Short-term and Long-term Racial Disparities in VA and non-VA Hospital Outcomes

This research used VA and Medicare data to examine racial patterns in short- and long-term mortality outcomes for elderly male black and white patients hospitalized for heart attack, stroke, hip fracture, congestive heart failure, gastrointestinal bleeding, and pneumonia from 1998 to 2002. The researchers found that at 30 days after admission for five of the six conditions, racial patterns in mortality outcomes were similar in VA and non-VA settings, with black patients having a survival advantage. Among Medicare patients, relative to the mortality outcomes for whites, mortality outcomes for black patients deteriorated over time until black Medicare patients had worse 2-year mortality for all conditions except congestive heart failure. In contrast, among VA patients, the relative decline in mortality for blacks was less marked and statistically significant only for hip fracture and stroke. These findings suggest that factors unrelated to hospital care play important roles in longer term mortality rates for the examined conditions. The findings also suggest that the integrated health care delivery system of the VA may attenuate racial disparities in health by mitigating the environmental factors that contribute to mortality for up to two years after hospitalization

The Impact of Increased Cost-Sharing on Utilization of Low Value Services: Evidence from the State of Oregon

In this study we examine the impact of a value-based insurance design (V-BID) program implemented between 2010 and 2013 at a large public employer in the state of Oregon. The program substantially increased cost-sharing, specifically copayments and coinsurance, for several healthcare services believed to be of low value and overused (sleep studies, endoscopies, advanced imaging, and surgeries). Using a differences-in-differences design coupled with granular, administrative health insurance claims data, we estimate the change in low value healthcare service utilization among beneficiaries before and after program implementation relative to a comparison group of beneficiaries who were not exposed to the V-BID. Our findings suggest that the V-BID significantly reduced utilization of targeted services. These findings have important implications for both public and private healthcare policies as V-BID principles are rapidly proliferating in healthcare markets

Paying People to Lose Weight and Stop Smoking

Unhealthy behaviors, such as smoking, poor diet, and sedentary lifestyles, account for as much as 40% of premature deaths in the U.S. Although behavioral interventions have the potential to improve health, behavior change is difficult, especially over the long term. Many people have difficulty changing health behaviors because it requires trade-offs between immediate consumption and delayed and often intangible health benefits. Incentives can provide people with immediate and tangible feedback that helps make it easier for them to do in the short term what is in their long-term best interest. This Issue Brief explores the use of financial incentives to motivate and sustain smoking cessation and weight loss

Regression modeling of longitudinal binary outcomes with outcome-dependent observation times

Conventional longitudinal data analysis methods assume that outcomes are independent of the data-collection schedule. However, the independence assumption may be violated, for example, when adverse events trigger additional physician visits in between prescheduled follow-ups. Observation times may therefore be associated with outcome values, which may introduce bias when estimating the eect of covariates on outcomes using standard longitudinal regression methods. Existing semi-parametric methods that accommodate outcome-dependent observation times are limited to the analysis of continuous outcomes. We develop new methods for the analysis of binary outcomes, while retaining the exibility of semi-parametric models. Our methods are based on counting process approaches, rather than relying on possibly intractable likelihood-based or pseudo-likelihood-based approaches, and provide marginal, population-level inference. In simulations, we evaluate the statistical properties of our proposed methods. Comparisons are made to \u27naive\u27 GEE approaches that either do not account for outcome-dependent observation times or incorporate weights based on the observation-time process. We illustrate the utility of our proposed methods using data from a randomized controlled trial of interventions designed to improve adherence to warfarin therapy. We show that our method performs well in the presence of outcome-dependent observation times, and provide identical inference to \u27naive\u27 approaches when observation times are not associated with outcomes

Reward-Based Incentives for Smoking Cessation: How a Carrot Became a Stick

Health care payers have an increasing interest in using financial incentives to change personal health behaviors, with an estimated 82% of employers using financial incentives for healthy behavior in 2013.1 Several factors are fueling this increased interest: steadily increasing costs that have been resistant to traditional forms of control, the realization that the majority of costs are driven by chronic conditions, which are themselves in large part a result of lifestyle choices, and emerging reports that incentives have successfully modified behaviors in a variety of contexts.2,3 In addition, the Affordable Care Act allows employers to use up to 30% of total premiums (50% if programs include smoking) for outcomes-based rewards or penalties.

Comparative Effectiveness — Thinking Beyond Medication A versus Medication B

The American Recovery and Reinvestment Act of 2009 (ARRA), the stimulus package signed into law by President Barack Obama on February 17, 2009, directs $1.1 billion to support “the development and dissemination of research assessing the comparative effectiveness of health care treatments and strategies, including through efforts that . . . conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions.

On the Way to Health

Information technology (IT) has fundamentally changed the way we work, bank, and communicate. Its impact on health care and health research, however, has been limited by the lack of a comprehensive infrastructure to connect patients, providers, and researchers. As we learn more about how to address the unhealthy behaviors that underlie many chronic conditions, researchers are seeking IT solutions to connect to patients in scalable ways. This Issue Brief describes the development and use of a new web-based IT platform, Way to Health, to deliver and evaluate behavioral interventions to improve health

A Wake-Up Call: Quality of Care After Resident Duty Hour Reform

On first glance, it seems self-evident: sleep-deprived physicians-intraining (residents) are more likely to make mistakes that could harm patients. Like pilots and truck drivers, these new physicians might need restrictions on how much they work. Such restrictions were created in 2003, but the impact of these new rules is unclear. Are patients any safer? Is hospital care more fragmented? Who’s doing the work that residents performed prior to duty hour reform? This Issue Brief summarizes several studies that offer evidence about the impact of these regulations on patient mortality, as well as on residents’ perceptions of the effects on quality of care, medical education, and residents’ quality of life

What Business are We In? The Emergence of Health as the Business of Health Care

On January 19, 2012, after 131 years of operation, the Eastman Kodak Company filed for Chapter 11 protection in U.S. bankruptcy court. No doubt some people were surprised by this filing, because they grew up at a time when bright yellow boxes of film accompanied every family vacation and celebration. Those who were paying more attention offered many explanations for the bankruptcy. Central among them was that Kodak was late to recognize that it was not in the film and camera business: it was in the imaging business. With the advent of digital imaging, Kodak was outpaced by other companies that could better achieve consumer goals

Incentives in Health: Different Prescriptions for Physicians and Patients

Financial incentives abound in health care. They are found in the ways physicians are paid and in the ways health insurance coverage, co-payments, and deductibles are structured for patients. The effects of these incentives are often understood through conventional economic principles, with the assumption that individuals are self-interest maximizers who respond directly to changes in incentives. In contrast, behavioral economics imports insights from psychology and recognizes that individuals often do not respond to incentives as rationally as they might. In some cases, individuals lack information, but in others, they just seem to act contrary to their own known interests, for example, when they overeat, fail to take medication, or neglect to wear seat belts