Daniel L. Friesner

Idiopathic intracranial hypertension in the USA: the role of obesity in establishing prevalence and healthcare costs.

This study documents for the first time the extraordinary costs to take care of patients with a chronic, non‐fatal, relatively rare disorder who have been incorrectly thought to have an insignificant and self‐limiting illness. Idiopathic intracranial hypertension (IIH) occurs worldwide and in all racial groups and is found predominantly in obese women (∼90%) of childbearing age. Although the incidence of IIH is increasing as a result of the rapid increase in obesity, the disorder in general receives little recognition, and no recognition of the extensive burden of healthcare costs placed on patients, their families and society. We established for the first time both the prevalence of IIH in the USA and the direct and indirect costs of IIH using a prevalence‐based model. IIH patients had an exceptionally high hospital admission rate of 38% (in 2007), a partial reflection of unsatisfactory treatment options. The total hospital costs per IIH admission in 2007 were four times greater than for a population‐based per person admission. Total economic costs of IIH patients exceeded

The Use of Exploratory Factor Analysis in Public Health: A Note on Parallel Analysis as a Factor Retention Criterion

444 million. Programmes designed to reduce obesity prior to and after diagnosis and better therapeutics will have a tremendous economic impact.

Cost Shifting Revisited: The Case of Service Intensity

Purpose. Exploratory factor analysis is used to identify latent factors for public health interventions. The most popular factor retention criterion, the eigenvalue greater than one (EVG1) rule, leads to the retention of more factors than warranted. The use of parallel analysis (PA) as a factor retention criterion is recommended. Design. Environmental factors that are likely to affect the propensity of individuals to walk are identified. Results from PA are compared with those obtained by using the EVG1 rule. Setting. Telephone survey data were collected from three communities (spanning 12 counties) in the Appalachian region. Participants. The sample was composed of adults between the ages of 40 and 65 years. There were 1019 completed surveys. Measures. The data on 14 variables, including measures of neighborhood safety, beauty, and access to walking facilities were collected. Analysis. A principal components analysis was performed. The factors retained after using the EVG1 rule were compared with the factors retained after using PA. Varimax rotation was used to aid factor interpretation. Results. The EVG1 rule led to the retention of nearly twice the number of latent factors as did the PA criterion. Conclusion. The use of the EVG1 rule in research may mislead policy makers to focus on trivial interventions. They are urged to use PA to obtain more parsimonious and externally valid interventions.

How to Improve Patient Satisfaction When Patients Are Already Satisfied: A Continuous Process-Improvement Approach

This paper examines whether a health care providers choice of service intensity for any patient group affects its cost shifting behavior. Our theoretical models indicate that firms may respond to lower prospective payment by decreasing service intensity to all of its patient groups, thereby giving firms an alternative to cost shifting. Additionally, the conditions under which cost shifting and lower service intensity occur are identical, regardless of profit status. Using a panel of California hospitals, we found that nonprofit hospitals do cost shift, while profit-maximizing hospitals do not. However, both firms respond to lower prospective payment by decreasing service intensity, thus supporting our theoretical conclusion that lower service intensity can be used as an alternative to cost shifting.

The Property Rights Theory of the Firm and Mixed Competition: A Counter-Example in the US Health Care Industry

The authors present a methodology that measures improvement in customer satisfaction scores when those scores are already high and the production process is slow and thus does not generate a large amount of useful data in any given time period. The authors used these techniques with data from a midsized rehabilitation institute affiliated with a regional, nonprofit medical center. Thus, this article functions as a case study, the findings of which may be applicable to a large number of other healthcare providers that share both the mission and challenges faced by this facility. The methodology focused on 2 factors: use of the unique characteristics of panel data to overcome the paucity of observations and a dynamic benchmarking approach to track process variability over time. By focusing on these factors, the authors identify some additional areas for process improvement despite the institutes past operational success.

The health sciences reasoning test in the pharmacy admissions process.

We present a counter-example to the conventional property rights theory of the firm, which indicates that not-for-profit firms are incapable of directly competing against strictly profit-maximizing firms without the presence of barriers to entry, outside assistance, changing profit status or economies of scale and scope. We employ a modified Bertrand duopoly model of mixed competition in the health care industry to show that, even when these four conditions do not hold, not-for-profit firms may still be able to compete and possibly dominate the market. Consequently, market fundamentals, rather than market intervention, regulation or uncertainty, determine a not-for-profit providers success or failure in the market. A necessary requirement is that the not-for-profit manager must care about non-pecuniary benefits but be willing to accept lower than normal returns. Moreover, under specific cost and demand conditions, a not-for-profits ability to compete may actually be enhanced by increasing its production of non-pecuniary benefits.

Do hospitals practice cream skimming

Objective. To evaluate the impact of including Health Sciences Reasoning Test (HSRT) scores in the doctor of pharmacy (PharmD) admissions process compared with other criteria used. Methods. The HSRT was administered to all prepharmacy students who were selected for an interview (n=122) as part of the PharmD program admissions process. The HSRT score and other evaluation criteria were used to establish candidate rankings. The correlation between total HSRT scores and other measures used in the admissions process then was evaluated. Results. Candidate rankings were not noticeably different when the HSRT scores were excluded from the admission process. The HSRT scores were significantly and highly correlated with applicants’ Pharmacy College Admission Test (PCAT) cumulative percentile scores. Conclusions. The HSRT can be an effective method to evaluate critical-thinking ability as part of the admissions process into a PharmD program. However, the usefulness of the HSRT as an admissions screening tool is mitigated by information redundancies with other evaluation criteria, specifically the PCAT.

Are hospitals seasonally inefficient? Evidence from Washington State

‘Cream skimming’ refers to choosing patients for some characteristic(s) other than their need for care, which enhances the profitability or reputation of the provider. Under capitation or other fixed payment schemes, this often means choosing less ill patients. We present a new methodology to measure cream skimming by hospitals. Our approach also provides a measure of a hospitals gain in productive efficiency by caring for patients with lower illness severity. Using a panel of Washington state hospitals, we find evidence that hospitals do practice cream skimming. However, we find little evidence to suggest that cream skimming varies by hospital size, profit status or time.

Welfare recipient work choice and in-kind benefits in Washington state

Efficiency measurement has been one of the most extensively explored areas of health services research over the past two decades. Despite this attention, few studies have examined whether a providers efficiency varies on a monthly, quarterly or other, sub-annual basis. This article presents an empirical study that looks for evidence of seasonal inefficiency. Using a quarterly panel of general, acute-care hospitals from Washington State, we find that hospital efficiency does vary over time; however, the nature of this dynamic inefficiency depends on the type of efficiency being measured. Our results suggest that technical and cost efficiency vary by quarter. Allocative and scale efficiency also vary on a quarterly basis, but only if the data are jointly disaggregated by quarter and another, firm-specific factor such as size or operating status. Thus, future research, corporate decisions and government policies designed to improve the efficiency of hospital care need to account for seasonal trends in hospital efficiency.

Benchmarking patient improvement in physical therapy with data envelopment analysis

We analyze the work choice of welfare recipients. Potential welfare recipients compare their on and off welfare utility from after-tax income and in-kind benefits via employment or welfare, and choose whether to work. Our null hypothesis, which we reject, is that benefits affect only the decision to work or not, not the hours worked, which will depend on wages. Using Temporary Assistance for Needy Families (TANF) administrative data from Washington state, we find that employer provided health insurance and child care subsidies significantly raise exit rates of TANF recipients and induce greater work effort. Other work inducing factors include wages and the Earned Income Tax Credit, while increased levels of Medicaid, Food Stamps and the income guarantee increase welfare dependency.