JAMA
Welch GH, Sharp SM, Gottlieb DJ, Skinner JS, Wennberg JE
Because diagnosis is typically thought of as purely a patient attribute, it is considered a critical factor in risk-adjustment policies designed to reward efficient and high-quality care.
McAllen and El Paso Revisited: Medicare Variations Not Always Reflected in the Under-65 Population
Health Affairs
Franzini L, Mikhail OI, Skinner JS
Medicare spending for the elderly is much higher in McAllen, Texas, than in El Paso, Texas, as reported in a 2009 New Yorker article by Atul Gawande. To investigate whether this disparity was present in the non-Medicare populations of those two cities, we obtained medical use and expense data for patients privately insured by Blue Cross and Blue Shield of Texas. In contrast to the Medicare population, the use of and spending per capita for medical services by privately insured populations in McAllen and El Paso was much less divergent, with some exceptions. For example, although spending per Medicare member per year was 86 percent higher in McAllen than in El Paso, total spending per member per year in McAllen was 7 percent lower than in El Paso for the population insured by Blue Cross and Blue Shield of Texas. We consider possible explanations but conclude that health care providers respond quite differently to incentives in Medicare compared to those in private insurance programs.
Measuring Racial Disparities in the Quality of Ambulatory Diabetes Care
Medical Care
Bynum JP, Fisher ES, Song Y, Skinner JS, Chandra A
Improving the health of minority patients who have diabetes depends in part on improving quality and reducing disparities in ambulatory care. It has been difficult to measure these components at the level of actionable units.
Medicare Payments for Common Inpatient Procedures: Implications for Episode-based Payment Bundling
Health Services Research
Birkmeyer JD, Gust C, Baser O, Dimick JB, Sutherland JM, Skinner JS
Aiming to align provider incentives toward improving quality and efficiency, the Center for Medicare and Medicaid Services is considering broader bundling of hospital and physician payments around episodes of inpatient surgery. Decisions about bundled payments would benefit from better information about how payments are currently distributed among providers of different perioperative services and how payments vary across hospitals.
Regional Variations in Diagnostic Practices
New England Journal of Medicine
Song Y, Skinner JS, Bynum J, Sutherland J, Wennberg, JE, Fisher ES
Current methods of risk adjustment rely on diagnoses recorded in clinical and administrative records. Differences among providers in diagnostic practices could lead to bias. We used Medicare claims data from 1999 through 2006 to measure trends in diagnostic practices for Medicare beneficiaries. Regions were grouped into five quintiles according to the intensity of hospital and physician services that beneficiaries in the region received. We compared trends with respect to diagnoses, laboratory testing, imaging, and the assignment of Hierarchical Condition Categories (HCCs) among beneficiaries who moved to regions with a higher or lower intensity of practice.
Looking Back, Moving Forward
New England Journal of Medicine
Skinner, JS , Staiger D and Fisher ES
The recent Senate election in Massachusetts may reshape or delay health care reform, but we still face the twin challenges of unsustainable cost increases and uneven quality that plague U.S. health care. Recent controversies have left many people confused about how we might wisely move forward. One such controversy is the debate over the “value index,” a reimbursement approach that would adjust providers’ payments on the basis of regional performance on quality and cost measures. Legitimately concerned that careless implementation of a value index might hurt some preeminent teaching institutions, some leaders of academic medical centers have responded to this proposal by questioning the validity of existing measures of cost performance, many of which have been generated from Medicare data by our Dartmouth research group.
Prices Don’t Drive Regional Medicare Spending Variations
Health Affairs
Gottlieb D, Zhou W, Song Y., Gilman K, Skinner JS, Sutherland JM
Per capita Medicare spending is more than twice as high in New York City and Miami than in places like Salem, Oregon. How much of these differences can be explained by Medicare’s paying more to compensate for the higher cost of goods and services in such areas? To answer this question, we analyzed Medicare spending after adjusting for local price differences in 306 Hospital Referral Regions. The priceadjustment analysis resulted in less variation in what Medicare pays regionally, but not much. The findings suggest that utilization—not local price differences—drives Medicare regional payment variations, along with special payments for medical education and care for the poor.
The Impact of Workers’ Compensation on Outcomes of Surgical and Nonoperative Therapy for Patients With a Lumbar Disc Herniation
Spine
Atlas SJ, Tosteson TD, Blood EA, Skinner JS, Pransky GS and Weinstein JN
Patients with at least 6 weeks of sciatica and a lumbar IDH were enrolled in either a randomized trial or observational cohort at 13 US spine centers. Patients were categorized as workers’ compensation or nonworkers’ compensation based on baseline disability compensation and work status. Treatment was usual nonoperative care or surgical discectomy. Outcomes included pain, functional impairment, satisfaction and work/disability status at 6 weeks, 3, 6, 12, and 24 months.
Comparative Effectiveness and Health Care Spending — Implications for Reform
New England Journal of Medicine
Weinstein MC and Skinner JS
Title VIII of the American Recovery and Reinvestment Act of 2009 authorizes the expenditure of $1.1 billion to conduct research comparing “clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions.” Federal support of “comparative effectiveness” research has been viewed as a cornerstone in controlling runaway health care costs.
Although cost is not mentioned explicitly in the comparative effectiveness legislation, the American College of Physicians and others have called for cost-effectiveness analysis — assessment of the added improvement in health outcomes relative to cost — to be on the agenda for comparative effectiveness research. This approach has come under harsh criticism from some who view it as the first step in health care rationing by the government — that cost cutting will mean the withdrawal of expensive treatments with small (but still positive) benefits. Some politicians have therefore tried to restrict any efforts to use comparative effectiveness to guide U.S. health care policy.