Firm Response to Low-Reimbursement Patients in the Market for Unscheduled Outpatient Care

Americans spent 13,400 person-years waiting in emergency departments (EDs) in 2009 alone, a figure that has been increasing at a compounded rate of 3.5% per year since at least the early 1990s. Furthermore, the quantity of emergency department services demanded has increased by 3.1% annually, but the supply of ED services has not increased concomitantly. This dissertation develops a theoretical model which explains this lack of supply response. In the model, consistent with anecdotal and cross-sectional evidence, hospitals are constrained from setting individual wait times based on non-clinical factors. However, the hospital chooses an overall set of policies (staffing levels, adoption of operations management innovations, etc.) which produces a hospital-wide baseline wait time. The hospital\u27s wait time is endogenous to the mix of patient profitabilities. Demand depends on the time price of services. The model predicts that higher wait times result from increased proportions of Medicaid and uninsured patients. A novel census of emergency department wait times in two states (MA, NJ) is used to test these predictions. First, the model\u27s assumption that hospitals are constrained in setting individual wait times based on profitability is supported by cross-sectional regression coefficients: hospitals with 50 percentage point greater uninsurance rates have 26.0 minute longer wait times (p\u3c.01; national mean wait time is 58 minutes), whereas conditional on hospital uninsurance rate individuals who are uninsured are not shown to have longer wait times (coefficient of 0.86 minutes, p=0.13). Next I use cross-sectional models which instrument for area uninsurance/Medicaid rates, models assessing the effect of entry of urgent care clinics into the market (since these clinics see predominantly insured, less severely injured patients), and triple-difference estimates of the differential effect of Massachusetts\u27 insurance expansion across the change in hospital insurance mix. Results support the theoretical model\u27s conclusions. The recent national expansion of insurance may mitigate the negative externality on the privately insured, providing a substantial welfare gain to those who do not otherwise benefit from the Affordable Care Act. Given the uncertainty as to the marginal costs of ED care, however, the full welfare implications are unknown

Screening for QT Prolongation in the Emergency Department: Is There a Better “Rule of Thumb?”

Introduction: Identification of QT prolongation in the emergency department (ED) is critical for appropriate monitoring, disposition, and treatment of patients at risk for torsades de pointes (TdP). Unfortunately, identifying prolonged QT is not straightforward. Computer algorithms are unreliable in identifying prolonged QT. Manual QT-interval assessment methods, including QT correction formulas and the QT nomogram, are time-consuming and are not ideal screening tools in the ED. Many emergency clinicians rely on the “rule of thumb” or “Half the RR” rule (Half-RR) as an initial screening method, but prior studies have shown that the Half-RR rule performs poorly as compared to other QT assessment methods. We sought to characterize the problems associated with the Half-RR rule and find a modified screening tool to more safely assess the QT interval of ED patients for prolonged QT.Methods: We created graphs comparing the prediction of the Half-RR rule to other common QT assessment methods for a spectrum of QT and heart rate pairs. We then proposed various modifications to the Half-RR rule and assessed these modifications to find an improved “rule of thumb.”Results: When compared to other methods of QT correction, the Half-RR rule appears to be more conservative at normal and elevated heart rates, making it a safe initial screening tool. However, in bradycardia, the Half-RR rule is not sufficiently sensitive in identifying prolonged QT. Adding a fixed QT cutoff of 485 milliseconds (ms) increases the sensitivity of the rule in bradycardia, creating a safer initial screening tool.Conclusion: For a rapid and more sensitive screening evaluation of the QT interval on electrocardiograms in the ED, we propose combining use of the Half-RR rule at normal and elevated heart rates with a fixed uncorrected QT cutoff of 485 ms in bradycardia

Relative Value Health Insurance and pay for Performance for Insurers: Complements, not Substitutes

The quest for value dominates contemporary health policy. Value, properly defined, is not about cost-savings but about the balance of costs and health benefits — improving the average cost-effectiveness of health interventions. In choosing which care is funded, insurers are a crucial but commonly neglected driver of health system value

King vs. Burwell Through the Lens of Economics

Now that Supreme Court arguments over the Affordable Care Act (ACA) are over, and the health insurance status of millions of Americans awaits a June decision, lets take a look at some of the economics of what a ruling for the plaintiff could mean

ED, Heal Thyself

Emergency department (ED) wait times have continued to worsen despite receiving considerable attention for more than 2 decades and despite the availability of a variety of methods to restructure care in a more streamlined fashion. This article offers an economic framework that abstracts away from the details of operations research to understand the fundamental disincentives to improving wait times. Hospitals that reduce wait times are financially penalized if they must provide more uncompensated care as a result. Pending changes under the Patient Protection and Affordable Care Act are considered. We find that the likely effect of the Patient Protection and Affordable Care Act\u27s insurance expansion is to reduce this penalty for improving ED wait times. Consequently, mandating adoption of solutions to ED crowding may be unnecessary and counterproductive. If the insurance expansion is insufficient to fully solve the problem, the hospital value-based purchasing initiative should adopt wait times as a goal in its next iteration