Janet B. Mitchell

Physician-induced demand for surgery

Following up the earlier findings by Fuchs on surgeon-induced demand, this paper makes numerous data and econometric improvements in conducting a test of neoclassical and inducement theories. A simultaneous equation model is used to estimate physician demand and equilibrium fees for surgery from a sample of 350 PSUs over the 1969-76 period. The results provide definite support for the notion of competitive market failure--particularly in large metropolitan areas. Other things equal, fees and utilization are higher in surgeon-rich areas although our estimated shift elasticities were only about one-third those found by Fuchs. A statistically significant, albeit small price elasticity of demand for surgery was also obtained, in contrast to Fuchs. Increasing monopoly and disequilibrium models are also tested without altering the basic findings. Where surgeons were in short supply, their availability significantly affected surgery rates, although a small supply effect was found in plentiful areas as well.

Physician participation in state Medicaid programs.

Medicaid requires that physicians who accept Medicaid reimbursement for treating a patient agree to accept its payment as payment in full. Policy instruments under Medicaids control are both levels of reimbursement and various administrative burdens imposed on physicians by the program. A model depicting the physicians participation decision is developed, and predictions from the comparative statics analysis are discussed. Data came from a 1975--76 survey of fee-for-service physicians. The results indicate that high fee schedules and low administrative burdens are ways to stimulate physician involvement with Medicaid patients. Results on the Medicaid policy instruments and other explanatory variables on the whole lend support to the model of physician behavior proposed earlier in the paper.

Using Medicare Claims for Outcomes Research

Medicare claims databases have several advantages for use in constructing episodes of care for outcomes research. They are population-based, relatively inexpensive to obtain, include large numbers of cases, and can be used for long-term follow-up. However, the sheer size of these claims databases, along with their primarily administrative (as opposed to clinical) nature, requires that researchers take special care in using them. The 10 PORTs using Medicare claims provided information on their approach to several key issues in working with these data, including: 1) identifying the index cases or patient cohorts to be studied; 2) defining the length of the episode; and 3) measuring outcomes. This paper reports the experience and knowledge gained by these PORTs in using these claims to create and analyze episodes of care.

A decision model and cost-effectiveness analysis of colorectal cancer screening and surveillance guidelines for average-risk adults.

OBJECTIVES Guidelines for colorectal cancer screening and surveillance in people at average risk and at increased risk have recently been published by the American Gastroenterological Association. The guidelines for the population at average risk were evaluated using cost-effectiveness analyses. METHODS Since colorectal cancers primarily arise from precancerous adenomas, a state transition model of disease progression from adenomatous polyps was developed. Rather than assuming that polyps turn to cancer after a fixed interval (dwell time), such transitions were modeled to occur as an exponential function of the age of the polyps. Screening strategies included periodic fecal occult blood test, flexible sigmoidoscopy, double-contrast barium enema, and colonoscopy. Screening costs in 1994 dollars were estimated using Medicare and private claims data, and clinical parameters were based upon published studies. RESULTS Cost per life-year saved was

Time trends in late-stage diagnosis of cervical cancer. Differences by race/ethnicity and income.

12,636 for flexible sigmoidoscopy every 5 years and

Pay for performance in health care: Methods and approaches

14,394 for annual fecal occult blood testing. The assumption made for polyp dwell time critically affected the attractiveness of alternative screening strategies. CONCLUSIONS Sigmoidoscopy every 5 years and annual fecal blood testing were the two most cost-effective strategies, but with low compliance, occult blood testing was less cost-effective. Lowering colonoscopy costs greatly improved the cost-effectiveness of colonoscopy every 10 years.

Physician behavior under the medicare assignment option

Early detection and treatment of cervical cancer while it is still localized can greatly improve the probability of survival. Available evidence suggests, however, that women in more vulnerable population groups (eg, the poor, racial/ethnic minorities) are less likely to have their cancer diagnosed while it still is in this early stage.1-3 Analysis of tumor registry data found that only 9.4% of cervical cancers among white women were diagnosed at a late stage, for example, compared with 13.8% for black women.1 Mortality rates were consistent with this differential: 69.6% of white women

Can price controls induce optimal physician behavior

document when you quote from it. You must not sell the document or make a profit from reproducing it. Chapter 4 Concerns about quality of care have accelerated since the 1990s, as studies by Wennberg, Fisher, and others have documented large and unexplained variations in rates of health care utilization and clinical outcomes across geographic areas, calling into question the traditional approach of relying on the medical profession to deliver high-quality care uniformly (Davis & Guterman, 2007; Wennberg et al., 2002). Since about 2000, several landmark publications have highlighted widespread problems with patient safety and quality of care, most notably from the Institute of Medicine (IOM) and the These studies helped to galvanize a policy consensus, leading the federal government and private health insurance plans to increasingly focus policy, regulatory, and management interventions more directly on quality of care measurement, quality improvement programs, and financial incentives for quality improvement through pay for performance (P4P). P4P programs have focused primarily on quality of care measures to assess provider performance. Although other performance evaluation approaches, such as efficiency measures, are possible for P4P, those in policy circles currently perceive the lack of incentives for improved quality in the prevailing fee-for-service (FFS) payment systems as a major problem in the US health care system. As a result, P4P programs have focused mainly on addressing this problem. This chapter reviews issues regarding the application of quality measures in P4P programs. The first section of the chapter provides background, including conceptual frameworks for quality of care, and reviews organizations that develop and certify quality measures. The second section discusses different types of quality measures, including structure, process, and outcome measures (Donabedian, 1966). The third section reviews issues in selecting quality measures for P4P programs. The fourth section describes methods for 100 Chapter 4 analyzing quality measures for P4P. The fifth section discusses public reporting of quality measures and how that separate approach to quality improvement can be integrated with P4P programs.

Impact of the Oregon Health Plan on children with special health care needs.

Using a national sample of general practitioners, internists, and general surgeons, we analyzed the willingness of physicians to accept Medicare patients on assignment. Assignment rates were found to be very sensitive to reimbursement and administrative practices under Medicare. A ten percent increase in the prevailing charge, for example, raised assignment by 14.7 percent. The assigned and non-assigned components of the Medicare program were found to compete with each other; assignment rates were lower where the demand for non-assigned services was stronger. As for the kinds of physicians who take assignment, they were disproportionately general surgeons and foreign medical graduates.

Learning by Doing in Cabg Surgery

Recently, budget-conscious policymakers have shifted their attention to the physician services market and have begun to consider a wide variety of price regulatory schemes for moderating expenditures in this market. In a recent article in this journal, Feldman and Sloan warned that price controls on physician services may cause undesirable declines in service quality, independent of their budgetary ramifications. Our aim in this article is to reconsider the effects of price controls in the broader context of insurance coverage and moral hazard. Our ultimate goal is to assess the benefits of price controls independent of specific assumptions about the controversial issues of demand inducement and income targeting. Using a simple extension of the Feldman/Sloan model, we find that price controls can be and almost certainly are welfare-improving as long as consumers are sufficiently well insured, regardless of where one stands on the inducement issue. The salutary effects of price controls, on the other hand, can be compromised by income-targeting behavior on the part of physicians. We also introduce evidence from Medicares recent fee freeze to evaluate the possibility of income-targeting behavior empirically. While formal studies of income targeting suggest that its magnitude is small in cross-section, we warn that its effects may be larger over time; this is what our descriptive evidence suggests. We conclude that more dramatic short-term progress on physician fee inflation will require stronger measures, such as putting physicians at risk for consumer expenditures.