Comments on Enthoven’s “The U.S. Experience with Managed Care and Managed Competition”

This session will provide an overview of the U.S. health care system with an emphasis on trends observed since the reforms of the early 1990s. ; How has the health care system adjusted to the introduction of market-oriented medicine? And what have been the consequences for access to care, health care costs (public and private), and the quality of care over the past decade? How does the U.S. health care system measure up in international comparisons, for instance? Does managed care work as its advocates expected or have inappropriate consumer and provider incentives undermined this experiment? What are the implications for reform?Health care reform

A New Medicare End-of-Life Benefit for Nursing Home Residents

A new Medicare benefit is needed to support end-of-life care for those spending their final days in a nursing home, say the authors of this article. Arguing that the current hospice benefit is a poor fit with the nursing home setting, the authors recommend a new benefit that would enable nursing home residents to receive individualized palliative and psychosocial services in addition to rehabilitative services

HEDIS Measures and Managed Care Enrollment

This article examines the relationship between 1996 health plan enrollment and both HEDIS-based plan performance ratings and individual HEDIS measures. Data were obtained from a large firm that collected, aggregated, and disseminated plan performance ratings to its employees. Plan market share regressions are estimated controlling for out-of-pocket price and model type in addition to the plan ratings and HEDIS measures. The results suggest that employees did not respond strongly to the provided ratings. There are several potential explanations for the lack of response, including difficulty understanding the ratings and never having seen them. In addition, employees may base their plan choices on information that is obtained from their own past experience, friends, family, and colleagues. The pattern of results suggests that such information is important. Counterintuitive signs most likely reflect an inverse correlation between some HEDIS ratings (or measures) and attributes employees observe informally.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68992/2/10.1177_107755879905600204.pd

THE PHYSICIAN LABOR MARKET IN A MANAGED CARE-DOMINATED ENVIRONMENT

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74586/1/j.1465-7295.1999.tb01430.x.pd

Measuring Health Care Costs of Individuals with Employer-Sponsored Health Insurance in the U.S.: A Comparison of Survey and Claims Data

As the core nationally representative health expenditure survey in the United States, the Medical Expenditure Panel Survey (MEPS) is increasingly being used by statistical agencies to track expenditures by disease. However, while MEPS provides a wealth of data, its small sample size precludes examination of spending on all but the most prevalent health conditions. To overcome this issue, statistical agencies have turned to other public data sources, such as Medicare and Medicaid claims data, when available. No comparable publicly available data exist for those with employer-sponsored insurance. While large proprietary claims databases may be an option, the relative accuracy of their spending estimates is not known. This study compared MEPS and MarketScan estimates of annual per person health care spending on individuals with employer-sponsored insurance coverage. Both total spending and the distribution of annual per person spending differed across the two data sources, with MEPS estimates 10 percent lower on average than estimates from MarketScan. These differences appeared to be a function of both underrepresentation of high expenditure cases and underestimation across the remaining distribution of spending.

The Effect of Bundled Payment on Emergency Department Use: Alternative Quality Contract Effects After Year One

ObjectivesThe objective was to identify the effect of the Alternative Quality Contract (AQC), a global payment system implemented by Blue Cross Blue Shield (BCBS) of Massachusetts in 2009, on emergency department (ED) presentations.MethodsBlue Cross Blue Shield of Massachusetts claims from 2006 through 2009 for 332,624 enrollees whose primary care physicians (PCPs) enrolled in the AQC, and 1,296,399 whose PCPs were not enrolled in the AQC, were evaluated. A pre–post, intervention–control, propensity‐scored difference‐in‐difference approach was used to isolate the AQC effect on ED visits. The analysis adjusted for age, sex, health status, and secular trends to compare ED use between the treatment and control groups.ResultsOverall, secular trends showed that the number of ED visits decreased slightly for both treatment and control groups. The adjusted analysis of the AQC group showed decreases from 0.131 to 0.127 visits per member/quarter, and the control group decreased from 0.157 to 0.152 visits per member/quarter. The difference‐in‐difference analysis showed the AQC had no statistically significant effect on total ED use compared to the control group.ConclusionsIn the first year of this AQC, we did not find evidence of change in aggregate ED use. Similar global budget programs may not alter ED use in the initial implementation period.ResumenEfecto del Pago Combinado en el Uso del Servicio de Urgencias: Los Efectos del Alternative Quality Contract tras un AñoObjetivosIdentificar el efecto del Alternative Quality Contract (AQC), un sistema de pago global implementado por el Blue Cross Blue Shield de Massachusetts en 2009, en las visitas a los servicios de urgencias (SU).MetodologíaSe evaluaron los 332.624 miembros cuyo médico de atención primaria (MAP) estaba incluido en el AQC y los 1.296.399 cuyo MAP no estaba incluido en el AQC del Blue Cross Blue Shield de Massachusetts de 2006 hasta 2009. Para identificar el efecto del AQC en las visitas al SU, se utilizó un diseño pre‐post, intervención‐control, con una aproximación por puntuación de propensión diferencia en diferencia. El análisis se ajustó por edad, sexo, estado de salud y tendencias seculares para comparar el uso del SU entre los grupos tratamiento y control.ResultadosDel total, las tendencias seculares mostraron que el número de visitas al SU descendió discretamente tanto para el grupo tratamiento como control. El análisis ajustado del grupo AQC mostró un descenso de 0,131 a 0,127 visitas por miembro/cuartil, y el grupo control descendió de 0,157 a 0,152 visitas por miembro/cuartil. El análisis de diferencia en diferencia mostró que el AQC no tuvo efecto estadísticamente significativo en el uso total del SU en comparación con el grupo control.ConclusionesEn su primer año, el AQC no tuvo un efecto significativo en el uso del SU. PLos programas económicos globales similares pueden no alterar la utilización del SU en el periodo inicial de implementación.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/112205/1/acem12205-sup-0001-DataSupplementS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/112205/2/acem12205.pd

Out-of-Pocket Health-Care Expenditures among Older Americans with Cancer

Objective:  There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx). Methods:  We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated. Results:  Of the 6370 respondents, 5382 (84%) reported No CA, 812 (13%) reported CA/No Tx, and 176 (3%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were $1210,$1450, and $1880, respectively ( P  < .01). Prescription medications ($1120 per year) and home care services ($250) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27% of their yearly income on OOPE compared to only 5% of yearly income for high-income individuals with no cancer history ( P  < .01). Conclusions:  Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73612/1/j.1524-4733.2004.72334.x.pd