RESEARCH
Spine
Birkmeyer N.J., Weinstein J.N., Tosteson A.N.A., Tosteson, T.D., Skinner J.S., Lurie J.D., Deyo D.A., Wennberg J.E.
The Spine Patient Outcomes Research Trial (SPORT) was designed to assess the relative efficacy and cost-effectiveness of surgical and nonsurgical approaches to the treatment of common conditions associated with low back and leg pain.
Health Affairs
Wennberg JE., Fisher E.S., and Skinner J.S.
Medicare spending varies more than twofold among regions, and the variations persist even after differences in health are corrected for. Higher levels of Medicare spending are due largely to increased use of “supply-sensitive” services–physician visits, specialist consultations, and hospitalizations, particularly for those with chronic illnesses or in their last six months of life. Also, higher spending does not result in more effective care, elevated rates of elective surgery, or better health outcomes. To improve the quality and efficiency of care, we propose a new approach to Medicare reform based on the principles of shared decision making and the promotion of centers of medical excellence. We suggest that our proposal be tested in a major demonstration project.
New England Journal of Medicine
Elaine M. Silverman, M.D., M.P.H., Jonathan S. Skinner, Ph.D., and Elliott S. Fisher, M.D., M.P.H.
The rate of conversion to for-profit ownership of hospitals has recently increased in the United States, with uncertain implications for health care costs. We compared total per capita Medicare spending in areas served by for-profit and not-for-profit hospitals. We used American Hospital Association data to categorize U.S. hospital service areas as for-profit (meaning that all beds in the area were in for-profit hospitals), not-for-profit (all beds were in not-for-profit hospitals), or mixed in 1989, 1992, and 1995. We then used data from the Continuous Medicare History Sample to calculate the 1989, 1992, and 1995 spending rates in each area, adjusting for other characteristics known to influence spending: age, sex, race, region of the United States, percentage of population living in urban areas, Medicare mortality rate, number of hospitals, number of physicians per capita, percentage of beds in hospitals affiliated with medical schools, percentage of beds in hospitals belonging to hospital chains, and percentage of Medicare beneficiaries enrolled in health maintenance organizations.
Health Affairs
McClellan M., and Skinner J.S.
As Medicare's share of federal spending and gross domestic product (GDP) rises, the program may have increasingly important consequences not only for the health of Americans but also for their net income and financial well-being. We use incidence analysis to study payments and benefits in Medicare to various generations and income groups. We find that Medicare actually provides larger net dollar transfers to wealthier beneficiaries, although the “insurance value” of these dollars is greater for low-income households. We then evaluate a range of proposed Medicare reforms with regard to their impact on the distribution of both health care and disposable income.
Medical Care
Moen EL, Bynum JP, Austin AA, Skinner JS, Chakraborti G, O’Malley AJ
Implantable cardioverter defibrillator (ICD) therapy is used for primary prevention of death among people with heart failure, and new evidence in 2005 on its effectiveness changed practice guidelines in the United States. The objective of this study is to examine how the connectedness of physicians and hospitals, measured using network analysis, relates to guideline-consistent ICD implantation. We constructed physician and hospital networks for cardiovascular disease. Physicians were linked if they shared cardiovascular disease patients; these links were aggregated by hospital affiliation to construct a hospital network…
JAMA
Amy Finkelstein, PhD; Yunan Ji, BA; Neale Mahoney, PhD; Jonathan Skinner, PhD
As part of a 5-year, mandatory-participation randomized trial by the Centers for Medicare & Medicaid Services, eligible metropolitan statistical areas (MSAs) were randomized to the Comprehensive Care for Joint Replacement (CJR) bundled payment model for LEJR episodes or to a control group. In the first performance year, hospitals received bonus payments if Medicare spending for LEJR episodes was below the target price and hospitals met quality standards. This interim analysis reports first-year data on LEJR episodes starting April 1, 2016, with data collection through December 31, 2016.
Health Affairs
Jonathan S. Skinner
Health economics as a profession has grown exponentially in the past half-century, but not everyone agrees on what health economics is. Many physicians think that health economists spend their days tabulating prices for cost-effectiveness studies. I once was called by a large pharmaceutical company seeking to recruit a health economist. Puzzled as to why any profitable company would want to employ me, I asked what they meant by “health economics.” With a sigh, the recruiter responded: “To prepare a business case for marketing new drugs.”
Cardiovascular Quality and Outcomes
Jesse A. Columbo, Ravinder Kang, Spencer W. Trooboff, Kristen S. Jahn, Camilo J. Martinez, Kayla O. Moore, Andrea M. Austin, Nancy E. Morden, Corinne G. Brooks, Jonathan S. Skinner, Philip P. Goodney
We devised an 8-step process to derive and validate ICD10 codes from an existing set of ICD-9 codes representing outcomes across several body systems (Figure 1). This process was developed in an iterative fashion with input from all coauthors and shared with collaborators as part of an ongoing National Institute on Aging Program Project (P01-AG019783).
Regional Science & Urban Economics
Francesco Moscone, Jonathan Skinner, Elisa Tosetti, Laura Yasaitis
As health care spending continues to strain government and household budgets, there is increasing interest in measuring whether the incremental dollar spent on health care is worth it. In studying this question, researchers often make two key assumptions: that health care intensity can be summarized by a single index such as average spending, and that samples of hospitals or regions are spatially independent: Manhattan and the Bronx are no more alike than are Manhattan and San Diego, for example. In this paper we relax both assumptions. Using detailed data on 897,008 elderly Medicare enrolees with acute myocardial infarction (or a heart attack) during 2007–11, we find first that the total level of health care spending has little impact on health outcomes; more important is how the money is spent. …
American Economic Journal
David Cutler, Jonathan S. Skinner, Ariel Dora Stern, and David Wennberg*
There is considerable controversy about the causes of regional variations in health care expenditures. Using vignettes from patient and physician surveys linked to fee-for-service Medicare expenditures, this study asks whether patient demand-side factors or physician supply-side factors explain these variations. The results indicate that patient demand is relatively unimportant in explaining variations. Physician organizational factors matter, but the most important factor is physician beliefs about treatment. In Medicare, we estimate that 35 percent of spending for end-of-life care and 12 percent of spending for heart attack patients (and for all enrollees) is associated with physician beliefs unsupported by clinical evidence. (JEL D83, H75, I11, I18)
Medical Care
Alexander J. Mainor, JD, MPH, Nancy E. Morden, MD, MPH, Jeremy Smith, MPH, Stephanie Tomlin, MS, MPA, and Jonathan Skinner, PhD
Using an analysis of Medicare data before and after the switch, we illustrate potential pitfalls of these crosswalks. We test some available translations by measuring weekly frequencies of common conditions during the transition and reveal the discontinuity of measures temporally aligned with the adoption of ICD-10 (October 1, 2015, the first day of the fourth quarter of 2015). We then suggest addressing this problem by creating a public good for all researchers, using a web-based platform, “Dataverse” for sharing ICD-9 and comparable ICD-10 definitions, rate comparisons that quantify the discontinuity in diverse datasets (to allow adjustment for comparisons over time), and the programming code used to make the comparisons. Our exploration of inpatient diagnostic code discontinuity illustrates the problem and serves as a starting point for the envisioned shared resource that would include a broad range of datasets.
Journal of the American Geriatrics Society
Julie Bynum, MD, MPH, Honor Passow, PhD, Donald Carmichael, MDiv, and Jonathan Skinner, PhD
Using PSA screening, we aimed to understand which factors influence practice change during a period when a decline in service use would be expected. First, we focused on national PSA screening in men aged 68 and older with fee-for-service Medicare from 2003 to 2013 and examine the influence of guidelines by assessing changes in likelihood of screening associated with factors directly mentioned in guidelines. Second, we focused on practice change across U.S. hospital referral regions (HRRs) for men aged 75 and older – for whom guidelines have been in agreement – to test whether practice variation declines and what contextual factors are associated with greater decline. We hypothesized that guidelines and the practice environment would influence the degree to which practitioners and patients would reduce their use of an existing practice in the face of converging evidence regarding effectiveness.
