Caroline S. Carlin

Site Choice among Minnesota Walleye Anglers: The Influence of Resource Conditions, Regulations and Catch Orientation on Lake Preference

Abstract Understanding angler site choice preferences is important in the management of recreational fisheries to forecast angling demand and effort. This study investigated lake choice by recreational anglers fishing for walleye Sander vitreus in Minnesota and examined how choices were influenced by lake characteristics, angler demographics, and angler catch orientation. We collected data through a stated choice preference experiment using a survey administered to a sample of Minnesota resident (n = 1096) and nonresident (n = 535) anglers. Multinomial probit choice models were used to estimate preferences in lake choice. Lake characteristics included walleye abundance, walleye size, bag limit, slot limit, and distance from primary residence. Models included (1) lake characteristics only, (2) lake characteristics and angler demographics, and (3) lake characteristics with angler demographics and catch orientation factors. The coefficients of lake attributes had expected signs with greater preference for hi...

Chronic Illness and Patient Satisfaction

OBJECTIVE To examine how the relationship between patient characteristics, patient experience with the health care system, and overall satisfaction with care varies with illness complexity. DATA SOURCES/STUDY SETTING Telephone survey in 14 U.S. geographical areas. STUDY DESIGN Structural equation modeling was used to examine how relationships among patient characteristics, three constructs representing patient experience with the health care system, and overall satisfaction with care vary across patients by number of chronic illnesses. DATA COLLECTION/EXTRACTION METHODS Random digital dial telephone survey of adults with one or more chronic illnesses. PRINCIPAL FINDINGS Patients with more chronic illnesses report higher overall satisfaction. The total effects of better patient-provider interaction and support for patient self-management are associated with higher satisfaction for all levels of chronic illness. The latter effect increases with illness burden. Older, female, or insured patients are more satisfied; highly educated patients are less satisfied. CONCLUSIONS Providers seeking to improve their patient satisfaction scores could do so by considering patient characteristics when accepting new patients or deciding who to refer to other providers for treatment. However, our findings suggest constructive actions that providers can take to improve their patient satisfaction scores without selection on patient characteristics.

Changes in Quality of Health Care Delivery after Vertical Integration

OBJECTIVES To fill an empirical gap in the literature by examining changes in quality of care measures occurring when multispecialty clinic systems were acquired by hospital-owned, vertically integrated health care delivery systems in the Twin Cities area. DATA SOURCES/STUDY SETTING Administrative data for health plan enrollees attributed to treatment and control clinic systems, merged with U.S. Census data. STUDY DESIGN We compared changes in quality measures for health plan enrollees in the acquired clinics to enrollees in nine control groups using a differences-in-differences model. Our dataset spans 2 years prior to and 4 years after the acquisitions. We estimated probit models with errors clustered within enrollees. DATA COLLECTION/EXTRACTION METHODS Data were assembled by the health plans informatics team. PRINCIPAL FINDINGS Vertical integration is associated with increased rates of colorectal and cervical cancer screening and more appropriate emergency department use. The probability of ambulatory care-sensitive admissions increased when the acquisition caused disruption in admitting patterns. CONCLUSIONS Moving a clinic system into a vertically integrated delivery system resulted in limited increases in quality of care indicators. Caution is warranted when the acquisition causes disruption in referral patterns.

The dynamics of community health care consolidation

CONTEXT Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing recent acquisitions of physician practices by integrated delivery systems. METHODS We used key informant interviews, supplemented by document analysis. FINDINGS The acquisition of physician practices is a process that will be difficult to reverse in the current health care environment. Provider revenue uncertainty is a key factor driving consolidation, with public and private attempts to control health care costs contributing to that uncertainty. As these efforts will likely continue, and possibly intensify, community health care systems now are less consolidated than they will be in the future. Acquisitions of multispecialty and primary care practices by integrated delivery systems follow a common process, with relatively predictable issues relating to purchase agreements, employment contracts, and compensation. Acquisitions of single-specialty practices are less common, with motivations for acquisitions likely to vary by specialty type, group size, and market structure. Total cost of care contracting could be an important catalyst for practice acquisitions in the future. CONCLUSIONS In the past, market and regulatory forces aimed at controlling costs have both encouraged and rewarded the consolidation of providers, with important new developments likely to create momentum for further consolidation, including acquisitions of physician practices.

The Dynamics of Community Health Care Consolidation: Acquisition of Physician Practices

CONTEXT Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing recent acquisitions of physician practices by integrated delivery systems. METHODS We used key informant interviews, supplemented by document analysis. FINDINGS The acquisition of physician practices is a process that will be difficult to reverse in the current health care environment. Provider revenue uncertainty is a key factor driving consolidation, with public and private attempts to control health care costs contributing to that uncertainty. As these efforts will likely continue, and possibly intensify, community health care systems now are less consolidated than they will be in the future. Acquisitions of multispecialty and primary care practices by integrated delivery systems follow a common process, with relatively predictable issues relating to purchase agreements, employment contracts, and compensation. Acquisitions of single-specialty practices are less common, with motivations for acquisitions likely to vary by specialty type, group size, and market structure. Total cost of care contracting could be an important catalyst for practice acquisitions in the future. CONCLUSIONS In the past, market and regulatory forces aimed at controlling costs have both encouraged and rewarded the consolidation of providers, with important new developments likely to create momentum for further consolidation, including acquisitions of physician practices.

The Impact of Hospital Acquisition of Physician Practices on Referral Patterns

Multiple parties influence the choice of facility for hospital-based inpatient and outpatient services. The patient is the central figure, but their choice of facility is guided by their physician and influenced by hospital characteristics. This study estimated changes in referral patterns for inpatient admissions and outpatient diagnostic imaging associated with changes in ownership of three multispecialty clinic systems headquartered in Minneapolis-St. Paul, MN. These clinic systems were acquired by two hospital-owned integrated delivery systems (IDSs) in 2007, increasing the probability that hospital preferences influenced physician guidance on facility choice. We used a longitudinal dataset that allowed us to predict changes in referral patterns, controlling for health plan enrollee, coverage, and clinic system characteristics. The results are an important empirical contribution to the literature examining the impact of hospital ownership on location of service. When this change in ownership forged new relationships, there was a significant reduction in the use of facilities historically selected for inpatient admissions and outpatient imaging and an increase in the use of the acquiring IDSs facilities. These changes were weaker in the IDS acquiring two clinic systems, suggesting that management of multiple acquisitions simultaneously may impact the ability of the IDS to build strong referral relationships.

Time for a change? Predictors of child care changes by low-income families

Instability in child care arrangements can negatively affect childrens development, especially in low-income families. However, few studies have examined what predicts changes over time in child care arrangements. This paper presents findings from a unique multiyear study tracking child care use in low-income families. We estimate rich quantitative models to analyze the relationships among child, household, and care provider characteristics and four different types of changes. We find turnover in child care arrangements to be common in this low-income population. Over a period of six months, half of the children changed primary provider. Child care changes were frequently related to job loss, changes in family composition, or the changing availability of caregivers. While concerns have been raised that short spells of child care subsidy receipt cause child care instability, we found that subsidy use was not associated with higher rates of change. In addition, we found that the lower a parents assessment of the childs experience in a particular arrangement in the prior time period, the higher the likelihood of changing providers by the next survey wave. These results indicate that low-income parents recognize quality factors and change arrangements to improve the quality of care.

Evidence of Pent-Up Demand for Care After Medicaid Expansion

We compared new Medicaid enrollees with similar ongoing enrollees for evidence of pent-up demand using claims data following Minnesota’s 2014 Medicaid expansion. We hypothesized that if new enrollees had pent-up demand, utilization would decline over time as testing and disease management plans are put in place. Consistent with pent-up demand among new enrollees, the probability of an office visit, a new patient office visit, and an emergency department visit declines over time for new enrollees relative to ongoing Medicaid enrollees. The pattern of utilization suggests that the newly insured are connecting with primary care after the 2014 Medicaid expansion and, unlike ongoing Medicaid enrollees; the newly insured have a declining reliance on the emergency department over time.

Patient Loyalty in a Mature IDS Market: Is Population Health Management Worth It?

OBJECTIVE To understand patient loyalty to providers over time, informing effective population health management. STUDY SETTING Patient care-seeking patterns over a 6-year timeframe in Minnesota, where care systems have a significant portion of their revenue generated by shared-saving contracts with public and private payers. STUDY DESIGN Weibull duration and probit models were used to examine patterns of patient attribution to a care system and the continuity of patient affiliation with a care system. Clustering of errors within family unit was used to account for within-family correlation in unobserved characteristics that affect patient loyalty. DATA COLLECTION The payer provided data from health plan administrative files, matched to U.S. Census-based characteristics of the patients neighborhood. Patients were retrospectively attributed to health care systems based on patterns of primary care. PRINCIPAL FINDINGS I find significant patient loyalty, with past loyalty a very strong predictor of future relationship. Relationships were shorter when the patients health status was complex and when the patients care system was smaller. CONCLUSIONS Population health management can be beneficial to the care system making this investment, particularly for patients exhibiting prior continuity in care system choice. The results suggest that co-located primary and specialty services are important in maintaining primary care loyalty.

Consumer Knowledge of the Impact of a Change in Prescription Drug Benefit Design

BackgroundMany employers are changing their pharmacy benefit designs to contain cost increases. The objective of this study was to evaluate employee awareness of the cost-saving potential of these changes in the context of one such employer initiative.MethodsWe analyzed data from a survey of employees in 16 firms in Minneapolis, MN, USA. All of the firms offered prescription drug coverage administered by Express Scripts, a large pharmacy benefit management company. A total of four firms introduced 3-tiered pricing for both retail and mail-order drugs in 2002, whereas 11 kept their traditional, less-restrictive drug benefit plans. One company offered a pharmacy benefit choice that was tied to the overall medical plan. We use ordered probit analysis to examine the set of factors associated with employee awareness of the cost-saving potential of formularies, generic drugs, and mail-order drugs.ResultsAge and education were positively associated with giving the correct response to a question on the cost-saving potential of formularies, generic drugs, and mail-order drugs. However, we found no significant effect of the drug benefit design change itself or of strategies used by the employers to communicate information about health benefits to employees.ConclusionsEducation is a powerful influence for single employees’ awareness and a significant but less powerful influence for families’ awareness of the cost-saving potential of formularies, generic drugs, and mail-order drugs. Our failure to find that employer communication methods had a significant impact on employee awareness may be because of the lack of specificity in the measurement of employer strategies. Future research might include questions more specific to employer strategies for informing employees about pharmacy benefits.