Public versus Private Care in the Military Health System: Evidence From Low Back Pain Patients

INTRODUCTION

There is a longstanding debate about whether health care is more efficiently provided by the public or private sector. The debate is particularly relevant to the Military Health System (MHS), which delivers care through a combination of publicly funded federal facilities and privately contracted providers. This study compares outcomes, treatments, and costs for MHS patients obtaining care for low back pain (LBP) from public versus private providers.

MATERIALS AND METHODS

A retrospective cohort study was completed using TRICARE Prime claims data from April 2015 to December 2018. The cohort was identified using International Classification of Diseases Ninth Revision and Tenth Revision diagnostic codes and then followed for 12 months after the index diagnosis to assess treatments, outcomes, and costs. Claims were classified as originating from either public or private providers. The primary outcome measure was resolution of LBP, defined as an absence of LBP diagnoses during the 6-to-12-month window following the index event. Instrumental variable models were used to assess the impact of care setting (i.e., private versus public), conditioning on the covariates. A regional measure of the fraction of private care was used as an instrument.

RESULTS

Resolution of LBP was achieved for 79.7% of 144,866 patients in the cohort. No significant association was found between resolution of LBP and fraction of privately provided care. Higher fraction of private care was associated with a greater likelihood of opioid treatments (odds ratio, 1.22; 95% CI, 1.02-1.46) and a lower likelihood of benzodiazepine (odds ratio, 0.56; 95% CI, 0.45-0.70) and physical therapy (odds ratio 0.55; 95% CI, 0.42-0.74) treatments; manual therapy was not significantly associated with the fraction of private care. There was a significant negative association between the fraction of private care and cost (coefficient -0.27; 95% CI, -0.44, -0.10).

CONCLUSION

This study found that privately provided care was associated with significantly higher opioid prescribing, less use of benzodiazepines and physical therapy, and lower costs. No systematic differences in outcomes (as measured by resolved cases) were identified. The findings suggest that publicly funded health care within the MHS context can attain quality comparable to privately provided care, although differences in treatment choices and costs point to possibilities for improved care within both systems.

Disparities in Access to Multidisciplinary Cancer Consultations and Treatment for Patients With Early-Stage Non-Small Cell Lung Cancer: A SEER-Medicare Analysis

PURPOSE

Disparities in access to a multidisciplinary cancer consultation (MDCc) persist, and the role of physician relationships remains understudied. This study examined the extent to which multilevel factors, including patient characteristics and patient-sharing network measures reflecting the structure of physician relationships, are associated with an MDCc and receipt of stereotactic body radiation therapy versus surgery among patients with early-stage non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results (SEER)-Medicare data for patients diagnosed with stage I-IIA NSCLC from 2016 to 2017. We assembled patient-sharing networks and identified cancer specialists who were locally unique for their specialty, herein referred to as linchpins. The proportion of linchpin cancer specialists for each hospital referral region (HRR) was calculated as a network-based measure of specialist scarcity. We used multilevel multinomial logistic regression to estimate associations between study variables and receipt of an MDCc and multilevel logistic regression to examine the relationship between patient receipt of an MDCc and initial treatment.

RESULTS

Our study included 6120 patients with stage I-IIA NSCLC, of whom 751 (12.3%) received an MDCc, 1729 (28.3%) consulted only a radiation oncologist, 2010 (32.8%) consulted only a surgeon, and 1630 (26.6%) consulted neither specialist within 2 months of diagnosis. Compared with patients residing in an HRR with a low proportion of linchpin surgeons, those residing in an HRR with a high proportion of linchpin surgeons had a 2.99 (95% CI, 1.87-4.78) greater relative risk of consulting only a radiation oncologist versus receiving an MDCc and a 2.70 (95% CI, 1.68-4.35) greater relative risk of consulting neither specialist versus receiving an MDCc. Patients who received an MDCc were 5.32 times (95% CI, 4.27-6.63) more likely to receive stereotactic body radiation therapy versus surgery.

CONCLUSIONS

Physician networks are associated with receipt of an MDCc and treatment, underscoring the potential for leveraging patient-sharing network analysis to improve access to lung cancer care.

Association between a network-based physician linchpin score and cancer patient mortality: a SEER-Medicare analysis

BACKGROUND

Patients with cancer frequently require multidisciplinary teams for optimal cancer outcomes. Network analysis can capture relationships among cancer specialists, and we developed a novel physician linchpin score to characterize "linchpin" physicians whose peers have fewer ties to other physicians of the same oncologic specialty. Our study examined whether being treated by a linchpin physician was associated with worse survival.

METHODS

In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results-Medicare data for patients diagnosed with stage I to III non-small cell lung cancer or colorectal cancer (CRC) in 2016-2017. We assembled patient-sharing networks and calculated linchpin scores for medical oncologists, radiation oncologists, and surgeons. Physicians were considered linchpins if their linchpin score was within the top 15% for their specialty. We used Cox proportional hazards models to examine associations between being treated by a linchpin physician and survival, with a 2-year follow-up period.

RESULTS

The study cohort included 10 081 patients with non-small cell lung cancer and 9036 patients with CRC. Patients with lung cancer treated by a linchpin radiation oncologist had a 17% (95% confidence interval = 1.04 to 1.32) greater hazard of mortality, and similar trends were observed for linchpin medical oncologists. Patients with CRC treated by a linchpin surgeon had a 22% (95% confidence interval = 1.03 to 1.43) greater hazard of mortality.

CONCLUSIONS

In an analysis of Medicare beneficiaries with nonmetastatic lung cancer or CRC, those treated by linchpin physicians often experienced worse survival. Efforts to improve outcomes can use network analysis to identify areas with reduced access to multidisciplinary specialists.

Do Physician Patient Sharing Networks Impact Disparities in Access to Multidisciplinary Cancer Consultation for Early-Stage Lung Cancer? A SEER-Medicare Network Analysis

PURPOSE/OBJECTIVE(S)

To examine early-stage non-small cell lung cancer (NSCLC) patient and physician network characteristics associated with receipt of multidisciplinary cancer consultations (MDCCs), defined as an encounter with both a surgeon and a radiation oncologist after diagnosis. We tested the hypothesis that physician roles in patient-sharing networks can modify disparities in access to surgical and radiotherapy care. Specifically, we investigated the role of "linchpin physicians" using a novel network measure that assesses the extent to which a physician is the sole type of specialist in their physician patient sharing network, and the association of these physicians on patterns of care.

MATERIALS/METHODS

The study cohort included patients diagnosed with stage I/IIA NSCLC in 2016-17 using Surveillance, Epidemiology and End Results (SEER)-Medicare data. We assembled a physician patient-sharing network using all NSCLC patient encounters between 3 months prior to and 12 months following diagnosis. We weighted physicians' patient-sharing ties by the number of shared patients and calculated physician's linchpin scores as a continuous variable measuring the extent to which a physicians' peers in the network lack ties to others of the same specialty as the focal physician. Physicians in the top 15%ile were considered a linchpin specialist. We then derived the proportion of linchpin surgeons or radiation oncologists per hospital referral region (HRR). We assessed patient characteristics including age, sex, race, ethnicity, cancer stage, comorbidity index, rurality, and socioeconomic status (SES). The study outcome was a surgical, radiation oncology, or MDCC in the 2 months following diagnosis. We then performed multivariable logistic regressions (MLR) to assess whether linchpins modified disparities in MDCC.

RESULTS

Of 6,148 patients in the study, 12% received a MDCC, 28% only saw a radiation oncologist, 33% only saw a surgeon, and 27% saw neither for 2 months after diagnosis. On MLR, Hispanic patients were significantly less likely than White patients to receive consultations with a radiation oncologist, while patients in lowest SES quintile were significantly less likely to receive a surgical consultation than those in the highest SES. The proportion of linchpin surgeons and radiation oncologists per HRR was negatively associated with receipt of MDCC (OR low vs high [95% CI] = 0.75 [0.66 to 0.86]; 0.70 [0.61 to 0.80, respectively), but our regressions did not show that any demographic or SES disparities were modified by linchpin specialists.

CONCLUSION

Linchpin specialists do not impact known disparities in access to cancer consultations. Identifying additional system-level factors that contribute to disparities in cancer consultations may lead to policy insights aimed at reducing unwarranted variation in care.