Using quantile regression to examine health care expenditures during the Great Recession

National Estimates of Incremental Work Absenteeism Costs Associated With Adult Children of Parents With Alzheimer's Disease and Related Dementias

OBJECTIVE

More than half of primary caregivers for ADRD patients are adult children, yet there is little empirical evidence on how caring for parents with ADRD affects their employment. Using a nationally representative dataset, this study aimed to estimate incremental work absenteeism costs for adult children of parents with ADRD.

DESIGN, SETTING, AND PARTICIPANTS

The study used the data from the 2015-2021 Medical Expenditure Panel Survey (MEPS). Multivariate regressions and two-part models were employed to estimate the incremental work absenteeism costs among adult children aged 40 to 64 who had at least one parent diagnosed with ADRD, compared with those who did not have ADRD parents.

MEASUREMENTS

The incremental work absenteeism costs due to caregiving for adult children with ADRD parents was a cumulated estimation of labor productivity cost at three stages: (1) the likelihood of not working due to unemployment, (2) the likelihood of missing any workdays for caregiving, and (3) the number of workdays missed due to caregiving.

RESULTS

Adult children with ADRD parents were more likely to be unemployed (OR = 1.80, p = 0.024) and 2.95 times more likely to miss work for caregiving (p = 0.002) than those with non-ADRD parents. The difference in the number of workdays missed for caregiving between children with and without ADRD parents was not significant. The incremental effects of having ADRD parents were estimated to be $4,510.29 ($1,702.09-$6,723.69) per person per year.

CONCLUSIONS

Having ADRD parents significantly increases the chances of unemployment and missing any workdays for caregiving, leading to higher lost labor productivity costs for adult children with ADRD parents.

Effects of private health insurance on medical expenditure and health service utilization in South Korea: a quantile regression analysis

BACKGROUND

Despite universal health insurance, South Korea has seen a sharp increase in the number of people enrolled in supplemental private health insurance (PHI) during the last decade. This study examined how private health insurance enrollment affects medical expenditure and health service utilization.

METHODS

Unbalanced panel data for adults aged 19 and older were constructed using the 2016-2018 Korea Health Panel Survey. Quantile regression for medical cost, and quantile count regression for health service utilization were utilized using propensity score-matched data. We included 17 variables representing demographic, socioeconomic, and health information, as well as medical costs and use of outpatient and inpatient care.

RESULTS

We discovered that PHI enrollees' socioeconomic and health status is more likely to be better than PHI non-enrollees'. Results showed that private health insurance had a greater effect on the lower quantiles of the conditional distribution of outpatient costs (coefficient 0.149 at the 10th quantile and 0.121 at the 25th quantile) and higher quantiles of inpaitent care utilization (coefficient 0.321 at the 90th quantile for days of hospitalization and 0.076 at the 90th quantile for number of inpatient visits).

CONCLUSIONS

PHI enrollment is positively correlated with outpatient costs and inpatient care utilization. Government policies should consider these heterogeneous distributional effects of private health insurance.

In the wake of a crisis: Caught between housing and healthcare

Objective

To measure the association between housing insecurity and foregone medication due to cost among Medicare beneficiaries aged 65+ during the Recession.

Methods

Data came from Medicare beneficiaries aged 65+ years from the 2006-2012 waves of the Health and Retirement Study (HRS). Two-wave housing insecurity changes are evaluated as follows: (i) No insecurity, (ii) Persistent insecurity, (iii) Onset insecurity, and (iv) Onset security. We implemented a series of four weighted longitudinal General Estimating Equation (GEE) models, two minimally adjusted and two fully adjusted models, to estimate the probability of foregone medications due to cost between 2008 and 2012.

Results

Our study sample was restricted to non-proxy interviews of non-institutionalized Medicare beneficiaries aged 65+ in the 2006 wave (n = 9936) and their follow up visits (n = 8753; in 2008; n = 7464 in 2010; and n = 6594 in 2012). Results from our fully adjusted model indicated that the odds of foregone medication was 64% higher among individuals experiencing Onset insecurity versus No insecurity in 2008, and also generally larger for individuals experiencing Onset Insecurity versus Persistent Insecurity. Odds of foregone medication was also larger among females, minority versus non-Hispanic white adults, those reporting a chronic condition, those with higher medical expenditures, and those living in the South versus Northeast.

Conclusion

This study drew from nationally representative data to elucidate the disparate health and financial impacts of a crisis on Medicare beneficiaries who, despite health insurance coverage, displayed variability in foregone medication patterns. Our findings suggest that the onset of housing insecurity is most closely linked with unexpected acute economic shocks leading households with little time to adapt and forcing trade-offs in their prescription and other needs purchases. Both housing and healthcare policy implications exist from these findings including expansion of low-income housing units and rent relief post-recession as well as wider prescription drug coverage for Medicare adults.

Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians

OBJECTIVES

In 2019, the Centers for Medicare & Medicaid Services began implementing the Patients Over Paperwork (POP) initiative in response to clinicians reporting burdensome documentation regulations. To date, no study has evaluated how these policy changes have influenced documentation burden.

METHODS

Our data came from the electronic health records of an academic health system. Using quantile regression models, we assessed the association between the implementation of POP and clinical documentation word count using data from family medicine physicians in an academic health system from January 2017 to May 2021 inclusive. Studied quantiles included the 10th, 25th, 50th, 75th, and 90th quantiles. We controlled for patient-level (race/ethnicity, primary language, age, comorbidity burden), visit-level (primary payer, level of clinical decision making involved, whether a visit was done through telemedicine, whether a visit was for a new patient), and physician-level (sex) characteristics.

RESULTS

We found that the POP initiative was associated with lower word counts across all of the quantiles. In addition, we found lower word counts among notes for private payers and telemedicine visits. Conversely, higher word counts were observed in notes that were written by female physicians, notes for new patient visits, and notes involving patients with greater comorbidity burden.

CONCLUSIONS

Our initial evaluation suggests that documentation burden, as measured by word count, has declined over time, particularly following implementation of the POP in 2019. Additional research is needed to see whether the same occurs when examining other medical specialties, clinician types, and longer evaluation periods.

Healthcare Costs of Major Morbidities Associated with Prematurity in US Children's Hospitals

OBJECTIVE

To evaluate the healthcare costs attributed to major morbidities associated with prematurity, namely, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage, necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and nosocomial infections.

STUDY DESIGN

This was a retrospective analysis of infants born at 24-30 weeks of gestation, admitted to children's hospitals in the Pediatric Health Information System between 2009 and 2018. Charges were adjusted by geographical price index, converted to costs using cost-to-charge ratios, inflated to 2018 US$, and total costs were accumulated for the initial hospitalization. Quantile regressions, which are less prone to bias from extreme outliers, were used to examine the incremental costs attributed to each morbidity across the entire cost distribution, including the median.

RESULTS

There were 19 232 patients from 30 children's hospitals who were eligible. Higher costs were seen in lower gestational age, more severe morbidity, and those with higher number of comorbidities. Patients with surgical NEC, severe ROP, and severe BPD were the costliest with median total costs of $430 860, $413 825, and $399 495, respectively. Quantile regressions showed surgical NEC had the highest adjusted median incremental total cost ($48 621; 95% CI, $39 617-$57 626) followed by severe BPD ($35 773; 95% CI, $32 018-$39 528) and severe ROP ($22 561; 95% CI, $16 699-$28 423). Quantile regressions also revealed that surgical NEC, severe BPD, and severe ROP had increasing incremental costs at higher total cost percentiles, indicating these morbidities have a greater cost impact on the costliest patients.

CONCLUSIONS

Severe BPD, surgical NEC, and severe ROP are the costliest morbidities and contribute the most incremental costs especially for the higher costs patients.

Analysis of Health Care Billing via Quantile Variable Selection Models

Fraudulent billing of health care insurance programs such as Medicare is in the billions of dollars. The extent of such overpayments remains an issue despite the emerging use of analytical methods for fraud detection. This motivates policy makers to also be interested in the provider billing characteristics and understand the common factors that drive conservative and/or aggressive behavior. Statistical approaches to tackling this problem are confronted by the asymmetric and/or leptokurtic distributions of billing data. This paper is a first attempt at using a quantile regression framework and a variable selection approach for medical billing analysis. The proposed method addresses the varying impacts of (potentially different) variables at the different quantiles of the billing aggressiveness distribution. We use the mammography procedure to showcase our analysis and offer recommendations on fraud detection.

Impact of Neighborhood Social and Environmental Resources on Medicaid Spending

INTRODUCTION

In an era of COVID-19, Black Lives Matter, and unsustainable healthcare spending, efforts to address the root causes of health are urgently needed. Research linking medical spending to variation in neighborhood resources is critical to building the case for increased funding for social conditions. However, few studies link neighborhood factors to medical spending. This study assesses the relationship between neighborhood social and environmental resources and medical spending across the spending distribution.

METHODS

Individual-level health outcomes were drawn from a sample of Medicaid enrollees living in Baltimore, Maryland during 2016. A multidimensional index of neighborhood social and environmental resources was created and stratified by tertile (high, medium, and low). Differences were examined in individual-level medical spending associated with living in high-, medium-, or low-resource neighborhoods in unadjusted and adjusted 2-part models and quantile regression models. Analyses were conducted in 2019.

RESULTS

Enrollees who live in neighborhoods with low social and environmental resources incur significantly higher spending at the mean and across the distribution of medical spending even after controlling for age, race, sex, and morbidity than those who live in neighborhoods with high social and environmental resources. On average, this spending difference between individuals in low- and those in high-resource neighborhoods is estimated to be $523.60 per person per year.

CONCLUSIONS

Living in neighborhoods with low (versus those with high) resources is associated with higher individual-level medical spending across the distribution of medical spending. Findings suggest potential benefits from efforts to address the social and environmental context of neighborhoods in addition to the traditional orientation to addressing individual behavior and risk.

Out-of-Pocket Healthcare Expenditures in Dependent Older Adults: Results From an Economic Evaluation Study in Mexico

Background: Dependence is a significant health-related condition for older adults (OA) and implies that self-care is transferred to other people, the community or institutions. Recent studies have analyzed the relationship between out-of-pocket (OOP) healthcare expenditures and dependence. Nonetheless, these studies were not specifically designed to estimate the economic impact of dependence. Our aim was to estimate the total adjusted annual OOP healthcare expenditures in dependent older adults compared to independent ones. Additionally, we explore the potential combined effect of basic activities of daily living (ADL) and instrumental activities of daily living (IADL) dependence on OOP healthcare expenditures.

Methods: Data comes from the cross-sectional study “Economic impact of physical dependence in older adults and the burden of informal care” conducted in 2018 with a sample of 735 community-dwelling older Mexican adults ages 60 and older. We used direct (medical and non-medical) and indirect costs to estimate the OOP healthcare expenditures associated with dependence. We applied the Katz scale to assess dependence in ADL and the Lawton scale to assess dependence in IADL. Two-Part regression models were used to analyze the relationship between dependence and OOP health expenditures.

Results: Presence of ADL dependence represented a higher level of expenditure, 107% compared to non-dependent OA (β = 1.07, CI95%: 0.43–1.71), and 97% for IADL dependence (β = 0.97, CI95%: 0.49–1.45). The combined effect of ADL and IADL dependence (132%) was greater (β = 1.32, CI95%: 0.74–1.90) than the effect of ADL or IADL dependence alone. In monetary terms, OA with ADL dependence had a total annualized mean OOP healthcare expenditure of $31,865 (Mexican pesos), OA with IADL $26,912, and combined ADL and IADL $39,520.

Conclusions: ADL and IADL dependence are associated with the total annualized OOP healthcare expenditures. This association is even higher when both conditions are present together. These findings highlight the economic implications of the dependence for individuals, their families, and the health system. Given that current evidence on effective interventions to prevent dependence in OA is insufficient, future studies should be conducted to estimate their costs and determine what interventions work, as well as their effectiveness and cost-effectiveness in different sub-groups of the population, and how these might be appropriately implemented.

What causes high costs for rural tuberculosis inpatients? Evidence from five counties in China

BACKGROUND

Tuberculosis (TB) still causes high economic burden on patients in China, especially for rural patients. Our study aims to explore the risk factors associated with the high costs for TB inpatients in rural China from the aspects of inpatients' socio-demographic and institutional attributes.

METHODS

Generalized linear models were utilized to investigate the factors associated with TB inpatients' total costs and out-of-pocket (OOP) expenditures. Quantile regression (QR) models were applied to explore the effect of each factor across the different costs range and identify the risk factors of high costs.

RESULTS

TB inpatients with long length of stay and who receive hospitalization services cross provincially, in tertiary and specialized hospitals were likely to face high total costs and OOP expenditures. QR models showed that high total costs occurred in Dingyuan and Funan Counties, but they were not accompanied by high OOP expenditures.

CONCLUSIONS

Early diagnosis, standard treatment and control of drug-resistant TB are still awaiting for more efforts from the government. TB inpatients should obtain medical services from appropriate hospitals. The diagnosis and treatment process of TB should be standardized across all designated medical institutions. Furthermore, the reimbursement policy for migrant workers who suffered from TB should be ameliorated.

After the COVID-19 Pandemic: Returning to Normalcy or Returning to a New Normal?

The novel coronavirus, severe acute respiratory coronavirus 2 (SARS-CoV-2), pandemic has delivered a profound and negative impact on the United States. The suspension of elective surgeries including arthroplasty will have a lasting effect on all stakeholders including patients, physicians, and healthcare organizations within the US healthcare system. Resumption of elective hip and knee arthroplasty will need to be carefully focused. The purpose of this work is to address potential strategies, concerns, and regulatory barriers in restarting elective hip and knee arthroplasty in the United States.

Does Vertical Integration Improve Access to Surgical Care for Medicaid Beneficiaries?

BACKGROUND

Vertical integration is increasingly common among surgical specialties in the US; however, the effect of vertical integration on access to care for low-income populations remains poorly understood. We explored the characteristics of surgical practices associated with vertical integration and the effect of integration on surgical access for Medicaid populations.

STUDY DESIGN

Using a survey of US office-based physician practices, we examined characteristics of 15 surgical subspecialties from 2007 to 2017, including provider sex and specialty, practice payer mix, surgical volume, and county socioeconomic status. Using multivariable logistic regression and time-series analysis, we evaluated practice and provider characteristics associated with vertical integration-our primary outcome-and practice Medicaid acceptance rates-our secondary outcome.

RESULTS

Our analysis included 84,795 unique surgical practices (303,903 practice-years). The rate of vertical integration during the 10-year period was 18.0%, with 72.1% of surgical practices never integrating. Practices that integrated were more likely to accept Medicaid patients than practices that did not (81.0% vs 60.8%, p < 0.001). Accepting Medicaid increased the likelihood of vertical integration relative to practices that did not (odds ratio [OR] 4.20, 95% CI 3.93 to 4.49). Practices that integrated were more likely to accept Medicaid in the future (OR 2.61, 95% CI 2.40 to 2.83), even after adjusting for previous Medicaid acceptance and hospital and time fixed effects.

CONCLUSIONS

Surgical practices caring for the underinsured are more likely to join larger health care systems, driven by market characteristics. Vertical integration is associated with future increased rates of Medicaid acceptance among practices, allowing for increased access to surgical care for vulnerable, low-income patients. The potential benefit of increased surgical access for low-income beneficiaries from vertical integration must be balanced with the potential for increased prices.

States with higher minimum wages have lower STI rates among women: Results of an ecological study of 66 US metropolitan areas, 2003-2015

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

Wealth and the health of older Black women in the United States

Public health scholars and policy-makers are concerned that the United States continues to experience unmanageable health care costs while struggling with issues surrounding access and equity. To addresses these and other key issues, the National Academy of Medicine held a public symposium, Vital Directions for Health and Health Care: A National Conversation during September 2016, with the goal of identifying clear priorities for high-value health care and improved well-being. One important area was addressing social determinants of health. This article contributes to this objective by investigating the impact of wealth on older Black women's health. Employing the 2008/2010 waves of the RAND Health and Retirement Study on a sample of 906 older Black women, this panel study examined self-assessed health ratings of very good/good/fair/poor within a relaxed random effects framework, thereby controlling for both (i) observed and (ii) unobserved individual-level heterogeneity. This analysis did not find a statistically significant association with wealth despite a difference of approximately $75 000 in its valuation from very good to poor health. This also occurred after wealth was (i) readjusted for outliers and (ii) reformulated as negative, no change or positive change from 2008. This finding suggests that wealth may not play as integral a role. However, the outcome was significant for earnings and education, particularly higher levels of education. Scholars should further this inquiry to better understand how earnings/education/wealth operate as social determinants of health for minority populations.

Medicare Spending and the Adequacy of Support With Daily Activities in Community-Living Older Adults With Disability: An Observational Study

BACKGROUND

Identifying factors that affect variation in health care spending among older adults with disability may reveal opportunities to better address their care needs while offsetting excess spending.

OBJECTIVE

To quantify differences in total Medicare spending among older adults with disability by whether they experience negative consequences due to inadequate support with household activities, mobility, or self-care.

DESIGN

Observational study of in-person interviews and linked Medicare claims.

SETTING

United States, 2015.

PARTICIPANTS

3716 community-living older adults who participated in the 2015 NHATS (National Health and Aging Trends Study) and survived for 12 months.

MEASUREMENTS

Total Medicare spending by spending quartile in multivariable regression models that adjusted for individual characteristics.

RESULTS

Negative consequences were experienced by 18.3% of participants with disability in household activities, 25.6% with mobility disability, and 20.0% with self-care disability. Median Medicare spending was higher for those who experienced negative consequences due to household ($4866 vs. $4095), mobility ($7266 vs. $4115), and self-care ($10 935 vs. $4436) disability versus those who did not. In regression-adjusted analyses, median spending did not differ appreciably for participants who experienced negative consequences in household activities ($338 [95% CI, -$768 to $1444]), but was higher for those with mobility ($2309 [CI, $208 to $4409]) and self-care ($3187 [CI, $432 to $5942]) disability. In the bottom-spending quartile, differences were observed for self-care only ($1460 [CI, $358 to $2561]). No differences were observed in the top quartile.

LIMITATION

This observational study could not establish causality.

CONCLUSION

Inadequate support for mobility and self-care is associated with higher Medicare spending, especially in the middle and lower ends of the spending distribution. Better support for the care needs of older adults with disability could offset some Medicare spending.

PRIMARY FUNDING SOURCE

The Commonwealth Fund.

Who had access to doctors before and after new universal capitated subsidies in New Zealand?

In 2002, the New Zealand government introduced universal capitated subsidies for general practitioner consultations amid a broader programme of reform intended to reduce inequities in access and encourage more preventive healthcare visits. While consultation numbers increased in the short run, the issue of cost barriers to access has once more garnered significant policy attention, with many commentators concerned that the funding necessary to maintain low fees has not kept up with cost pressures. A longer-term assessment is useful in understanding the relationship between evolving policy conditions and service use. This article explores how the distribution of access to GPs changed in the short and long run using New Zealand Health Survey data from 2002/03 to 2015/16. I find that the capitation subsidies were associated with improved access for indigenous Māori and more preventive visits as intended by 2006/07. However, from 2006/07 onward patients with the greatest health need began reporting fewer and less frequent doctors' visits per annum. I discuss potential explanations, focussing on the role of capitation subsidies and the successor price-capping scheme. This research contributes evidence to international scholarship on the long-term factors necessary for universal capitated subsidisation to sustainably reduce access inequities, with attention to local nuance.

Impact of Economic Downturn on the Surgical Volumes of Common Hand Procedures

BACKGROUND

Economic conditions affect surgical volumes, particularly for elective procedures. In this study, the authors aimed to identify the effects of the 2008 U.S. economic downturn on hand surgery volumes to guide surgeons and managers when facing future economic crises.

METHODS

The authors used the California State Ambulatory Surgery and Services Database from January of 2005 to December of 2011, which includes the entire period of the Great Recession (December of 2007 to June of 2009). The authors abstracted the monthly volume of five common hand procedures using International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Pearson statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure.

RESULTS

The total number of operative cases was 345,583 during the 7-year study period. Most common elective hand procedures, such as carpal tunnel release and trigger finger release, had a negative correlation with unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation.

CONCLUSIONS

The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. Taking advantage of the principle that increased volume reduces unit cost may mitigate the lost revenue from these elective procedures. In addition, consolidating hand surgery services at larger, regional centers may reduce the effect of the economic environment on individual hand surgeons.

State minimum wage laws and newly diagnosed cases of HIV among heterosexual black residents of US metropolitan areas

This ecologic cohort study explores the relationship between state minimum wage laws and rates of HIV diagnoses among heterosexual black residents of U.S metropolitan areas over an 8-year span. Specifically, we applied hierarchical linear modeling to investigate whether state-level variations in minimum wage laws, adjusted for cost-of-living and inflation, were associated with rates of new HIV diagnoses among heterosexual black residents of metropolitan statistical areas (MSAs; n=73), between 2008 and 2015. Findings suggest that an inverse relationship exists between baseline state minimum wages and initial rates of newly diagnosed HIV cases among heterosexual black individuals, after adjusting for potential confounders. MSAs with a minimum wage that was $1 higher at baseline had a 27.12% lower rate of newly diagnosed HIV cases. Exploratory analyses suggest that income inequality may mediate this relationship. If subsequent research establishes a causal relationship between minimum wage and this outcome, efforts to increase minimum wages should be incorporated into HIV prevention strategies for this vulnerable population.

A quantile regression approach to panel data analysis of health-care expenditure in Organisation for Economic Co-operation and Development countries

This paper investigates the variation in the effects of various determinants on the per capita health-care expenditure. A total of 28 Organisation for Economic Co-operation and Development countries are studied over the period 1990-2012, employing an instrumental variable quantile regression method for a dynamic panel model with fixed effects. The results show that the determinants of per capita health-care expenditure growth, involving the growth of lagged health spending, of per capita gross domestic product (GDP), of physician density, of elderly population, of life expectancy, of urbanization, and of female labor force participation, do vary with the conditional distribution of the health-care expenditure growth, while the changing patterns are dissimilar. Moreover, we show that Baumol's model of "unbalanced growth" has a significantly positive effect on per capita health spending growth, and its effect is quite stable over the entire distribution. However, the correlation between the components (wage growth and labor productivity growth) of the "Baumol variable" and health expenditure growth is more varied. As a comparison, only the growth of lagged health spending, per capita GDP, and the Baumol variable (or its components) are found related to health spending growth in conditional mean regressions. The prediction results were also quite different between the quantile regression dynamic panel instrumental variable models and linear panel data models. More attention needs to be paid to the varying influence of determinants in health expenditure study.

Uncertainty about the effort-performance relationship in threshold-based payment schemes

Incentive schemes often feature a threshold beyond which providers receive no additional payment for performance. We investigate whether providers' uncertainty about the relationship between effort and measured performance leads to financially unrewarded performance in such schemes. Using data from the British Quality and Outcomes Framework, we proxy general practitioners' uncertainty about the effort-performance relationship by their experience with the scheme and their span of control. We find evidence that providers respond to uncertainty by exerting financially unrewarded performance, suggesting that uncertainty may be a mechanism by which payers can extract unrewarded performance.

Predicting Length of Hospice Stay: An Application of Quantile Regression

BACKGROUND

Use of the Medicare hospice benefit has been associated with high-quality care at the end of life, and hospice length of use in particular has been used as a proxy for appropriate timing of hospice enrollment. Quantile regression has been underutilized as an alternative tool to model distributional changes in hospice length of use and hospice payments outside of the mean.

OBJECTIVE

To test for heterogeneity in the relationship between patient characteristics and hospice outcomes across the distribution of hospice days.

SETTING

Medicare Beneficiary Summary File and survey data (2014) for hospice beneficiaries in North and South Carolina with common terminal diagnoses.

MEASUREMENTS

Distributional shifts associated with patient characteristics were evaluated at the 25th and 75th percentiles of hospice days and hospice payments using quantile regressions and compared to the mean shift estimated by ordinary least squares (OLS) regression.

PRINCIPAL FINDINGS

Significant (p < 0.001) heterogeneity in the marginal effects on hospice days and costs was observed, with patient characteristics associated with generally larger shifts in the 75th percentile than the 25th percentile. Mean effects estimated by OLS regression overestimate the magnitude of the median marginal effects for all patient characteristics except for race. Results for hospice payments in 2014 were similar.

CONCLUSIONS

Methodological decisions can have a meaningful impact in the evaluation of factors influencing hospice length of use or cost.

Increasing Inequality in Physical Activity Among Minnesota Secondary Schools, 2001-2010

BACKGROUND

Two Healthy People 2020 goals are to increase physical activity (PA) and to reduce disparities in PA. We explored whether PA at the school level changed over time in Minnesota schools and whether differences existed by demographic and socioeconomic factors.

METHODS

We examine self-reported PA (n = 276,089 students; N = 276 schools) for 2001-2010 from the Minnesota Student Survey linked to school demographic data from the National Center for Education Statistics and the Rural-Urban Commuting Area Codes. We conducted analyses at the school level using multivariable linear regression with cluster-robust recommendation errors.

RESULTS

Overall, students who met PA recommendations increased from 59.8% in 2001 to 66.3% in 2010 (P < .001). Large gains in PA occurred at schools with fewer racial/ethnic minority students (0%-60.1% in 2001 to 67.5% in 2010, P < .001), whereas gains in PA were comparatively small at schools with a high proportion of racial/ethnic minority students in 2001 (30%-59.2% in 2001 to 62.7% in 2010).

CONCLUSIONS

We found increasing inequalities in school-level PA by racial/ethnic characteristics of their schools and communities among secondary school students. Future research should monitor patterns of PA over time and explore mechanisms for patterns of inequality.

Use of Quantile Regression to Determine the Impact on Total Health Care Costs of Surgical Site Infections Following Common Ambulatory Procedures

OBJECTIVE

To determine the impact of surgical site infections (SSIs) on health care costs following common ambulatory surgical procedures throughout the cost distribution.

BACKGROUND

Data on costs of SSIs following ambulatory surgery are sparse, particularly variation beyond just mean costs.

METHODS

We performed a retrospective cohort study of persons undergoing cholecystectomy, breast-conserving surgery, anterior cruciate ligament reconstruction, and hernia repair from December 31, 2004 to December 31, 2010 using commercial insurer claims data. SSIs within 90 days post-procedure were identified; infections during a hospitalization or requiring surgery were considered serious. We used quantile regression, controlling for patient, operative, and postoperative factors to examine the impact of SSIs on 180-day health care costs throughout the cost distribution.

RESULTS

The incidence of serious and nonserious SSIs was 0.8% and 0.2%, respectively, after 21,062 anterior cruciate ligament reconstruction, 0.5% and 0.3% after 57,750 cholecystectomy, 0.6% and 0.5% after 60,681 hernia, and 0.8% and 0.8% after 42,489 breast-conserving surgery procedures. Serious SSIs were associated with significantly higher costs than nonserious SSIs for all 4 procedures throughout the cost distribution. The attributable cost of serious SSIs increased for both cholecystectomy and hernia repair as the quantile of total costs increased ($38,410 for cholecystectomy with serious SSI vs no SSI at the 70th percentile of costs, up to $89,371 at the 90th percentile).

CONCLUSIONS

SSIs, particularly serious infections resulting in hospitalization or surgical treatment, were associated with significantly increased health care costs after 4 common surgical procedures. Quantile regression illustrated the differential effect of serious SSIs on health care costs at the upper end of the cost distribution.

Income Inequities and Medicaid Expansion are Related to Racial and Ethnic Disparities in Delayed or Forgone Care Due to Cost

BACKGROUND

Monitoring political and social determinants of delayed or forgone care due to cost is necessary to evaluate efforts to reduce racial and ethnic disparities in access to care. Our objective was to examine the extent to which state Medicaid expansion decisions and personal household income may be associated with individual-level racial and ethnic disparities in delayed or forgone care due to cost, at baseline, before the implementation of the Affordable Care Act.

METHODS

We used 2012 Behavioral Risk Factor Surveillance System survey data to examine racial and ethnic differences in delayed or forgone care due to cost in states that do and do not plan Medicaid expansion. We examined personal household income as a social factor that could contribute to racial and ethnic disparities in delayed or forgone care.

RESULTS

We found that personal income differences were strongly related to disparities in delayed or forgone care in places with and without plans to expand Medicaid. In addition, while delayed or forgone care disparities between non-Hispanic whites and non-Hispanic blacks were lowest in places with plans to expand Medicaid access, disparities between non-Hispanic whites and Hispanics did not differ by state Medicaid expansion plans.

CONCLUSIONS

As access to insurance improves for diverse groups, health systems must develop innovative strategies to overcome social determinants of health, including income inequities, as barriers to accessing care for Hispanic and non-Hispanic blacks. Additional efforts may be needed to ensure Hispanic groups achieve the benefits of investments in health care access.

Gender and Race/Ethnicity Differences in Mental Health Care Use before and during the Great Recession

This study examines the changes in health care utilization for mental health disorders among patients who were diagnosed with depressive and/or anxiety disorders during the Great Recession 2007-2009 in the USA. Negative binomial regressions are used to estimate the association of the economic recession and mental health care use for females and males separately. Results show that prescription drug utilization (e.g., antidepressants, psychotropic medications) increased significantly during the economic recession 2007-2009 for both females and males. Physician visits for mental health disorders decreased during the same period. Results show that racial disparities in mental health care might have increased, while ethnic disparities persisted during the Great Recession. Future research should separately examine mental health care utilization by gender and race/ethnicity.

Reducing Young Adults' Health Care Spending through the ACA Expansion of Dependent Coverage

OBJECTIVE

To estimate health care expenditure trends among young adults ages 19-25 before and after the 2010 implementation of the Affordable Care Act (ACA) provision that extended eligibility for dependent private health insurance coverage.

DATA SOURCES

Nationally representative Medical Expenditure Panel Survey data from 2008 to 2012.

STUDY DESIGN

We conducted repeated cross-sectional analyses and employed a difference-in-differences quantile regression model to estimate health care expenditure trends among young adults ages 19-25 (the treatment group) and ages 27-29 (the control group).

PRINCIPAL FINDINGS

Our results show that the treatment group had 14 percent lower overall health care expenditures and 21 percent lower out-of-pocket payments compared with the control group in 2011-2012. The overall reduction in health care expenditures among young adults ages 19-25 in years 2011-2012 was more significant at the higher end of the health care expenditure distribution. Young adults ages 19-25 had significantly higher emergency department costs at the 10th percentile in 2011-2012. Differences in the trends of costs of private health insurance and doctor visits are not statistically significant.

CONCLUSIONS

Increased health insurance enrollment as a consequence of the ACA provision for dependent coverage has successfully reduced spending and catastrophic expenditures, providing financial protections for young adults.

Cost analysis of minimally invasive hysterectomy vs open approach performed by a single surgeon in an Italian center

Despite the rapid uptake of robotic surgery, the effectiveness of robotically assisted hysterectomy (RAH) remains uncertain, due to the costs widely variable. Observed the different related costs of robotic procedures, in different countries, we performed a detailed economic analysis of the cost of RAH compared with total laparoscopic (TLH) and open hysterectomy (OH). The three surgical routes were matched according to age, BMI, and comorbidities. Hysterectomy costs were collected prospectively from September 2014 to September 2015. Direct costs were determined by examining the overall medical pathway for each type of intervention. Surgical procedure cost for RAH was €3598 compared with €912 for TLH and €1094 for OH. The cost of the robot-specific supplies was €2705 per intervention. When considering overall medical surgical care, the patient treatment average cost of a RAH was €4695 with a hospital stay (HS) of 2 days (range 2-4) compared with €2053 for TLH and €2846 for OH. The main driver of additional costs is disposable instruments of the robot, which is not compensated by the hospital room costs and by an experienced team staff. Implementation of strategies to reduce the cost of robotic instrumentation is due. No significant cost difference among the three procedures was observed; however, despite the optimal operative time, the experienced, surgeon and the lower HS, RAH resulted 2, 3 times and 1, 6 times more expensive in our institution than TLH and OH, respectively.

The Effects of Job Insecurity on Health Care Utilization: Findings from a Panel of U.S. Workers

OBJECTIVE

To examine the impacts of job insecurity during the recession of 2007-2009 on health care utilization among a panel of U.S. employees.

DATA SOURCES/STUDY SETTING

Linked administrative and claims datasets on a panel of continuously employed, continuously insured individuals at a large multisite manufacturing firm that experienced widespread layoffs (N = 9,486).

STUDY DESIGN

We employed segmented regressions to examine temporal discontinuities in utilization during 2006-2012. To assess the effects of job insecurity, we compared individuals at high- and low-layoff plants. Because the dataset includes multiple observations for each individual, we included individual-level fixed effects.

PRINCIPAL FINDINGS

We found discontinuous increases in outpatient (3.5 visits/month/10,000 individuals, p = .002) and emergency (0.4 visits/month/10,000 individuals, p = .05) utilization in the panel of all employees. Compared with individuals at low-layoff plants, individuals at high-layoff plants decreased outpatient utilization (-4.0 visits/month/10,000 individuals, p = .008), suggesting foregone preventive care, with a marginally significant increase in emergency utilization (0.4 visits/month/10,000 individuals, p = .08).

CONCLUSIONS

These results suggest changes in health care utilization and potentially adverse impacts on employee health in response to job insecurity during the latest recession. This study contributes to our understanding of the impacts of economic crises on the health of the U.S. working population.

Latino Population Growth and Hospital Uncompensated Care in California

OBJECTIVES

We examined the association between the size and growth of Latino populations and hospitals' uncompensated care in California.

METHODS

Our sample consisted of general acute care hospitals in California operating during 2000 and 2010 (n = 251). We merged California hospital data with US Census data for each hospital service area. We used spatial analysis, multivariate regression, and fixed-effect models.

RESULTS

We found a significant association between the growth of California's Latino population and hospitals' uncompensated care in the unadjusted regression. This association was still significant after we controlled for hospital and community population characteristics. After we added market characteristics into the final model, this relationship became nonsignificant.

CONCLUSIONS

Our findings suggest that systematic support is needed in areas with rapid Latino population growth to control hospitals' uncompensated care, especially if Latinos are excluded from or do not respond to the insurance options made available through the Affordable Care Act. Improving availability of resources for hospitals and providers in areas with high Latino population growth could help alleviate financial pressures.

Health care spending and utilization by race/ethnicity under the Affordable Care Act's dependent coverage expansion

OBJECTIVES

We estimated the effect of the ACA expansion of dependents' coverage on health care expenditures and utilization for young adults by race/ethnicity.

METHODS

We used difference-in-difference models to estimate the impact of the ACA expansion on health care expenditures, out-of-pocket payments (OOP) as a share of total health care expenditure, and utilization among young adults aged 19 to 26 years by race/ethnicity (White, African American, Latino, and other racial/ethnic groups), with adults aged 27 to 30 years as the control group.

RESULTS

In 2011 and 2012, White and African American young adults aged 19 to 26 years had significantly lower total health care spending compared with the 27 to 30 years cohort. OOP, as a share of health care expenditure, remained the same after the ACA expansion for all race/ethnicity groups. Changes in utilization following the ACA expansion among all racial/ethnic groups for those aged 19 to 26 years were not significant.

CONCLUSIONS

Our study showed that the impact of the ACA expansion on health care expenditures differed by race/ethnicity.

An economic analysis of robotically assisted hysterectomy

OBJECTIVE

To perform an econometric analysis to examine the influence of procedure volume, variation in hospital accounting methodology, and use of various analytic methodologies on cost of robotically assisted hysterectomy for benign gynecologic disease and endometrial cancer.

METHODS

A national sample was used to identify women who underwent laparoscopic or robotically assisted hysterectomy for benign indications or endometrial cancer from 2006 to 2012. Surgeon and hospital volume were classified as the number of procedures performed before the index surgery. Total costs as well as fixed and variable costs were modeled using multivariable quantile regression methodology.

RESULTS

A total of 180,230 women, including 169,324 women who underwent minimally invasive hysterectomy for benign indications and 10,906 patients whose hysterectomy was performed for endometrial cancer, were identified. The unadjusted median cost of robotically assisted hysterectomy for benign indications was $8,152 (interquartile range [IQR] $6,011-10,932) compared with $6,535 (IQR $5,127-8,357) for laparoscopic hysterectomy (P<.001). The cost differential decreased with increasing surgeon and hospital volume. The unadjusted median cost of robotically assisted hysterectomy for endometrial cancer was $9,691 (IQR $7,591-12,428) compared with $8,237 (IQR $6,400-10,807) for laparoscopic hysterectomy (P<.001). The cost differential decreased with increasing hospital volume from $2,471 for the first 5 to 15 cases to $924 for more than 50 cases. Based on surgeon volume, robotically assisted hysterectomy for endometrial cancer was $1,761 more expensive than laparoscopy for those who had performed fewer than five cases; the differential declined to $688 for more than 50 procedures compared with laparoscopic hysterectomy.

CONCLUSION

The cost of robotic gynecologic surgery decreases with increased procedure volume. However, in all of the scenarios modeled, robotically assisted hysterectomy remained substantially more costly than laparoscopic hysterectomy.

The great recession and health spending among uninsured U.S. immigrants: implications for the Affordable Care Act implementation

OBJECTIVE

We study the association between the timing of the Great Recession (GR) and health spending among uninsured adults distinguishing by citizenship/nativity status and time of U.S. residence.

DATA SOURCE

Uninsured U.S. citizens and noncitizens from the 2005-2006 and 2008-2009 Medical Expenditure Panel Survey.

STUDY DESIGN

The probability of reporting any health spending and the natural logarithm of health spending are our main dependent variables. We compare health spending across population categories before/during the GR. Subsequently, we implement two-part regression analyses of total and specific health-spending measures. We predict average health spending before/during the GR with a smearing estimation.

PRINCIPAL FINDINGS

The probability of reporting any spending diminished for recent immigrants compared to citizens during the GR. For those with any spending, recent immigrants reported higher spending during the GR (27 percent). Average reductions in total spending were driven by the decline in the share of the population reporting any spending among citizens and noncitizens.

CONCLUSIONS

Our study findings suggest that recent immigrants could be forgoing essential care, which later translates into higher spending. It portrays the vulnerability of a population that would remain exposed to income shocks, even after the Affordable Care Act (ACA) implementation.