in years of life expectancy

BACKGROUND

African Americans have higher cancer mortality rates than whites. Understanding the relative contribution of cancer incidence, stage at diagnosis and survival after diagnosis to the racial gap in life expectancy has important implications for directing future health disparity interventions toward cancer prevention, screening and treatment.

OBJECTIVE

We estimated the degree to which higher cancer mortality among African Americans is due to higher incidence rates, later stage at diagnosis or worse survival after diagnosis.

DESIGN

Stochastic model of cancer incidence and survival after diagnosis.

PATIENTS

Surveillance and Epidemiology End Result cancer registry and National Health Interview Survey data.

MEASUREMENTS

Life expectancy if African Americans had the same cancer incidence, stage and survival after diagnosis as white adults.

RESULTS

African-American men and women live 1.47 and 0.91 fewer years, respectively, than whites as the result of all cancers combined. Among men, racial differences in cancer incidence, stage at diagnosis and survival after diagnosis account for 1.12 (95% CI: 0.52 to 1.36), 0.17 (95% CI: -0.03 to 0.33) and 0.21 (95% CI: 0.05 to 0.34) years of the racial gap in life expectancy, respectively. Among women, incidence, stage and survival after diagnosis account for 0.41 (95% CI: -0.29 to 0.60), 0.26 (95% CI: -0.06 to 0.40) and 0.31 (95% CI: 0.05 to 0.40) years, respectively. Differences in stage had a smaller impact on the life expectancy gap compared with the impact of incidence. Differences in cancer survival after diagnosis had a significant impact for only two cancers-breast (0.14 years; 95% CI: 0.05 to 0.16) and prostate (0.05 years; 95% CI 0.01 to 0.09).

CONCLUSIONS

In addition to breast and colorectal cancer screening, national efforts to reduce disparities in life expectancy should also target cancer prevention, perhaps through smoking cessation, and differences in survival after diagnosis among persons with breast and prostate cancer.

Medicare Part D coverage gap and diabetes beneficiaries

OBJECTIVE

To examine drug costs and entry and exit rates into the Part D coverage gap for beneficiaries with diabetes in Medicare Advantage managed care plans.

STUDY DESIGN

Cross-sectional observational study.

METHODS

Study patients were Medicare Advantage Part D beneficiaries with diabetes from 2 large California health plans who were continuously enrolled in 2006 and had a drug coverage gap starting at $2250. Entry and exit into the gap, total drug costs, and out-of-pocket drug costs were determined using pharmacy databases.

RESULTS

In 2006, 26% of the 42,801 beneficiaries with diabetes reached the coverage gap; 2% of beneficiaries exited the gap and qualified for catastrophic coverage. Beneficiaries incurred a mean of $2182 in total drug costs during 2006. Drug expenditures remained stable over the year for beneficiaries who did not enter the gap. For beneficiaries who entered the gap, total drug costs were higher overall and decreased at year's end as out-of-pocket expenses increased.

CONCLUSIONS

Fewer diabetes patients in this study entered the coverage gap than had been previously estimated, but the entry rate was much higher than that of the general Medicare Advantage Part D population. Patients entering the gap had lower subsequent monthly drug expenditures; this may be due to lower-than-expected drug prices and greater use of generics in managed care, or it may potentially signal poorer drug adherence. Future work should examine these hypotheses and explore risk factors for entering the Part D coverage gap.

Cost-effectiveness analysis of integrated care for people with HIV, chronic mental illness and substance abuse disorders

BACKGROUND

Triply diagnosed patients, who live with HIV and diagnosed mental health and substance abuse disorders, account for at least 13% of all HIV patients. This vulnerable population has substantial gaps in their care, attributable in part to the need for treatment for three illnesses from three types of providers.

AIMS OF THE STUDY

The HIV/AIDS Treatment Adherence, Health Outcomes and Cost study (HIV Cost Study) sought to evaluate the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services among triply diagnosed patients. The analysis was conducted from a health sector budget perspective.

METHODS

Patients from four sites were randomly assigned to intervention group (n=232) or control group (n=199) that received care-as-usual. Health service costs were measured at baseline and three, six, nine and 12 months and included hospital stays, emergency room visits, outpatient visits, residential treatment, formal long-term care, case management, and both prescribed and over-the-counter medications. Costs for each service were the product of self-reported data on utilization and unit costs based on national data (2002 dollars). Quality of life was measured at baseline and six and 12 months using the SF-6D, as well as the SF-36 physical composite score (PCS) and mental composite score (MCS).

RESULTS

During the 12 months of the trial, total average monthly cost of health services for the intervention group decreased from USD 3235 to USD 3052 and for the control group decreased from USD 3556 to USD 3271, but the decreases were not significant. For both groups, the percentage attributable to hospital care decreased significantly. There were no significant differences in annual cost of health services, SF-6D, PCS or MCS between the intervention and control group.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

The results of this randomized controlled trial did not demonstrate that the integrated interventions significantly affected the health service costs or quality of life of triply diagnosed patients. Professionals could pursue coordination or integration of care guided by the evidence that it does not increase the cost of care. The results do not however, provide an imperative to introduce multi-disciplinary care teams, adherence counseling, or personalized nursing services as implemented in this study.

IMPLICATIONS FOR HEALTH POLICIES

There is not enough evidence to either limit continued exploration of integration of care for triply diagnosed patients or adopt policies to encourage it, such as financial reimbursement, grants regulation or licensing.

IMPLICATIONS FOR FURTHER RESEARCH

Future trials with interventions with lower baseline levels of integration, longer duration and larger sample sizes may show improvement or slow the decline in quality of life. Future researchers should collect comprehensive cost data, because significant decreases in the cost of hospital care did not necessarily lead to significant decreases in the total cost of health services.

Are rural hospices at a financial disadvantage? Evidence from California

Concerns have been voiced about financial pressures faced by rural hospices, because of possible implications for hospice access in rural areas. To assess whether financial performance differs between existing urban and rural hospices, we used the 2003 California Office of Statewide Health Planning and Development survey to compare revenues, costs, and profitability (with and without charitable donations). We adjusted for factors related to financial performance, including agency size, years in operation, profit status, whether hospices were freestanding or chain-, home-health-, or hospital-based, and the proportion of patients by insurance type and referral source, race/ethnicity, and diagnosis. One hundred forty-four (91%) hospices were urban, and 14 (9%) were rural. Mean values per patient for total revenue, total cost, and post-tax profit were $7203, $7440 and -$256, respectively, for urban hospices and $6726, $6274 and $452, respectively, for rural hospices. Compared with urban hospices, rural hospices were at least as profitable per patient-day (+$33, P=0.15). They were significantly more profitable (+$47, P=0.05) when charitable donations were excluded. In summary, we found that in California, rural hospices fared no worse financially than urban hospices. These counterintuitive findings underscore the need to examine urban-rural hospice financial differences using a national sample.

Physician perception of reimbursement for outpatient procedures among managed care patients with diabetes mellitus

OBJECTIVE

To examine the association between physicians' reimbursement perceptions and outpatient test performance among patients with diabetes mellitus.

STUDY DESIGN

Cross-sectional analysis.

METHODS

Participants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiography, radiography or x-ray films, urine microalbumin levels, glycosylated hemoglobin levels, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician-level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for health plan as a fixed effect. Therefore, we estimated variation between physicians using only the variance within health plans.

RESULTS

Patients of physicians who reported reimbursement for electrocardiography were more likely to undergo electrocardiography than patients of physicians who did not perceive reimbursement (unadjusted mean difference, 4.9%; 95% confidence interval, 1.1%-8.9%; and adjusted mean difference, 3.9%; 95% confidence interval, 0.2%-7.8%). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement.

CONCLUSIONS

Reimbursement perception was associated with electrocardiography but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and their interactions with other influences on test-ordering behavior such as perceived appropriateness.

Paying the price at the end of life: a consideration of factors that affect the profitability of hospice

OBJECTIVE

To evaluate factors that affect the financial performance of hospice.

METHODS

Using the California Office of Statewide Health Planning and Development 2003 survey, we evaluated the organizational attributes, clinical care, and financial performance of 185 operational hospices. As outcomes, we evaluated revenues, costs, and profits per patient and per patient-day, the intensity and skill mix of care, and the provision of charitable and special palliative services. We evaluated regression-adjusted differences by profit status controlling for other organizational features and aggregate patient characteristics.

RESULTS

Hospices reported median revenue of $6865 per patient and $138 per patient-day (for-profit-not-for profit [FP-NFP] difference -$20, p = 0.045), median cost of $6737 per patient, and $135 per patient-day (FP-NFP difference -$55, p = 0.002), and median pretax profit of $334 per patient and $6 per patient-day (FP-NFP difference $34, p = 0.026). Patients received a median of 29.9 total visits by all providers per patient (FP-NFP difference 8.8 visits, p = 0.010), but there was no difference in total visits per patient-day. A median of 50.8% of all nursing visits were registered nurse (RN) visits (FP-NFP difference -14.1%, p < 0.001). Few hospices provided charity care, and only 4% of hospices reported expenditures on chemotherapy and only 9% on radiation therapy.

CONCLUSIONS

Overall hospice profitability is low. Length of stay is strongly associated with financial performance, and greater FP profitability is related to lower costs. FP hospices also provide less RN care as a proportion of nursing care. Few hospices provide charitable care or special costly services. The relationship of service patterns to patient quality needs to be examined.

Economic benefits of intensive insulin therapy in critically Ill patients: the targeted insulin therapy to improve hospital outcomes (TRIUMPH) project

OBJECTIVE

The purpose of this study was to analyze the economic outcomes of a clinical program implemented to achieve strict glycemic control with intensive insulin therapy in patients admitted to the intensive care unit (ICU).

RESEARCH DESIGN AND METHODS

A difference-in-differences (quasi-experimental) study design was used to examine the associations of an intensive insulin therapy intervention with changes in hospital length of stay (ICU and total), costs (ICU and total), and mortality. Hospital administrative data were obtained for 6,719 adult patients admitted between 2003 and 2005 to one of five intervention or four comparison ICUs in a large academic medical center. Linear regression models with log transformations and appropriate retransformations were used to estimate length of stay (LOS) and costs; logistic regressions were used to estimate mortality.

RESULTS

After adjustment for observable patient characteristics and secular time trends, the intervention was consistently associated with lower average glucose levels and a trend toward shorter LOS, lower costs, and lower mortality. However, associations with resource use and outcomes were statistically significant in only ICU LOS, with an average reduction of 1.19 days of ICU care per admission. Other associations, although large in magnitude and in the hypothesized directions, were not estimated with sufficient precision to rule out other net effects. The associations with ICU days and costs were larger in magnitude than total days and costs.

CONCLUSIONS

A clinical team focused on hyperglycemia management for ICU patients can be a valuable investment with significant economic benefits for hospitals.

Prescription drug coverage and effects on drug expenditures among elderly Medicare beneficiaries

OBJECTIVE

To identify determinants of drug coverage among elderly Medicare beneficiaries and to investigate the impact of drug coverage on drug expenditures with and without taking selection bias into account.

DATA SOURCES/STUDY SETTING

The primary data were from the 2000 Medicare Current Beneficiary Survey (MCBS) Cost and Use file, linked to other data sources at the county or state-level that provided instrumental variables. Community-dwelling elderly Medicare beneficiaries who completed the survey were included in the study (N=7,525). A probit regression to predict the probability of having drug coverage and the effects of drug coverage on drug expenditures was estimated by a two-part model, assuming no correlation across equations. In addition, the discrete factor model estimated choice of drug coverage and expenditures for prescription drugs simultaneously to control for self-selection into drug coverage, allowing for correlation of error terms across equations.

PRINCIPAL FINDINGS

Findings indicated that unobservable characteristics leading elderly Medicare beneficiaries to purchase drug coverage also lead them to have higher drug expenditures on conditional use (i.e., adverse selection), while the same unobservable factors do not influence their decisions whether to use any drugs. After controlling for potential selection bias, the probability of any drug use among persons with drug coverage use was 4.5 percent higher than among those without, and drug coverage led to an increase in drug expenditures of $308 among those who used prescription drugs.

CONCLUSIONS

Given significant adverse selection into drug coverage before the implementation of the Medicare Prescription Drug Improvement and Modernization Act, it is essential that selection effects be monitored as beneficiaries choose whether or not to enroll in this voluntary program.

Drinkers and bettors: investigating the complementarity of alcohol consumption and problem gambling

Regulated gambling is a multi-billion dollar industry in the United States with greater than 100% increases in revenue over the past decade. Along with this rise in gambling popularity and gaming options comes an increased risk of addiction and the associated social costs. This paper focuses on the effect of alcohol use on gambling-related problems. Variables correlated with both alcohol use and gambling may be difficult to observe, and the inability to include these items in empirical models may bias coefficient estimates. After addressing the endogeneity of alcohol use when appropriate, we find strong evidence that problematic gambling and alcohol consumption are complementary activities.

Use of VA and Medicare services by dually eligible veterans with psychiatric problems

OBJECTIVE

To examine how service accessibility measured by geographic distance affects service sector choices for veterans who are dually eligible for veterans affairs (VA) and Medicare services and who are diagnosed with mental health and/or substance abuse (MH/SA) disorders.

DATA SOURCES

Primary VA data sources were the Patient Treatment (acute care), Extended Care (long-term care), and Outpatient Clinic files. VA cost data were obtained from (1) inpatient and outpatient cost files developed by the VA Health Economics and Resource Center and (2) outpatient VA Decision Support System files. Medicare data sources were the denominator, Medicare Provider Analysis Review (MEDPAR), Provider-of-Service, Outpatient Standard Analytic and Physician/Supplier Standard Analytic files. Additional sources included the Area Resource File and Census Bureau data.

STUDY DESIGN

We identified dually eligible veterans who had either an inpatient or outpatient MH/SA diagnosis in the VA system during fiscal year (FY)'99. We then estimated one- and two-part regression models to explain the effects of geographic distance on both VA and Medicare total and MH/SA costs.

PRINCIPAL FINDINGS

Results provide evidence for substitution between the VA and Medicare, demonstrating that poorer geographic access to VA inpatient and outpatient clinics decreased VA expenditures but increased Medicare expenditures, while poorer access to Medicare-certified general and psychiatric hospitals decreased Medicare expenditures but increased VA expenditures.

CONCLUSIONS

As geographic distance to VA medical facility increases, Medicare plays an increasingly important role in providing mental health services to veterans.

Perception of neighborhood problems, health behaviors, and diabetes outcomes among adults with diabetes in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE

Recent data suggest that residential environment may influence health behaviors and outcomes. We assessed whether perception of neighborhood problems was associated with diabetes behaviors and outcomes.

RESEARCH DESIGN AND METHODS

This cross-sectional analysis included 7,830 diabetic adults enrolled in Translating Research Into Action for Diabetes, a study of diabetes care and outcomes in managed care settings. Perception of neighborhood problems was measured using a summary score of participants' ratings of crime, trash, litter, lighting at night, and access to exercise facilities, transportation, and supermarkets. Outcomes included health behaviors and clinical outcomes. Hierarchical regression models were used to account for clustering of patients within neighborhoods and to adjust for objective neighborhood socioeconomic status (percentage living in poverty) and potential individual-level confounders (age, sex, race/ethnicity, education, income, comorbidity index, and duration of diabetes).

RESULTS

After adjustment, residents of neighborhoods in the lowest tertile (most perceived problems) reported higher rates of current smoking (15 vs. 11%) than those in the highest tertile and had slightly lower participation in any weekly physical activity (95 vs. 96%). In addition, their blood pressure control was worse (25 vs. 31% <130/80 mmHg), and their Short Form 12 scores were slightly lower (44 vs. 46 units for emotional well-being and 43 vs. 44 units for physical well-being); all P < 0.01.

CONCLUSIONS

Neighborhood problems were most strongly associated with more smoking and higher blood pressure, both of which have significant implications for cardiovascular risk. Potential mechanisms that explain these associations should be further explored in longitudinal studies.

Educational disparities in health behaviors among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study

Background

Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors.

Methods

This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans.

Results

Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25–44, modest for those ages 45–64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings.

Conclusion

The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

How does the persistence of depression influence the continuity and type of health insurance and coverage limits on mental health therapy?

AIM OF THE STUDY

To determine the structural effect of the persistence of depression on continuity and type of health insurance and coverage limits on mental health therapy.

METHODS

Data came from the Partners in Care study (PIC), a randomized controlled trial examining the effect of quality improvement (QI) programs involving medication or psychotherapy on the outcomes of initially depressed patients in seven managed care settings. The sample included approximately 945 adult patients under the age of 63 years who were primarily depressed and insured at baseline. Single-equation multivariate probit regressions were estimated to determine the association of depression burden days aggregated over the 6 to 24-month period post-baseline with the following dichotomous outcomes: continuous health insurance over 6 to 24 months; continuous private health insurance over 6 to 24 months; any public health insurance over 6 to 24 months; and reporting no insurance limits on mental health therapy coverage at 24 months. Other control variables included baseline insurance status, age, sex, race, marital status, education, income, assets, fixed site effects, and (in sensitivity analyses) number of medical comorbidities, alcohol use and drug use. To address the possibility of endogeneity bias in the relationship between depression and insurance, consistent estimates were derived from instrumental variables (IV) probit regressions and the endogeneity of depression burden days was tested. Potential instruments included the random assignment to intervention and control groups in the PIC study, type of depression at baseline, and baseline Mental Component Summary (MCS) score from the Short Form-12 (SF-12). In sensitivity analyses, data pooled (rather than aggregated) across waves were used to estimate probit and IV probit regressions, using Generalized Estimating Equations methods to adjust for within-person correlation of the error terms.

RESULTS

Evidence was found that depression burden days were exogenous to all of the health insurance outcomes except for coverage limits on mental health therapy. Based on the appropriate estimates (single-equation if exogenous, IV if endogenous), depression burden days appeared to increase the probability of having any public health insurance coverage and decrease the probability of having no coverage limits on mental health therapy. However, these effects were small in magnitude.

CONCLUSIONS

Reverse causality may be more of a concern when examining the influence of depression on mental health care coverage than on health insurance in general. Consistent with the government's historical role in financing mental health services, patients whose depression persisted to a greater extent were slightly more likely to have some public health insurance during an 18-month follow-up period. Furthermore, they were slightly more likely to have limits on mental health therapy coverage, suggesting that insurers may be more likely to control access at the level of the benefits structure than at the level of insurance coverage per se. Future analyses should examine the mediating factors in the relationship between depression and limits on mental health therapy coverage, e.g., diminished employment opportunities with large companies that offer more generous benefits.

Patient, physician, pharmacy, and pharmacy benefit design factors related to generic medication use

BACKGROUND

Increased use of generic medications conserves insurer and patient financial resources and may increase patient adherence.

OBJECTIVE

The objective of the study is to evaluate whether physician, patient, pharmacy benefit design, or pharmacy characteristics influence the likelihood that patients will use generic drugs

DESIGN, SETTING, AND PARTICIPANTS

Observational analysis of 2001-2003 pharmacy claims from a large health plan in the Western United States. We evaluated claims for 5,399 patients who filled a new prescription in at least 1 of 5 classes of chronic medications with generic alternatives. We identified patients initiated on generic drugs and those started on branded medications who switched to generic drugs in the subsequent year. We used generalized estimating equations to perform separate analyses assessing the relationship between independent variables and the probability that patients were initiated on or switched to generic drugs.

RESULTS

Of the 5,399 new prescriptions filled, 1,262 (23.4%) were generics. Of those initiated on branded medications, 606 (14.9%) switched to a generic drug in the same class in the subsequent year. After regression adjustment, patients residing in high-income zip codes were more likely to initiate treatment with a generic than patients in low-income regions (RR = 1.29; 95% C.I. 1.04-1.60); medical subspecialists (RR = 0.82; 0.69-0.95) and obstetrician/gynecologists (RR = 0.81; 0.69-0.98) were less likely than generalist physicians to initiate generics. Pharmacy benefit design and pharmacy type were not associated with initiation of generic medications. However, patients were over 2.5 times more likely to switch from branded to generic medications if they were enrolled in 3-tier pharmacy plans (95% C.I. 1.12-6.09), and patients who used mail-order pharmacies were 60% more likely to switch to a generic (95% C.I. 1.18-2.30) after initiating treatment with a branded drug.

CONCLUSIONS

Physician and patient factors have an important influence on generic drug initiation, with the patients who live in the poorest zip codes paradoxically receiving generic drugs least often. While tiered pharmacy benefit designs and mail-order pharmacies helped steer patients towards generic medications once the first prescription has been filled, they had little effect on initial prescriptions. Providing patients and physicians with information about generic alternatives may reduce costs and lead to more equitable care.

Effect of cost-sharing changes on self-monitoring of blood glucose

OBJECTIVE

To study the effect of cost-sharing policy changes on utilization of test strips for self-monitoring of blood glucose.

STUDY DESIGN

A legislative mandate (January 1, 2000) required California health plans to cover diabetes supplies, including those for self-monitoring of blood glucose. One health plan, Kaiser Permanente Northern California, initially waived established copayments and provided free test strips to members with diabetes mellitus for 2 years but later instituted a 20% coinsurance charge for a portion of their membership.

METHODS

A retrospective cohort design was used to study pharmacy-based estimates of test strip utilization changes during this natural experiment. Analyses included 2 cohort investigations using pretest-posttest analysis with control subjects to study transitions from a copayment period to a free test strip period and from the free test strip period to a coinsurance period.

RESULTS

During the copayment period, test strip utilization was inversely related to copayments for test strips. Offering free test strips did not increase utilization, even among those paying higher copayments before the policy change. Price-elastic patterns formed before and during the copayment period persisted, despite receiving free test strips for 2 years. The coinsurance, introduced after 2 years of receiving free test strips, resulted in statistically significant (but not clinically relevant) decreased utilization (approximately 1-3 fewer test strips/month). Change patterns did not differ by socioeconomic status.

CONCLUSIONS

Offering free test strips shifted costs from patient to health plan, without improving adherence. The introduced coinsurance slightly reduced utilization and adherence to recommendations about self-monitoring of blood glucose. Neither intervention had marked clinical effect. Cross-sectional analyses should not be used to predict utilization changes in the face of rapidly evolving benefit policies.

Educational disparities in rates of smoking among diabetic adults: the translating research into action for diabetes study

OBJECTIVES

We assessed educational disparities in smoking rates among adults with diabetes in managed care settings.

METHODS

We used a cross-sectional, survey-based (2002-2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders.

RESULTS

Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly (P<.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25-44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%).

CONCLUSIONS

Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed.

An international perspective on worker mental health problems: who bears the burden and how are costs addressed?

OBJECTIVE

To discuss the burden of poor mental health in workers, who currently bears it, and how the associated rising costs are being addressed, from an international perspective.

METHOD

We identify the stakeholder groups and the costs they incur as a result of problems related to mental health in 6 different domains. In addition, we offer examples of programs, services, and strategies being used to either decrease costs or enhance benefits.

RESULTS

Mental illness is associated with a wide range of costs distributed across multiple stakeholders including government, employers, workers and their families, and the health care system. The costs incurred by the groups are interrelated; an attempt to decrease the burden for one group of stakeholders will inevitably affect other stakeholders. Thus the answer to the question of who bears the costs of poor mental health is "everyone."

CONCLUSIONS

Everyone could benefit from investment in improved mental health in the workplace. However, because the benefits associated with improved worker mental health are often distributed among several stakeholders, the incentives for any single stakeholder to pay for additional services for workers may be diluted. As a consequence, no one invests. Nevertheless, there is a role for all stakeholders, just as there are potential benefits for all. Along with government, employers, employees, and the health care system must invest in promoting good workplace health.

Physician compensation from salary and quality of diabetes care

OBJECTIVE

To examine the association between physician-reported percent of total compensation from salary and quality of diabetes care.

DESIGN

Cross-sectional analysis.

PARTICIPANTS

Physicians (n = 1248) and their patients with diabetes mellitus (n = 4200) enrolled in 10 managed care plans.

MEASUREMENTS

We examined the associations between physician-reported percent compensation from salary and processes of care including receipt of dilated eye exams and foot exams, advice to take aspirin, influenza immunizations, and assessments of glycemic control, proteinuria, and lipid profile, intermediate outcomes such as adequate control of hemoglobin A1c, lipid levels, and systolic blood pressure levels, and satisfaction with provider communication and perceived difficulty getting needed care. We used hierarchical logistic regression models to adjust for clustering at the health plan and physician levels, as well as for physician and patient covariates. We adjusted for plan as a fixed effect, meaning we estimated variation between physicians using the variance within a particular health plan only, to minimize confounding by other unmeasured health plan variables.

RESULTS

In unadjusted analyses, patients of physicians who reported higher percent compensation from salary (>90%) were more likely to receive 5 of 7 diabetes process measures and more intensive lipid management and to have an HbA1c<8.0% than patients of physicians who reported lower percent compensation from salary (<10%). However, these associations did not persist after adjustment.

CONCLUSIONS

Our findings suggest that salary, as opposed to fee-for-service compensation, is not independently associated with diabetes processes and intermediate outcomes.

Methods for Improving Regression Analysis for Skewed Continuous or Counted Responses

Standard inference procedures for regression analysis make assumptions that are rarely satisfied in practice. Adjustments must be made to insure the validity of statistical inference. These adjustments, known for many years, are used routinely by some health researchers but not by others. We review some of these methods and give an example of their use in a health services study for a continuous and a count outcome. For the continuous outcome, we describe re-transformation using the smear factor, accounting for missing cases via multiple imputation and attrition weights and improving results with bootstrap methods. For the count outcome, we describe zero inflated Poisson and negative binomial models and the two-part model to account for overabundance of zero values. Recent advances in computing and software development have produced user-friendly computer programs that enable the data analyst to improve prediction and inference based on regression analysis.