Association Between Medicare Expenditure Growth and Mortality Rates in Patients With Acute Myocardial Infarction A Comparison From 1999 Through 2014

JAMA
Donald S. Likosky, Jessica Van Parys, Weiping Zhou, William B. Borden, Milton C.Weinstein, Jonathan S. Skinner

Many studies have considered the association between Medicare spending and health outcomes at a point in time; few have considered the association between the long-term growth in spending and outcomes.

Replacing the Affordable Care Act: Lessons From Behavioral Economics

JAMA
Jonathan S. Skinner and Kevin G. Volpp

Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults

JAMA Surgery
Regenbogen SE, Cain-Nielsen AH, Norton EC, Chen LM, Birkmeyer JD, Skinner JS

As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions.

Physician Practice Style Variation—Implications for Policy

JAMA Internal Medicine
Van Parys J and Skinner J

Practice style variation at the regional level has been well documented at different geographic levels, but there is much less research focusing on the role of individual physician variability in practice. Two studies have shown considerable variation in the practice styles of cardiologists who treat patients with acute myocardial infarction and obstetricians who perform cesarean-sections, but less is known about how the use of non-recommended or “low-value” care varies across physicians.

Primary Stroke Center Hospitalization for Elderly Patients With Stroke Implications for Case Fatality and Travel Times

JAMA Internal Medicine
Kimon Bekelis, MD; Nancy J. Marth, MS, MSN; Kendrew Wong, BS; Weiping Zhou, MS; John D. Birkmeyer, MD; Jonathan Skinner, PhD

Physicians often must decide whether to treat patients with acute stroke locally or refer them to a more distant Primary Stroke Center (PSC). There is little evidence on how much the increased risk of prolonged travel time offsets benefits of a specialized PSC care.

The Past and Future of the Affordable Care Act

JAMA
Jonathan Skinner and Amitabh Chandra

President Barack Obama has provided a comprehensive assessment of the Affordable Care Act (ACA),1 which as he indicates is the most comprehensive health care reform since Medicare. In 1965, Medicare passed in the House with a 313-115 vote and in the Senate with a 68-21 vote. By contrast, the ACA barely reached the filibusterproof threshold of 60 votes in the Senate and passed the House with a 219-212 vote. As President Obama has chronicled, that the ACA passed at all, let alone survived multiple Supreme Court and Congressional challenges, is a political miracle.

Despite these compromises and partial setbacks, the primary goal of the ACA has been met: to expand the number of people with health insurance. With an estimated expansion in health insurance of 20 million individuals, President Obama is right to claim credit for the ACA. But counting up the number of individuals with insurance is not enough to assess if the ACA was a success. Perhaps the more important measures are whether the ACA improved health and saved money. For example, the 2008 Oregon Health Insurance Experiment, a randomized trial of Medicaid expansion, found that newly insured individuals used more hospital care, were given more prescription drugs, and received more preventive care than before receiving insurance. Individuals were less likely to be diagnosed with depression and experienced lessmedical debt, a leading source of bankruptcy. Although almost everyone reported being able to see a physician, hypertension and diabetes control did not change relative to the control group, overall medical spending increased by $1000 per person annually, and emergency department use increased by 40%.

These findings from Oregon, in contrast to claims that were made to justify the ACA,4 suggest both optimism and caution for the ACA’s primary goal of expanding insurance coverage and the related consequences. Even Medicaid—an insurance program that offers lower payment rates and narrower networks than commercial insurers andMedicare—is valuable but possibly less valuable than had been hoped. In other words, providing health insurance may not automatically result in an improvement in health when health care systems are fragmented and inefficient.

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Spending Differences Associated With the Medicare Physician Group Practice Demonstration

JAMA
Colla CH, Wennberg DE, Meara E, Skinner JS, Gottlieb D, Lewis VA, Snyder CM, Fisher ES

The Centers for Medicare & Medicaid Services (CMS) recently launched accountable care organization (ACO) programs designed to improve quality and slow cost growth. The ACOs resemble an earlier pilot, the Medicare Physician Group Practice Demonstration (PGPD), in which participating physician groups received bonus payments if they achieved lower cost growth than local controls and met quality targets. Although evidence indicates the PGPD improved quality, uncertainty remains about its effect on costs.

Geographic Variation in Diagnosis Frequency and Risk of Death among Medicare Beneficiaries

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.

Relationship Between Regional Per Capita Medicare Expenditures and Patient Perceptions of Quality of Care

JAMA
Fowler FJ, Gallagher PM, Anthony DL, Larsen K, Skinner JS

Wide variations in Medicare expenditures exist across regions, but little is known about whether beneficiaries residing in low-expenditure regions perceive receiving lower-quality care than those in high-expenditure regions. Our objective was to evaluate how Medicare beneficiaries’ perceptions of their health care are related to per capita expenditure in the areas where they live.

Surgical vs Nonoperative Treatment for Lumbar Disk Herniation The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial

JAMA
Weinstein J, Tosteson T, Lurie JD, Tosteson ANA, Hancome B, Skinner JS, Abdu WA, Hilibrand, AS, Boden SD, Deyo RA

Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.

Surgical vs Nonoperative Treatment for Lumbar Disk Herniation The Spine Patient Outcomes Research Trial (SPORT): Observational Cohort

JAMA
Weinstein J, Lurie JD, Tosteson T, Skinner JS, Hanscom B, Tosteson ANA, Herkowitz H, Fischgrund J, Cammisa F, Albert T, Deyo R

For patients with lumbar disk herniation, the Spine Patient Outcomes Research Trial (SPORT) randomized trial intent-to-treat analysis showed small but not statistically significant differences in favor of diskectomy compared with usual care. However, the large numbers of patients who crossed over between assigned groups precluded any conclusions about the comparative effectiveness of operative therapy vs usual care.