RESEARCH
Journal of the American Heart Association
Goodney PP, Newhall KA, Bekelis K, Gottlieb D, Comi R, Chaudrain S, Faerber AE, Mackenzie TA, Skinner JS
Annual hemoglobin A1c testing is recommended for patients with diabetes mellitus. However, it is unknown how consistently patients with diabetes mellitus receive hemoglobin A1c testing over time, or whether testing consistency is associated with adverse cardiovascular outcomes.
Fiscal Studies
Sean Fahle, Kathleen McGarry, and Jonathan Skinner
We use data from the Health and Retirement Study (HRS) to document the distribution of out-of-pocket medical spending among individuals aged 55 and over in the US. The HRS data permit us to examine out-of-pocket spending close to the end of life and to analyse the components of spending in more detail than has been done in previous studies. We find that spending risk rises sharply at older ages and near the end of life. While the median individual spent $6,328 out-of-pocket in the last year of life, 5 per cent were reported to have spent over $62,040. Our results also indicate that out-of-pocket spending is highly concentrated, with the top 10 per cent of spenders accounting for 42 per cent of all spending, and very persistent, even over periods spanning many years. Finally, while certain categories of spending are very responsive to income and wealth, we do not find overall spending to be highly concentrated along these dimensions. Viewed within the international context, our results suggest that the fraction of households facing very high out-of-pocket spending is substantially greater in the US than in other developed countries.
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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Vascular
Karina A Newhall, Kimon Bekelis, Bjoern D Suckow, Daniel J Gottlieb, Adrienne E Farber, Philip P Goodney, and Jonathan S Skinner
The risk of leg amputation among patients with diabetes has declined over the past decade, while use of preventative measures—such as hemoglobin A1c monitoring—has increased. However, the relationship between hemoglobin A1c testing and amputation risk remains unclear.
Journal of the American College of Cardiology
Roth GA , Poole JE , Zaha R , Zhou W , Skinner JS , Morden NE
Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is recommended before primary prevention implantable cardioverter-defibrillator (ICD) placement. Adherence to this recommendation and associated outcomes are unknown.
Review of Economics and Statistics
Jonathan Skinner and Douglas Staiger
We draw on macroeconomic models of diffusion and productivity to explain empirical patterns of survival gains in heart attacks. Using Medicare data for 2.8 million patients from 1986 to 2004, we find that hospitals rapidly adopting cost-effective innovations such as beta blockers, aspirin, and reperfusion had substantially better outcomes for their patients. Holding technology adoption constant, the marginal returns to spending were relatively modest. Hospitals increasing the pace of technology diffusion (‘‘tigers’’) experienced triple the survival gains compared to those with diminished rates (‘‘tortoises’’). In sum, small differences in the propensity to adopt effective technology lead to wide productivity differences across hospitals
Medical Care
Alsan M, Morden NE, Gottlieb JD, Zhou W , Skinner JS
Excessive antibiotic use in cold and flu season is costly and contributes to antibiotic resistance. The study objective was to develop an index of excessive antibiotic use in cold and flu season and determine its correlation with other indicators of prescribing quality.
Annals of Internal Medicine
Kelley AS, McGarry K, Gorges R, Skinner JS
Common diseases, particularly dementia, have large social costs for the U.S. population. However, less is known about the end-of-life costs of specific diseases and the associated financial risk for individual households.
International Journal of Stroke
Bekelis K, Smith J, Zhou W, MacKenzie TA, Roberts DW, Skinner JS, …
Statins have been shown to decrease aneurysm progression and rupture in two experimental settings: animals with cerebral aneurysm and humans with abdominal aortic aneurysms.
Aims: To investigate statin use and outcomes in humans with unruptured cerebral aneurysms through Medicare administrative data.
Insights in the Economics of Aging
Chandra A, Hoppenfeld T, Skinner J
There is a vast literature documenting the presence of pervasive racial disparities in U.S. health care (IOM, 2002). More recently, researchers have studied changes over time in the extent of racial and socioeconomic disparities, to test whether the public focus on disparities in health care has led to fundamental changes in practice styles, improved sensitivity by health care providers to different cultural norms, and less biased treatment and outcome decisions. In many cases, there has been a notable reduction in the magnitude of disparities in treatment and the use of “effective” care (Trivedi et al., 2005; Trivedi et al., 2011; Jha et al., 2005). There is less progress, however, with respect to racial disparities in overall health outcomes (e.g. Cutler and Meara, 2008).
How can this puzzle be explained? Many efforts to address disparities have focused on how physicians treat patients of different races and ethnicities. For example, the public knowledge that stenting rates for Black patients are so much lower than those for white patients could lead to cardiologists at the margin to question their decisions not to provide stents to their Black patients. An increasing share of minority health professionals could also lead to a decline in the extent of disparities in treatments of diverse patient populations. Over a sufficiently lengthy period of time, we might expect to see a convergence in treatment patterns as a result of efforts to reduce both implicit and explicit biases in health care within the hospital.
PloS One
Yasaitis LC, Bubolz T, Skinner JS, Chandra A
Proposed payment reforms in the US healthcare system would hold providers accountable for the care delivered to an assigned patient population. Annual hemoglobin A1c (HbA1c) tests are recommended for all diabetics, but some patient populations may face barriers to high quality healthcare that are beyond providers’ control. The magnitude of fine-grained variations in care for diabetic Medicare beneficiaries, and their associations with local population characteristics, are unknown.
Medical Care
Morden NE, Munson JC, Colla CH, Skinner JS, Bynum JPW, Zhou, W, Meara E
Prescription opioid use and overdose deaths are increasing in the United States. Among disabledMedicare beneficiaries under the age of 65, the rise in musculoskeletal conditions as qualifying diagnoses suggests that opioid analgesic use may be common and increasing, raising safety concerns.
COPD Exacerbations: Precipitating Factors, Prevention, and Outcomes
Jeffrey C. Munson, Donald A. Mahler, Jeremy Smith, Nancy E. Morden, Jonathan S. Skinner
Inhaled corticosteroids have been shown to reduce exacerbation frequency in select patients with COPD; however, they are also associated with adverse effects and high costs. Careful patient selection is therefore important. This study aimed to evaluate the extent to which clinicians target inhaled steroid therapy to patients most likely to benefit.
Stroke
Kimon Bekelis, Jeremy Smith, Weiping Zhou, David Roberts, Jonathan Skinner, and Nancy Morden
Animal studies have demonstrated that statins decrease cerebral aneurysm progression and the risk of subarachnoid hemorrhage (SAH). A protective effect has also been observed in human studies of abdominal aortic aneurysms. We investigated the association between statin use and SAH in Medicare beneficiaries.
Circulation: Cardiovascular Quality and Outcomes
Kimon Bekelis, David W. Roberts, Weiping Zhou, and Jonathan S. Skinner
Computed tomographic (CT) scans are central diagnostic tests for ischemic stroke. Their inefficient use is a negative quality measure tracked by the Centers for Medicare and Medicaid Services. We performed a retrospective analysis of Medicare fee-for-service claims data for adults admitted for ischemic stroke from 2008 to 2009, with 1-year follow-up. The outcome measures were risk-adjusted rates of high-intensity CT use (≥4 head CT scans) and risk- and price-adjusted Medicare expenditures in the year after admission. The average number of head CT scans in the year after admission, for the 327 521 study patients, was 1.94, whereas 11.9% had ≥4. Risk-adjusted rates of high-intensity CT use ranged from 4.6% (Napa, CA) to 20.0% (East Long Island, NY). These rates were 2.6% higher for blacks than for whites (95% confidence interval, 2.1%–3.1%), with considerable regional variation. Higher fragmentation of care (number of different doctors seen) was associated with high-intensity CT use. Patients living in the top quintile regions of fragmentation experienced a 5.9% higher rate of high-intensity CT use, with the lowest quintile as reference; the corresponding odds ratio was 1.77 (95% confidence interval, 1.71–1.83). Similarly, 1-year risk- and price-adjusted expenditures exhibited considerable regional variation, ranging from $31 175 (Salem, MA) to $61 895 (McAllen, TX). Regional rates of high-intensity CT scans were positively associated with 1-year expenditures (r=0.56; P<0.01).
British Medical Journal
Wennberg, DE, Sharp SM, Bevaan, G, Skinner JS, Gottlieb D
Per capita medical spending and utilization varies extensively among healthcare regions, as reported in the Dartmouth Atlas of Healthcare, the NHS Atlas of Variation, and the Spanish Atlas of Variability. These variations have raised major concerns about the effectiveness and equitable distribution of healthcare services, and led naturally to an important question: “To what extent can variations be explained by differences in illness of the regions’ populations?”
Brookings Papers on Economic Activity
A. Chandra, J. Holmes, J. Skinner
Why have health care costs moderated in the last decade? Some have suggested that the Great Recession alone was the cause, but health expenditure growth in the depths of the recession was nearly identical to growth prior to the recession. Nor can the Affordable Care Act (ACA) take credit, since the slowdown began prior to its implementation. Instead, we identify three primary causes of the slowdown: the rise in high-deductible insurance plans, state-level efforts to control Medicaid costs, and a general slowdown in the diffusion of new technology, particularly for use by the Medicare population. A more difficult question is: Will this slowdown continue? On this question we are pessimistic, and not entirely because a similar (and temporary) slowdown occurred in the early 1990s. The primary determinant of long-term growth is the continued development of expensive technology, and there is little evidence of a permanent slowdown in that pipeline. Proton beam accelerators are on target to double between 2010 and 2014, while the market for heartassist devices (costing more than $300,000 each) is projected to grow rapidly. Accountable care organizations (ACOs) and emboldened insurance companies may yet stifle health care cost growth, but our best estimate over the next two decades is that health care costs will grow at GDP plus 1.2 percent, a rate lower than previous estimates but still on track to cause serious fiscal pain for taxpayers and workers who bear the costs of higher premiums.
Medical Care
Yasaitis LC, Bynum JP, Skinner JS
There is considerable regional variation in Medicare outpatient visit rates; such variations may be the consequence of patient health, race/ethnicity differences, patient preferences, or physician supply and beliefs about the efficacy of frequently scheduled visits. The objective of the study was to test associations between varying regional Medicare outpatient visit rates and beneficiaries' health, race/ethnicity, preferences, and physician practice norms and supply.
Health Affairs
Katherine Baicker, Mark Shepard, and Jonathan Skinner
The US Medicare program consumes an ever-rising share of the federal budget. Although this public spending can produce health and social benefits, raising taxes to finance it comes at the cost of slower economic growth. In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the “one-size-fits-all” Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product. Our framework highlights the key trade-offs between Medicare spending and economic prosperity.
Journal of General Internal Medicine
Kelley AS, McGarry K, Fahle S, Marshall SM, Du Q, Skinner JS
A key objective of the Medicare program is to reduce risk of financial catastrophe due to out-of-pocket healthcare expenditures. Yet little is known about cumulative financial risks arising from out-of-pocket healthcare expenditures faced by older adults, particularly near the end of life.
