Treatments and Health Outcomes of Medicare Patients With Back Pain.

Back pain treatments are costly and frequently involve use of procedures that may have minimal benefit on improving patients' functional status. Two recent studies evaluated adverse outcomes (mortality and major medical complications) following receipt of spinal surgery but neither examined whether such treatments affected functional ability. Using a sample composed of Medicare patients with persistent back pain, we examined whether functional ability improved after treatment, comparing patients treated with back surgery or spinal injections to nonrecipients.

Physician compensation strategies and quality of care for Medicare beneficiaries.

Objectives: To examine the relationship between the compensation strategies of primary care physicians (PCPs) and the quality and outcomes of care delivered to Medicare beneficiaries.

Study Design: Cross-sectional analysis of physician survey data linked to Medicare claims. We used a previously constructed typology that was developed based on the survey to categorize physician compensation strategies.

Factors associated with geographic variation in cost per episode of care for three medical conditions.

Objective: To identify associations between market factors, especially relative reimbursement rates, and the probability of surgery and cost per episode for three medical conditions (cataract, benign prostatic neoplasm, and knee degeneration) with multiple treatment options.

Methods: We use 2004-2006 Medicare claims data for elderly beneficiaries from sixty nationally representative communities to estimate multivariate models for the probability of surgery and cost per episode of care as a function local market factors, including Medicare physician reimbursement for surgical versus non-surgical treatment and the availability of primary care and specialty physicians. We used Symmetry's Episode Treatment Groups (ETG) software to group claims into episodes for the three conditions (n = 540,874 episodes).

Higher practice intensity is associated with higher quality of care but more avoidable admissions for medicare beneficiaries.

Background: The relationship between practice intensity and the quality and outcomes of care has not been studied.

Objective: To examine the relationship between primary care physicians' costliness both for defined episodes of care and for defined patients and the quality and outcomes of care delivered to Medicare beneficiaries.

Study Design: Cross sectional analysis of physician survey data linked to Medicare claims.

Geographic variations in the cost of treating condition-specific episodes of care among Medicare patients.

Objectives: To measure geographic variations in treatment costs for specific conditions, explore the consistency of these patterns across conditions, and examine how service mix and population health factors are associated with condition-specific and total area costs.

Data Sources: Medicare claims for 1.5 million elderly beneficiaries from 60 community tracking study (CTS) sites who received services from 5,500 CTS Physician Survey respondents during 2004-2006.

Geographic variation in fee-for-service medicare beneficiaries' medical costs is largely explained by disease burden.

Control for area differences in population health (casemix adjustment) is necessary to measure geographic variations in medical spending. Studies use various casemix adjustment methods, resulting in very different geographic variation estimates. We study casemix adjustment methodological issues and evaluate alternative approaches using claims from 1.

Medicare spending, mortality rates, and quality of care.

We applied instrumental variable analysis to a sample of 388,690 Medicare beneficiaries predicted to be high-cost cases to estimate the effects of medical care use on the relative odds of death or experiencing an avoidable hospitalization in 2006. Contrary to conclusions from the observational geographic variations literature, the results suggest that greater medical care use is associated with statistically significant and quantitatively meaningful health improvements: a 10% increase in medical care use is associated with a 8.4% decrease in the mortality rate and a 3.

The relationship between physician compensation strategies and the intensity of care delivered to Medicare beneficiaries.

Objective: To examine the relationship between primary care physicians' (PCPs) payment arrangements and the total costs and intensity of care for specific episodes of care for Medicare beneficiaries.

Data Sources/study Setting: We combined data from the 2004 to 2005 Community Tracking Study Physician Survey on PCP compensation methods with administrative data from the Medicare program for beneficiaries to whom these physicians provided services over the time period 2004-2006.

Study Design: Cross-sectional analysis of physician survey data linked to Medicare claims.

Medical spending and the health of the elderly.

Objective: To estimate the relationship between variations in medical spending and health outcomes of the elderly.

Data Sources: 1992-2002 Medicare Current Beneficiary Surveys.

Study Design: We used instrumental variable (IV) estimation to identify the relationships between alternative measures of elderly Medicare beneficiaries' medical spending over a 3-year observation period and health status, measured by the Health and Activity Limitation Index (HALex) and survival status at the end of the 3 years.

Following the money: factors associated with the cost of treating high-cost Medicare beneficiaries.

Objective: To identify factors associated with the cost of treating high-cost Medicare beneficiaries.

Data Sources: A national sample of 1.6 million elderly, Medicare beneficiaries linked to 2004-2005 Community Tracking Study Physician Survey respondents and local market data from secondary sources.

Creating a parsimonious typology of physician financial incentives.

In order to create an empirically derived parsimonious typology of physician financial incentives that will be useful for future research, we used data from the nationally representative 2004-2005 Community Tracking Study Physician Survey (N = 6,628). Linear regression analyses informed by economic theory were used to identify the combinations of incentives associated with an overall financial incentive to expand services to individual patients. The approach was validated using two nonparametric methods (CART analysis and data mining techniques) and by examining the relationship between the resulting typology and other measures of physician behavior including hours worked, visit volume, and specialty-adjusted income.

Comparative effectiveness of prostate cancer treatments: evaluating statistical adjustments for confounding in observational data.

Background: Using observational data to assess the relative effectiveness of alternative cancer treatments is limited by patient selection into treatment, which often biases interpretation of outcomes. We evaluated methods for addressing confounding in treatment and survival of patients with early-stage prostate cancer in observational data and compared findings with those from a benchmark randomized clinical trial.

Methods: We selected 14 302 early-stage prostate cancer patients who were aged 66-74 years and had been treated with radical prostatectomy or conservative management from linked Surveillance, Epidemiology, and End Results-Medicare data from January 1, 1995, through December 31, 2003.

Clarifying sources of geographic differences in Medicare spending.

Background: Although geographic differences in Medicare spending are widely considered to be evidence of program inefficiency, policymakers need to understand how differences in beneficiaries' health and personal characteristics and specific geographic factors affect the amount of Medicare spending per beneficiary before formulating policies to reduce geographic differences in spending.

Methods: We used Medicare Current Beneficiary Surveys from 2000 through 2002 to examine differences across geographic areas (grouped into quintiles on the basis of Medicare spending per beneficiary over the same period). We estimated multivariate-regression models of individual spending that included demographic and baseline health characteristics, changes in health status, other individual determinants of demand, and area-level measures of the supply of health care resources.

Medicare fees and the volume of physicians' services.

This paper estimates the relationship between Medicare fees and quantities provided by physicians for eight specific services. It uses data for 13,707 physicians who responded to surveys in 2000/2001 and/or 2004/2005 and were linked to all Medicare claims for their Medicare patients. Results show that Medicare fees are positively related to quantity provided for all eight services, and are significantly different from zero and elastic for five of them.

Covering the uninsured in 2008: current costs, sources of payment, and incremental costs.

People uninsured for any part of 2008 spend about $30 billion out of pocket and receive approximately $56 billion in uncompensated care while uninsured. Government programs finance about 75 percent of uncompensated care. If all uninsured people were fully covered, their medical spending would increase by $122.

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients.

Context: The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients.

Why do Hispanics have so little employer-sponsored health insurance?

This paper investigates low rates of employer health insurance coverage among Hispanics using national data from the Community Tracking Study Household Survey. Interview language served as a proxy for the degree of assimilation. Findings indicate that English-speaking Hispanics are more similar to whites in their labor market experiences and coverage than they are to Spanish-speaking Hispanics.

Differences between symptom-specific and general survey questions of unmet need in measuring insurance and racial/ethnic disparities in access to care.

Objective: To examine differences in insurance and racial/ethnic disparities in access to care between a single-item measure of general unmet medical need and a multi-item measure of symptom-specific unmet medical need.

Data Source: The 2003 Community Tracking Study Household Survey, which included both a single question about any unmet medical needs over the last year, and a measure of unmet medical need keyed to the recent occurrence of 1 of 15 symptoms that a panel of physicians considered serious enough to warrant seeking medical care.

Study Design/methods: We constructed 3 measures of unmet need (general perceived unmet need, perceived unmet need for a specific new symptom, and actual unmet need for the new symptom).

Setting a standard of affordability for health insurance coverage.

Recently, Massachusetts passed landmark legislation designed to expand health insurance coverage. This legislation includes a requirement that all adults enroll in a health insurance plan. This mandate takes effect only if an "affordable" plan is available.

Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition.

Context: Given the large and increasing number of uninsured US individuals, identifying the health consequences of being uninsured has assumed increased importance.

Objective: To compare medical care use and short-term health changes among US uninsured individuals and insured nonelderly individuals following a health shock caused by either an unintentional injury or the onset of a chronic condition.

Design, Setting, And Participants: Multivariate logistic regression analysis of longitudinal data from Medical Expenditure Panel Surveys (1997-2004) limited to nonelderly individuals whose insurance status was established for 2 months prior to 1 or more unintentional injuries (20 783 cases among 15 866 individuals) and onset of 1 or more chronic conditions (10 485 cases among 7954 individuals).

Identifying affordable sources of medical care among uninsured persons.

Objective: To examine the effects of policy, health system, and sociodemographic characteristics on the likelihood that uninsured persons pay a lower price at their regular source of care, or that they are aware of lower priced providers in their community.

Data Sources: The 2003 Community Tracking Study household survey, a nationally representative sample of the U.S.

Insurance premiums and insurance coverage of near-poor children.

States increasingly are using premiums for near-poor children in their public insurance programs (Medicaid/SCHIP) to limit private insurance crowd-out and constrain program costs. Using national data from four rounds of the Community Tracking Study Household Surveys spanning the seven years from 1996 to 2003, this study estimates a multinomial logistic regression model examining how public and private insurance premiums affect insurance coverage outcomes (Medicaid/SCHIP coverage, private coverage, and no coverage). Higher public premiums are significantly associated with a lower probability of public coverage and higher probabilities of private coverage and uninsurance; higher private premiums are significantly related to a lower probability of private coverage and higher probabilities of public coverage and uninsurance.

Effects of public premiums on children's health insurance coverage: evidence from 1999 to 2003.

This study uses 2000 to 2004 Current Population Survey data to examine the effects of public premiums on the insurance coverage of children whose family incomes are between 100% and 300% of the federal poverty level. The analysis employs multinomial logistic models that control for factors other than premium costs. While the magnitude of the estimated effects varies across models, the results consistently indicate that raising public premiums reduces enrollment in public programs, with some children who forgo public coverage having private coverage instead and others being uninsured.

Physician financial incentives: use of quality incentives inches up, but productivity still dominates.

The proportion of physicians in group practice whose compensation is based in part on quality measures increased from 17.6 percent in 2000-01 to 20.2 percent in 2004-05, according to a new national study from the Center for Studying Health System Change (HSC).

Would safety-net expansions offset reduced access resulting from lost insurance coverage? Race/ethnicity differences.

This study simulated whether increased community health center (CHC) funding under the Bush administration narrowed racial/ethnic gaps in access to care among low-income people. Expanded CHC funding resulted in small increases in access to care, more so for minorities than for whites. Spanish-speaking Hispanics had the largest improvements in access in the simulation.