Copyright (c) 2008 All rights reserved. http://works.bepress.com/melinda_buntin Recent documents in Melinda Beeuwkes Buntin en-us Sun, 31 Aug 2008 19:52:03 PDT 3600 http://works.bepress.com/melinda_buntin/12 http://works.bepress.com/melinda_buntin/12 Thu, 16 Nov 2006 17:10:58 PST Purpose: This article reviews the state of science on the economics of end-of-life care for Medicare beneficiaries and outlines the research needed to fill gaps in that literature. Design and Methods: Searches of the medical, health services, and economics literature were conducted. Key topics examined were studies of spending on end-of-life care and financial, organizational, and nonfinancial barriers to high-quality end-of-life care. Results: Studies have documented poor quality of care, dissatisfaction with care, and limitations in the coverage of end-of-life care for Medicare beneficiaries. However, critical gaps in our knowledge about how to design a better end-of-life care system for Medicare beneficiaries remain. Implications: Further research on how treatment decisions at the end of life are made and prospective studies of costs, satisfaction, and outcomes are needed. Melinda Beeuwkes Buntin http://works.bepress.com/melinda_buntin/11 http://works.bepress.com/melinda_buntin/11 Thu, 16 Nov 2006 17:05:12 PST Many methods for modeling skewed health care cost and use data have been suggested in the literature. This paper compares the performance of eight alternative estimators, including OLS and GLM estimators and one- and two-part models, in predicting Medicare costs. It finds that four of the alternatives produce very similar results in practice. It then suggests an efficient method for researchers to use when selecting estimators of health care costs. Melinda Beeuwkes Buntin http://works.bepress.com/melinda_buntin/10 http://works.bepress.com/melinda_buntin/10 Thu, 16 Nov 2006 16:59:58 PST The individual market is the only source of health insurance for the more than 20 percent of Americans not eligible for group or public health insurance, yet participation rates are low and shrinking. This paper examines this market's structural features and assesses the likelihood that it will play an expanded role in the future. We describe how pressures such as cost growth, new technologies, and changes in the nature of the workplace are shaping the individual market. We conclude that the future of the market will depend largely on whether there are policy interventions that balance the problems of affordability, risk sharing, and adverse selection. Melinda Beeuwkes Buntin http://works.bepress.com/melinda_buntin/9 http://works.bepress.com/melinda_buntin/9 Thu, 16 Nov 2006 16:56:10 PST Objective. To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life--a group that accounts for more than one-quarter of Medicare's annual expenditures. Data Source. Medicare administrative claims for 1994 and 1995. Study Design. We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. Data Extraction Methods. The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. Principal Findings. Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. Conclusions. More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries. Melinda Buntin http://works.bepress.com/melinda_buntin/8 http://works.bepress.com/melinda_buntin/8 Thu, 16 Nov 2006 16:50:29 PST Objective. To estimate the effect of changes in premiums for individual insurance on decisions to purchase individual insurance and how this price response varies among subgroups of the population. Data Source. Survey responses from the Current Population Survey (http://www.bls.census.gov/cps/cpsmain.htm), the Survey of Income and Program Participation (http://www.sipp.census.gov/sipp), the National Health Interview Survey (http://www.cdc.gov/nchs/nhis.htm), and data about premiums and plans offered in the individual insurance market in California, 1996-2001. Study Design. A logit model was used to estimate the decisions to purchase individual insurance by families without access to group insurance. This was modeled as a function of premiums, controlling for family characteristics and other characteristics of the market. A multinomial model was used to estimate the choice between group coverage, individual coverage, and remaining uninsured for workers offered group coverage as a function of premiums for individual insurance and out-of-pocket costs of group coverage. Principal Findings. The elasticity of demand for individual insurance by those without access to group insurance is about −.2 to −.4, as has been found in earlier studies. However, there are substantial differences in price responses among subgroups with low-income, young, and self-employed families showing the greatest response. Among workers offered group insurance, a decrease in individual premiums has very small effects on the choice to purchase individual coverage versus group coverage. Conclusions. Subsidy programs may make insurance more affordable for some families, but even sizeable subsidies are unlikely to solve the problem of the uninsured. We do not find evidence that subsidies to individual insurance will produce an unraveling of the employer-based health insurance system. M. Susan Marquis http://works.bepress.com/melinda_buntin/7 http://works.bepress.com/melinda_buntin/7 Thu, 16 Nov 2006 16:22:09 PST The primary objective of this study is to conduct a set of analyses comparing costs and outcomes of lower extremity joint replacement patients discharged to three different post-acute settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and patient homes. Multivariate techniques are employed in order to adjust these analyses for observable differences in severity of illness across sites of care. In doing so, multinomial models are used that predict which type of institutional post-acute care a beneficiary accesses, and these predictors are described. In addition, instrumental variables (IV) techniques are used that allow for the accounting of unobserved patient selection into IRFs and SNFs in order to learn how patient costs and outcomes are affected by the availability of IRF and SNF care. Melinda Beeuwkes Buntin http://works.bepress.com/melinda_buntin/6 http://works.bepress.com/melinda_buntin/6 Thu, 16 Nov 2006 16:15:06 PST Medicare spends more than a quarter of its annual budget on care for those in their last year of life and covers more than 80 percent of decedents. Studies have documented poor quality of care, gaps in care, and patient and family dissatisfaction with care received by dying patients. Nineteen percent of Medicare decedents, nearly 360,000 beneficiaries, used the Medicare hospice benefit in 1998. In recent years we have heard providers report anecdotes about cases in which Medicare coverage and reimbursement rules may have impeded the delivery of high-quality end-of-life care to terminally ill Medicare beneficiaries. Among these anecdotes are that (1) skilled nursing facilities (SNFS) are transferring dying patients to hospitals in part so that the SNF does not incur the costs of the intensive treatments that the patients might need, (2) hospitals are discharging dying patients in response to diagnosis-related group (DRG) payment incentives; (3) patients are being dissuaded from electing hospice if they need particularly high-cost palliative care; (4) hospices and home health agencies are avoiding patients without caregivers in the home or with high levels of need for home care; and (5) physicians are not referring patients (particularly noncancer patients) to hospice because they fear that they will be charged with fraud if the referred patients do not die within six months. No information has been systematically gathered about the extent to which Medicare coverage and reimbursement methods have affected care or how widespread these issues may be. In this study we assess problems faced by several types of providers delivering end-of- life services under fee-for-service (FFS) Medicare. We identify important ways in which Medicare benefit design and financing rules both facilitate and create barriers to effective end-of-life care. Haiden A. Huskamp http://works.bepress.com/melinda_buntin/5 http://works.bepress.com/melinda_buntin/5 Thu, 16 Nov 2006 16:06:35 PST We use the implementation of a new prospective payment system (PPS) for inpatient rehabilitation facilities (IRFs) to investigate the effect of changes in marginal and average reimbursement on costs. The results show that the IRF PPS led to a significant decline in costs and length of stay. Changes in marginal reimbursement associated with the move from a cost based system to a PPS led to a 7 to 11% reduction in costs. The elasticity of costs with respect average reimbursement ranged from 0.26 to 0.34. Finally, the IRF PPS had little or no impact on costs in other sites of care, mortality, or the rate of return to community residence. Neeraj Sood http://works.bepress.com/melinda_buntin/4 http://works.bepress.com/melinda_buntin/4 Thu, 16 Nov 2006 16:00:08 PST Objective. To examine how much pooling of risks occurs among potential purchasers in the individual market, how much pooling occurs among those who purchase coverage, and whether there is greater pooling among longer-term enrollees. Data Sources. The data are administrative records for enrollees in individual insurance plans in California in 2001, and from a survey of Californians enrolled in the individual insurance market and the uninsured. Study Design. Logit models were estimated for 5 health outcome measures to compare the insured and uninsured after adjusting for other factors that affect insurance status and health. Multivariate models were also estimated to explore the relationship between health and three measures of pooling in the market: plan type, pricing tier, and the actuarially adjusted premium paid by the enrollee. Principal Findings. Those who purchase individual health insurance are in better health than those who remain uninsured. On the other hand, a large share of people with health problems does obtain individual insurance. The distribution of subscribers across plan type and pricing tier varies with their health status. Those in poor health are less likely to purchase low benefit plans. There is less separation of risks for those who become sick after enrollment based on the measure of pricing tier. The distribution of subscribers across plan type for those who have health problems at enrollment and those who become sick differs, but so does the distribution of those who become sick and those who remain healthy. Conclusions. Despite small differences among the healthy and sick, our results support the conclusion that there is considerable risk pooling in the individual market. To some extent, this pooling occurs because underwriting happens at the time people enroll and there is greater pooling among those who become sick than those who enroll sick. Our results however suggest that health savings accounts may further fragment the market. M. Susan Marquis http://works.bepress.com/melinda_buntin/3 http://works.bepress.com/melinda_buntin/3 Thu, 16 Nov 2006 15:55:05 PST Objective. To assess the relative impact of clinical factors versus nonclinical factors--such as postacute care (PAC) supply--in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care. Data Sources and Study Setting. Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data. Study Design. We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements. Data Collection/Extraction Methods. A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999. Principal Findings. PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there. Conclusions. We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes--or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes. Melinda Beeuwkes Buntin