John A. Graves

Effects of furosemide versus isolated ultrafiltration on extravascular lung water in oleic acid-induced pulmonary edema

We studied the effects of no treatment, furosemide treatment, and isolated ultrafiltration on extravascular lung water (ETV1.) in mongrel dogs in whom pulmonary edema was induced with oleic acid. In all treatment groups, ETV1. was significantly elevated 90 min after oleic acid infusion. At 270 min, we found no difference between nontreatment and furosemide. There was, however, a significant difference between no treatment and ultrafiltration but not between furosemide and ultrafiltration. In spite of observations which suggest that ultrafiltration is of benefit in reducing ETVL, we could not demonstrate superiority of one therapy over another.

Measuring Returns to Hospital Care: Evidence from Ambulance Referral Patterns

We consider whether hospitals that receive higher payments from Medicare improve patient outcomes, using exogenous variation in ambulance company assignment among patients who live near one another. Using Medicare data from 2002–10 on assignment across ambulance companies and New York State data from 2000–6 on assignment across area boundaries, we find that patients who are brought to higher-cost hospitals achieve better outcomes. Our estimates imply that a one standard deviation increase in Medicare reimbursement leads to a 4 percentage point (or 10 percent) reduction in mortality; the implied cost per at least 1 year of life saved is approximately

Role of Geography and Nurse Practitioner Scope-of-Practice in Efforts to Expand Primary Care System Capacity: Health Reform and the Primary Care Workforce.

80,000.

Medicaid Expansion Opt-Outs and Uncompensated Care

Background:Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians—particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured. Objective:We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws. Research Design:An observational study. Subjects:2013 Area Health Resource File (AHRF) and US Census Bureau county travel data. Measures:The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC. Results:We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations. Conclusions:Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.

Does managed care improve access to care for Medicaid beneficiaries with disabilities? A national study.

A number of states plan to forgo the Affordable Care Acts Medicaid expansion, but they could face substantial erosion of Disproportionate Share Hospital funds despite seeing little or no change in the amount of uncompensated care they provide.

Employment Outcomes After Critical Illness: An Analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors Cohort.

States increasingly are shifting Medicaid beneficiaries with disabilities from the fee-for-service (FFS) delivery system to managed care in an effort to control program costs and address long-standing problems with access to care under the program. Using a county-based measure of managed care enrollment and pooled data from the 1997 to 2004 National Health Interview Surveys, we investigate whether Medicaid managed care (MMC), relative to FFS Medicaid, improves access to care. We find some evidence of improved access to care under MMC; however, the gains appear to be largely limited to beneficiaries in urban areas with fully capitated managed care. There is little evidence of improved access under primary care case management or, regardless of MMC type, in rural areas.

Success and Failure in the Insurance Exchanges

Objective To characterize survivors’ employment status after critical illness and to determine if duration of delirium during hospitalization and residual cognitive function are each independently associated with decreased employment.Objectives:To characterize survivors’ employment status after critical illness and to determine if duration of delirium during hospitalization and residual cognitive function are each independently associated with decreased employment. Design:Prospective cohort investigation with baseline and in-hospital clinical data and follow-up at 3 and 12 months. Setting:Medical and surgical ICUs at two tertiary-care hospitals. Patients:Previously employed patients from the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors study who survived a critical illness due to respiratory failure or shock were evaluated for global cognition and employment status at 3- and 12-month follow-up. Measurements and Main Results:We used multivariable logistic regression to evaluate independent associations between employment at both 3 and 12 months and global cognitive function at the same time point, and delirium during the hospital stay. At 3-month follow-up, 113 of the total survival cohort of 448 (25%) were identified as being employed at study enrollment. Of these, 94 survived to 12-month follow-up. At 3- and 12-month follow-up, 62% and 49% had a decrease in employment, 57% and 49% of whom, respectively, were newly unemployed. After adjustment for physical health status, depressive symptoms, marital status, level of education, and severity of illness, we did not find significant predictors of employment status at 3 months, but better cognition at 12 months was marginally associated with lower odds of employment reduction at 12 months (odds ratio, 0.49; p = 0.07). Conclusions:Reduction in employment after critical illness was present in the majority of our ICU survivors, approximately half of which was new unemployment. Cognitive function at 12 months was a predictor of subsequent employment status. Further research is needed into the potential relationship between the impact of critical illness on cognitive function and employment status.

Balancing Coverage Affordability and Continuity under a Basic Health Program Option

The available data on the health insurers participating in the Affordable Care Act exchanges reveal patterns of market entry and exit that are consistent with natural competitive processes separating out firms that are best suited to adapt to a new market.

The Growing Integration of Physician Practices: With a Medicaid Side Effect.

Under health care reform, changes in income, employment, and family composition may result in “churning” — shifting of people into and out of different insurance-coverage arrangements over time. How will a states adoption of a Basic Health Program affect churning?

Uncovering Waste in U.S. Healthcare

Background:Strategic alignment and integration is currently in vogue throughout the health care industry, but its diffusion and pace have not been documented in recent years. The full range of downstream implications from greater alignment between hospitals and physicians has also not been completely explored. Objectives:We track the organizational landscape among all office-based US physician practices from 2009 to 2015 and document the degree of vertical integration over time. Then, we examine the implications of vertical integration on practices’ acceptance of publicly insured patients. Research Design:We use descriptive trends and linear regression models with practice level fixed effects to capture the relationships between within-office changes in integration behavior and changes in public payer acceptance. Results:Independent (nonintegrated) physician practices are still the most common organizational type, but their share is declining as the share of practices integrated with a health system increases 3-fold between 2009 and 2015. Although >80% of practices that are part of a health system accept Medicaid, <60% of independent practices will see these patients. Vertically integrating with a health system makes it more likely a practice will start seeing Medicaid patients. Conclusions:Integration—and possibly consolidation—appears to be occurring and may be increasing over time in the United States. However, it also seems to increase the number of physician practices participating in the Medicaid program. This beneficial side effect has not been previously documented and should be kept in mind as policymakers weigh the pros and cons of a more integrated health care system.